This is the first study investigating the course of depressive, manic and anxiety symptoms in OABD during the COVID-19 pandemic. The results of our study show that these symptoms were of relatively low intensity in the first month of the pandemic, but they increased in six months as the pandemic continued. Mastery seemed to be a significant effect modifier of changes for depressive and anxiety symptoms, whereas loneliness did not interact with the course of psychiatric symptoms.
In line with our hypothesis; depressive and mania symptoms increased during the whole period and anxiety symptoms only increased in the first three months of the pandemic, and stayed relatively stable thereafter. In this period, the Netherlands experienced several months of lockdown, with closing of almost all facilities and without a solution in prospect. This increase in symptoms might be an effect of diminishing of the earlier mentioned ‘pulling together’ effect (Reger et al. 2020). Our study is in line with a study conducted in older adults with pre-existing depressive symptoms during COVID-19 (Hamm et al. 2020). In this study, it was observed that during the first two months of the COVID-19 pandemic participants were doing relatively well, but most of the participants forecasted that their mental health would deteriorate as the COVID-19 measures continued. This finding is supported by an often experienced emotionally positive “honeymoon phase” of the disaster response (Math et al. 2006). This concept has been used to describe resilient psychological responses directly following acute disasters, including community bonding and optimism that everything will return to normal quickly. After the “honeymoon phase”, the “disillusionment phase” enters. This phase might be represented by the increase in depressive, manic and anxiety symptoms in our group, since this phase includes optimism turning into discouragement and stress concerning the situation increases.
Besides the course of mental health symptoms, we also studied the effect of the sense of mastery on this course. Mastery is seen as a psychological coping resource and has been recognized as an indicator of resilience (Skinner 1998). In our sample, we found that in the first three months of the pandemic, participants with a higher sense of mastery showed a greater increase in depressive and anxiety symptoms than participants with a lower sense of mastery. However, participants with a higher sense of mastery still showed less psychiatric symptoms, which is in line with an earlier study in younger adult patients that showed that a higher sense of mastery was associated with less depressive symptoms during COVID-19 (Orhan et al. 2021a).
Additionally, a study on the effects of accumulation of negative life events on depressive symptoms in old age, it was found (Kok et al. 2021) that the detrimental effect of recent life events on mental health was weaker for persons who had previously been exposed to more negative events. However, this ‘steeling’ effect was stronger in persons with lower mastery. It is possible that COVID-19 related stressors, including quarantine, fear and loss of loved ones, lead to learning those who felt strongly in control of their lives, that circumstances can actually arise that one cannot control. This might have learned that their more active coping style, fell short in this specific situation. A more passive coping, and thereby having a lower sense of mastery, could be more adequate in this situation. The more passive use of acceptance in combination with novelty seeking as main coping strategies can be useful in chronic circumstances that one has no control over (Schouws et al. 2015). A high sense of mastery can thus be regarded as non-beneficial when circumstances arise that one cannot control, where it might be more beneficial to accept this and to seek pleasure in other aspects of life. However, in the long run, mastery might contribute to better resilience.
We also found that the initial negative effect of loneliness on mental health symptoms, did not persist after the first three months of the pandemic. In a study conducted in community-dwelling older adults it was found that they experienced an increase in loneliness in the first two months of the pandemic, but mental health remained roughly stable (Tilburg et al. 2021). In our earlier study (Orhan et al. 2021a), we have found that loneliness was cross-sectionally associated with depressive symptoms. However, by conducting analyses on interaction effect, we studied whether the increase in symptoms was greater in participants that had high loneliness at T1, when compared to participants that had low loneliness at t1. We did not find any significant interaction effects. However, post-hoc analyses. Revealed that participants that already showed the highest loneliness scores at baseline (highest quartile), also had higher depression scores than the other participants (median = 15 vs. median = 8). Therefore, a greater increase was not to be expected. Thus, loneliness is associated with mental health symptoms (Heinrich and Gullone 2006) but during the pandemic it was not a risk factor for a (further) increase in depressive, manic and anxiety symptoms. This is in line with findings in the general Dutch population, that suggest that the pandemic did not negatively affect the prevalence of anxiety and depression during the first four months, but that loneliness did increase (Kok et al. 2022). It was also found in patients with pre-existing psychiatric symptoms, that there was not a strong increase in symptoms during the COVID-19 pandemic in those with a higher burden of disorders. In fact, changes in scores from before to during the pandemic, indicated increased symptom levels in people without psychiatric disorders whereas this was not found in participants with more chronic psychiatric disorders (Van der Velden et al. 2022).
Our study has several strong points. First, we were able to collect data on different timepoints during this global pandemic. From a scientific perspective, this pandemic offers a unique possibility to study the course of mental health symptoms and risk factors for adverse outcome during a collective negative life event. Despite these strong points, there are also some limitations that need to be acknowledged. We have included a relatively small group of participants, therefore statements about generalizability should be made with caution. Next, our data were collected in the first six months of the pandemic, thus our findings might not reflect the long-term effects of the COVID-19 pandemic.
The results of our study warrant clinical implications. Clinicians need to be aware of a possible increase of mental health symptoms during a global life event, such as a pandemic and the possible role of inadequate coping strategies as these situations continue. We found that mastery might be beneficial on the short-term, but when uncontrollable events happen, mastery might not be the most beneficial coping style. In addition, it deserves to be stressed that OABD are not experiencing disproportionately increased mental health symptoms, regarding that most participants still do not experience symptoms above the cut-off score. This was also the case for participants that were included at T1, but were lost to follow-up. However, we observed an increase in depressive, manic and anxiety symptoms and therefore this group needs to be carefully monitored as the pandemic continues. In order to prevent further increase of symptoms, clinicians can focus on teaching more adequate coping strategies, e.g., by learning cognitive behavioral therapy (CBT) techniques. CBT aims to improve patients’ ability to cope with their illness and possibly their sense of mastery (Henken et al. 2020). CBT is a relatively short-term, focused treatment for many types of psychiatric disorders that helps individuals to identify dysfunctional thoughts, attitudes, and behaviors and learn healthier skills and habits (Beck 2011). Our study shows a disadvantageous effect of higher mastery for the course of depressive and anxiety symptoms during the COVID-19 pandemic. However, participants with higher sense of mastery still reported less psychiatric symptoms during the COVID-19 pandemic. A suggestion for future research might therefore be looking more closely into the concept of mastery and its effect on mental health symptoms.