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The Influence of Repeated Mild Lockdown on Mental and Physical Health During the COVID-19 Pandemic: a Large-Scale Longitudinal Study in Japan

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The Influence of Repeated Mild Lockdown on Mental and Physical Health During the COVID-19 Pandemic: a Large-Scale Longitudinal Study in Japan medRxiv preprint doi: https://doi.org/10.1101/2021.08.10.21261878; this version posted August 13, 2021. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license . The influence of repeated mild lockdown on mental and physical health during the COVID-19 pandemic: a large-scale longitudinal study in Japan Tetsuya Yamamoto1,2,*, Chigusa Uchiumi1, Naho Suzuki3, Nagisa Sugaya4, Eric Murillo- Rodriguez2,5, Sérgio Machado2,6,7, Claudio Imperatori2,8, and Henning Budde2,9 8FIFYJBHMTTQTCJHMSTQTL:SIYNFQFSIBTHNFQBHNJSHJCTPMNRFDSNJNYCTPMNRFFUFS (:SYJHTSYNSJSYFQJTHNJSHJAJJFHM8TUCTPMNRFFUFS )8FIFYJBHMTTQTBHNJSHJFSICJHMSTQTLT:SSTFYNTSCTPMNRFDSNJNYCTPMNRFFUFS *DSNYTGQNH9JFQYMFSIJJSYNJJINHNSJBHMTTQTJINHNSJETPTMFRF4NYDSNJNYETPTMFRF FUFS +FGTFYTNTIJJTHNJSHNFTQJHQFJJ:SYJLFYNF6HJQFIJJINHNSF5NNNaS4NJSHNFIJQFBFQI DSNJNIFI2SMFHFFGNIFJNHT ,5JUFYRJSYTBUTYJYMTIFSICJHMSNJ7JIJFQDSNJNYTBFSYFFNFBFSYFFNF3FNQ -FGTFYTTMNHFQ2HYNNYJTHNJSHJJTINJNY:SYNYYJ@JNRFITA3FNQ .4TLSNYNJFSI4QNSNHFQHMTQTLFGTFYT5JUFYRJSYT9RFSBHNJSHJ6TUJFSDSNJNYTATRJ ATRJ:YFQ 7FHQYT9RFSBHNJSHJJINHFQBHMTTQ9FRGL9FRGL8JRFS Abstract The mental and physical effects of repeated lockdowns are unknown. We conducted a longitudinal study of the influence of repeated mild lockdowns during two emergency declarations in Japan, in May 2020 and February 2021. The analyses included 7,893 people who participated in all online surveys. During repeated mild lockdowns, mental and physical symptoms decreased overall, while loneliness increased and social networks decreased. Subgroup analyses revealed that depression and suicidal ideation did not decrease only in the younger age group (aged 18-29) and that younger and middle-aged people (aged 18- 49), women, people with a history of treatment for mental illness, and people who were socially disadvantaged in terms of income had higher levels of mental and physical symptoms at all survey times. Additionally, comprehensive extraction of the interaction structure between depression, demographic attributes, and psychosocial variables indicated that loneliness and social networks were most closely associated with depression. These results indicate that repeated lockdowns have cumulative negative effects on interpersonal interaction and loneliness and that susceptible populations, such as young people and those with high levels of loneliness, require special consideration during repetitive lockdown situations. Keywords: COVID-19, pandemic, lockdown, mental health, longitudinal study, depression, PHQ-9 4TJUTSINSLFYMTCJQ0...,+,-,- 6RFNQFIIJ0YFRFRTYT1YTPMNRFFHUCEFRFRTYT NOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice. The onslaught of the coronavirus disease 2019 (COVID-19) remains severe as of June 2021 1. Many countries have implemented lockdowns to prevent the spread of infection. While these lockdowns have been effective in reducing the spread of infection, many negative psychological effects have been reported, including a high prevalence of psychiatric symptoms, such as depression and anxiety 2–7. Previous studies reporting the negative effects during lockdown have been limited to cross-sectional surveys 3,4,6 and follow-up studies under single lockdown situations 5,7. There have been no longitudinal data demonstrating the effects of repeated lockdowns. Therefore, the question of whether multiple lockdowns have a negative influence on symptoms, or whether the influence can be reduced as people become accustomed to lockdown circumstances remains 8. Considering that lockdowns have a significant impact on people's lives and economic activities 9, it can be assumed that repeated lockdowns have different effects on people's mental health and interpersonal interaction styles than single lockdowns. Since repeated lockdown policies have already been implemented in many parts of the world and may continue to be implemented in the future due to new outbreaks, it is essential to elucidate the influence of repeated lockdowns on mental health. Japan is one country that has implemented repeated lockdowns. The Japanese government declared a state of emergency on 7 April 2020 and 8 January 2021 and implemented a "mild lockdown” 6, an unenforceable request for self-restraint (Figure 1). During the first mild lockdown, a significant increase in psychological distress and depression was reported, despite the lack of legal enforcement of self- restraint 6,10,11, the effect of the second mild lockdown on those participants is unclear. Wave 1 of the survey Wave 2 of the survey (11-12 May 2020) (24 FeB - 1 Mar 2021) 9,000 8,000 2nd mild lockdown 7,000 8 Jan - 21 Mar 2021 6,000 1st mild lockdown 7 Apr - 25 May 2020 5,000 19 in Japan in 19 - 4,000 Phasing out of the 3,000 declaration of a state of emergency of COVID of 2,000 NumBer of reported cases cases reported of NumBer 1,000 0 1-Jul-20 1-Mar-201-Apr-201-May-201-Jun-20 1-Aug-201-Sep-201-Oct-201-Nov-201-Dec-201-Jan-211-FeB-211-Mar-211-Apr-21 Figure 1. Status of COVID-19 infection in Japan from March 2020 to April 2021 and timing of this study ( In this lockdown context in Japan, longitudinal studies of mental health characteristics are critical to understanding the influence of repeated lockdowns. Such analyses will provide important fundamental data for improving lockdown approaches that still permit maximum infection prevention and maintain mental health. The influence of lockdown is also particularly prevalent among certain groups, such as women, the young, the socially disadvantaged in terms of income, and those with a history of mental illness 6,12,13. Because the effects of repeated lockdowns may be specific to these groups, a detailed examination of these associations would provide information regarding what groups require particular attention. In this study, we examined the influence of repeated lockdowns by conducting a large-scale panel survey of the mental health of people in urban areas under two lockdowns due to declared states of emergency in Japan. Results Participant characteristics Of the 11,333 participants in the first wave of the survey, 7,893 participated in the second wave (response rate: 69.6%) (Table 1). The mean age of those who participated in both surveys was 49.6 years (SD=13.7), with the 30-49 age group the most highly represented (41.8%). Of the respondents, 65.6% were married and 68.2% were employed. Compared to those who participated in the first wave only (N = 3,440), those who participated in both were older and had a larger proportion of men and married people (Supplementary Table S1). In addition, those who participated in both experienced greater loneliness and smaller social networks, while fewer people exceeded the cut-off points for depression (PHQ9 ≥ 10) and psychological stress (K6 ≥ 5) and reported suicidal ideation in the first survey (Supplementary Table S1). ) Table 1. Demographic characteristics of the participants Characteristics (N=7,893) n (%) Age, years 18-29 637 (8.1%) 30-49 3,302 (41.8%) 50-64 2,701 (34.2%) ≥ 65 1,253 (15.9%) Gender Men 4,201 (53.2%) Women 3,692 (46.8%) Occupation category Employed 5,384 (68.2%) Homemaker 1,236 (15.7%) Student 111 (1.4%) Unemployed 901 (11.4%) Other 261 (3.3%) Marital status Married 5,174 (65.6%) Unmarried 2,719 (34.4%) Annual household income (JPY) <2 million a 438 (5.5%) 2 million to <4 million 1,421 (18.0%) 4 million to <6 million 1,562 (19.8%) 6 million to <8 million 1,078 (13.7%) ≥8 million 1,613 (20.4%) Unknown 1781 (22.6%) Currently receiving treatment for mental illness Yes 431 (5.5%) No 7,462 (94.5%) Received treatment For mental illness in the past Yes 875 (11.1%) No 7,018 (88.9%) a 2 million JPY = approximately £15,000 Mental health under repeated mild lockdown in the whole sample Depression, suicidal ideation, psychological distress, and physical symptoms were significantly lower in the second than the first wave (all ps < 0.001; Table 2). Alternatively, in the second wave, loneliness increased significantly (b = 0.24, 95% CI = 0.15 to 0.33, p < .001) and social network decreased significantly (b = -0.43, 95% CI = -0.54 to -0.33, p < .001). The percentage of patients who exceeded the cut-off score for GAD, measured only in the second wave, was 8.5% (Table 2). * Table 2. Changes in outcome variables over waves 1 and 2 with odds ratios, betas, and 95% confidence interval N=7,893 Wave 1 Wave 2 ORa 95% Cl p Depression (PHQ9 ≥ 10), n (%) 1,286 (16.3%) 989 (12.5%) 0.74 0.69 to 0.79 <0.001 Suicidal ideation, n (%) 1,503 (19.0%) 1,212 (15.4%) 0.77 0.73 to 0.82 <0.001 Psychological Distress (K6 ≥ 5), n (%) 3,595 (45.5%) 2,507 (31.8%) 0.56 0.53 to 0.58 <0.001 Wave 1 Wave 2 Beta (SE) 95% Cl p Somatic Symptoms, mean (SD) 6.39 (5.50) 4.89 (5.38) -1.49 (0.05) -1.59 to -1.40 <0.001 Loneliness, mean (SD) 23.59 (5.74) 23.83 (5.85) 0.24 (0.05) 0.15 to 0.33 <0.001 Social Network, mean (SD) 10.14 (6.13) 9.71 (6.06) -0.43 (0.05) -0.54 to -0.33 <0.001 GAD7 (% ≥ 10) - 667 (8.5%) - - - PHQ9 score, mean (SD) 4.54 (5.40) 3.78 (5.39) - - - K6 score, mean (SD) 5.27 (5.34) 3.85 (5.11) - - - GAD7 score, mean (SD) - 2.84 (4.27) - - - a. Reference group: wave 1. Mental health under repeated mild lockdown with a focus on subgroups The first- and second-wave data for all subgroups are included in the Supplementary Materials (Supplementary Tables S2-S4). Estimated rate of depression There was a significant interaction between gender and wave, and between each age group and wave, for the estimated rate of depression as assessed by the PHQ-9 (Gender: Wald χ2(1) = 7.49, p = .006; Age: χ2(3) = 24.70, p < .001).
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