Mental Health Consequences of the Coronavirus 2020 Pandemic (COVID-19) in Spain. A Longitudinal Study

Abstract

Background: Covid-19 remains a pandemic that most countries in the world are still dealing with. This is study aims to report the psychological impact of Covid-19 over time on the Spanish population.
Methods: A longitudinal study (N = 1041) was carried out with two measurements: after 2 and 5 weeks starting from the declaration of the state of emergency in Spain. The presence of depressive symptoms, anxiety, and posttraumatic stress disease (PTSD) was evaluated by means of screening tests. Sociodemographic data, variables about Covid-19, loneliness, spiritual well-being, social support, discrimination, and a sense of belonging were collected.
Results: The data showed how depressive symptomatology increased significantly over time, while anxiety and PTSD did not show statistically significant changes. Spiritual well-being and loneliness were the main predictors of psychological impact. A younger age was a significant predictor of depression and anxiety, while female gender was associated with anxiety and PTSD.
Conclusions: The impact of the pandemic is sustained over time, even increasing in depression, and vulnerable groups that need greater psychological health support could be identified.

Full text

BRIEF RESEARCH REPORT
published: 09 November 2020
doi: 10.3389/fpsyt.2020.565474
Frontiers in Psychiatry | www.frontiersin.org 1November 2020 | Volume 11 | Article 565474
Edited by:
Gian Mauro Manzoni,
University of eCampus, Italy
Reviewed by:
Maria Angeles Gomez Martínez,
Pontifical University of
Salamanca, Spain
María Márquez-González,
Autonomous University of
Madrid, Spain
*Correspondence:
Clara González-Sanguino
Clagon06@ucm.es
Specialty section:
This article was submitted to
Public Mental Health,
a section of the journal
Frontiers in Psychiatry
Received: 25 May 2020
Accepted: 20 October 2020
Published: 09 November 2020
Citation:
González-Sanguino C, Ausín B,
Castellanos MÁ, Saiz J, López-Gómez
A, Ugidos C and Muñoz M (2020)
Mental Health Consequences of the
Coronavirus 2020 Pandemic
(COVID-19) in Spain. A Longitudinal
Study. Front. Psychiatry 11:565474.
doi: 10.3389/fpsyt.2020.565474
Mental Health Consequences of the
Coronavirus 2020 Pandemic
(COVID-19) in Spain. A Longitudinal
Study
Clara González-Sanguino1*, Berta Ausín1, Miguel Ángel Castellanos 2, Jesús Saiz 3,
Aída López-Gómez4, Carolina Ugidos4and Manuel Muñoz5
1Personality, Evaluation and Clinical Psychology Department, School of Psychology, Complutense University of Madrid,
Madrid, Spain, 2Psychobiology and Methodology in Behavioral Sciences Department, School of Psychology, Complutense
University of Madrid, Madrid, Spain, 3Department of Social, Labor and Differential Psychology, School of Psychology,
Complutense University of Madrid, Madrid, Spain, 4School of Psychology, Chair Against Stigma Grupo 5-Complutense
University of Madrid, Complutense University of Madrid, Madrid, Spain, 5Personality, Evaluation and Clinical Psychology
Department, School of Psychology, Chair Against Stigma Grupo 5-Complutense University of Madrid Director, Complutense
University of Madrid, Madrid, Spain
Background: Covid-19 remains a pandemic that most countries in the world are still
dealing with. This is study aims to report the psychological impact of Covid-19 over time
on the Spanish population.
Methods: A longitudinal study (N=1041) was carried out with two measurements:
after 2 and 5 weeks starting from the declaration of the state of emergency in Spain. The
presence of depressive symptoms, anxiety, and posttraumatic stress disease (PTSD)
was evaluated by means of screening tests. Sociodemographic data, variables about
Covid-19, loneliness, spiritual well-being, social support, discrimination, and a sense of
belonging were collected.
Results: The data showed how depressive symptomatology increased significantly over
time, while anxiety and PTSD did not show statistically significant changes. Spiritual
well-being and loneliness were the main predictors of psychological impact. A younger
age was a significant predictor of depression and anxiety, while female gender was
associated with anxiety and PTSD.
Conclusions: The impact of the pandemic is sustained over time, even increasing in
depression, and vulnerable groups that need greater psychological health support could
be identified.
Keywords: COVID-19, anxiety, depression, quarantine, postraumatic stress disorder
INTRODUCTION
Covid-19 has spread throughout the world and most countries have implemented severe health and
social measures to deal with it. The pandemic, which began in China, has had a special incidence
in Europe and North America, with Spain being one of the most affected countries. On 14 March,
a state of emergency was declared with drastic stay-at-home measures. Since then, the population
has had to remain in their homes and have only been able to go out in certain cases. From 30

González-Sanguino et al. Mental Health Consequences Covid-19 Spain
March to 12 April, all non-essential work activity was suspended,
which aggravated the already serious economic crisis. By 27
April 2020, a total of 210,773 confirmed cases of COVID-19
had been detected by Polymerase Chain Reaction (PCR) tests.
The pandemic had caused 23,822 deaths and 102,548 people had
recovered (1). At this point, Spain was the European country
with the most infections, only behind the United States, and close
behind Italy in terms of the total number of deaths.
The psychological consequences of this crisis are multiple.
Studies are now being published, especially from China, and
indicate the presence of anxiety, depression, post-traumatic
stress disorders, or insomnia in a significant percentage of the
population (2–6). In a previous study by this research team, we
showed the short-term psychological impact of the pandemic on
the Spanish population (7), revealing the presence of depression,
anxiety, and post-traumatic stress. Although we are beginning to
understand the most immediate effects of the pandemic on our
psychological health, little is known about how this psychological
impact evolves over time, with only one longitudinal study
examining this to date. Wang et al. (8) studied the evolution
of the psychological impact in the Chinese population 4 weeks
after the start of the pandemic in 333 people, observing that the
initial levels of stress, anxiety, and depression continued. This
type of research, although requiring a great deal of effort, is
very valuable, as it provides data that can explain the evolution
of the impact on our mental health and the main predictive
and protective variables involved, which will then enable more
effective measures to be taken to combat the psychological effects
of the pandemic.
The present study aims to longitudinally study the effects
that the Covid-19 emergency and the stay-at-home measures
have had on the psychological health of the Spanish population,
together with the identification of the main predictors and
protectors, from mid-March to the end of April 2020.
METHODS
Procedure
The longitudinal study took place between 21 March and 27
April and used two measurements, one from 21 to 28 March
and the other from 13 to 27 April. The evaluation was carried
out using an online survey. This option was considered the
most appropriate since it was impossible to conduct personal
interviews, it reduced the cost per participant, and because this
type of evaluation has shown good performance when assessing
certain variables (9).
At the end of the first survey (80 items, 7-min duration
approximately) an independent section was included
informing the respondents that they could participate
in a second evaluation, if they were willing. Those who
agreed completed the second evaluation. In both cases,
the signature of the informed consent and acceptance of
the data protection laws were included. The study also
received the approval of the Deontological Commission of
the Faculty of Psychology of the Complutense University of
Madrid (pr_2019_20_029).
Participants
In the first evaluation, participants were recruited through
snowball sampling (N=3480) using social networks and the
website www.contraelestigma.com to send the survey. For the
second evaluation, those people who had agreed to participate
in the study (N=1,041) were directly contacted by email on a
longitudinal basis.
The inclusion criteria were: (1) to be over 18 years old; (2) to
be living in Spain during the Covid-19 health emergency; (3) to
have agreed to participate in the second evaluation of the study.
Instruments and Variables
The variables and instruments included in the assessment were
the following:
Sociodemographic variables and variables related to Covid-19
were collected through questions developed ad hoc.
Psychological Impact
The possible symptomatology was measured using the following
screening instruments: Patient Health Questionnaire-2 (PHQ-2)
(10,11). Generalized Anxiety Disorder Scale-2 (GAD-2) (12,13).
Civilian version of the Post-traumatic Stress Disorder Checklist-
Reduced version (PCL-C-2) (14,15). The PHQ-2 and the GAD-
2 are brief self-report screening questionnaires that address the
frequency of depressive symptoms and anxiety. They consist of
two Likert-type questions ranging from 0 to 3. The PCL-C-2
was used to detect the presence of certain phenomena related to
traumatic experience. The Likert-answers range from 0 to 4.
Discrimination
Day-to-Day Discrimination Index (InDI-D) (16). We used the
main scale formed by nine Likert-type items with four response
options (1–4) referring to the intersectional discrimination that
can be produced by different conditions: gender, ethnicity,
mental health diagnosis, and in this case, the presence
of Covid-19.
Loneliness
Three-item version of the UCLA Loneliness Scale (UCLA-3) (17),
Spanish version (18). Three items in Likert-type format with
three response options.
Social Support
Multidimensional Scale of Perceived Social Support (EMAS)
(19), adapted to Spanish (20). The scale has 12 Likert-type items
with a scale of seven possible responses (1–7).
Spiritual Well-Being
Spiritual well-being understood as a personal search for meaning
and purpose in life, in connection with a transcendent dimension
of existence, and the experiences and feelings associated with that
search and that connection (21). It was evaluated through the
Spanish version of the Functional Assessment of Chronic Illness
Therapy Spiritual Well-Being (FACIT-Sp12) (22). The answers
were Likert-type from 0 to 4.
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González-Sanguino et al. Mental Health Consequences Covid-19 Spain
Self-Compassion
Self-Compassion measured by the Self-Compassion Scale (SCS)
(23) Spanish version (13) evaluating how the subject usually acts
toward himself in difficult moments in different dimensions. The
items are Likert type (1–5).
Sense of Belonging
Sense of belonging was evaluated by means of four Likert-type
items (1–4) previously used in other studies (24). These questions
evaluated being a member of different groups.
Analysis
The graphical representation of change for the psychological
impact variables (PHQ-2, GAD-2, and PCL-C-2) was made using
the standardized differences between the two measurements (T0
and T1). In addition, descriptive statistics, and coefficients for
Time (and its p-value) from a linear mixed model are included
in the results table.
To analyze the longitudinal data, linear mixed models (LMM)
with random slopes (time nested to subjects) were calculated
for each mental health variable. The estimation method was
maximum likelihood (ML) and models were built with a step-up
and theory driven approach, testing the significant change
associated with fixed effects terms. As a goodness of fit index,
Nakawaga’s marginal pseudo-R2 statistic, which reports the
percentage of variance explained by fixed effects, is provided.
The analyses have been performed in R (v3.5.6) with the
lme4 package.
RESULTS
Characteristics of the Sample
The sample was composed of a majority of women (81%),
and the 40–59 year old age group predominated (64%). About
half of the sample had a partner and shared the same home
with them (56%), had children in their care (55.71%) and a
higher proportion had university or postgraduate studies (72%).
Sixty-six percent of the persons had a job at the time of
the interview, and considered that their economic situation
was good-very good (66%). Fifteen percent of the sample had
shown Covid-19 symptoms, while only 1% had been diagnosed,
although 29% had a person or close relative with a positive
diagnosis. Overall, about half of the people felt they were well-
informed about the pandemic (54%), although 29% felt they had
too much information.
Longitudinal Changes in Psychological
Impact
The results in the second assessment showed a significant
increase in depression scores (B=0.31, p<0.01), while anxiety
and PTSD scores showed no statistically significant change,
only decreasing slightly (B= −0.014, p=0.752; B= −0.072,
p=0.193). These results can be seen in Figure 1.
Linear Mixed Models for the Psychological
Impact
The regression models for the different variables showed that,
for depression, the model explained 42% of the variance of the
fixed effects, with the variables of spiritual well-being, loneliness,
and a younger age as the main predictors. For anxiety, the
model explains 30% of the fixed-effect variance, with spiritual
well-being, loneliness, younger age, and female gender as the
main predictors. For PTSD, the model explains 11% of the
variance of the fixed effects, with spiritual well-being, loneliness,
the obligation to work face-to-face, and female gender as the
main predictors. This results can be seen in Table 1.
DISCUSSION
The results of the present study reflect the psychological impact
of Covid-19 over time on the Spanish population. After 44 days
of confinement, there was a significant increase in depressive
symptoms, with no statistically significant changes in anxiety
and PTSD symptoms, which even decreased slightly compared
to the first evaluation (7). In China, another longitudinal study
(8), showed that depression, stress, and anxiety did not present
statistically significant changes, the results being consistent with
our study except for depression. On the other hand, another
longitudinal study carried out in Spain (25) revealed that anxiety,
depression, and stress increased after 1 month. These results
show discrepancies in terms of the evolution of anxiety, although
it should be noted that the second evaluation of this study was
made in early April, while that of the present study was made at
the end, so that the greater time elapsed and the changes in the
country’s situation may explain these results.
Having the same or lower values for anxiety over time may
be explained by the fact that the initial origin of the anxiety
was based on the novelty of the situation with the consequent
uncertainty and fear of contagion, a common response to a
stressful situation (26). However, with the implementation of
isolation measures and verification of their effectiveness, this
anxiety does not intensify. Some authors have shown how the
anxiety associated with Covid-19 decreases as social isolation
measures such as staying home and not traveling are increased
(27), which is consistent with our results. On the other hand,
the increase in depression can be explained by several factors.
Increased confinement time may have increased apathy and
feelings of sadness, which may also be exacerbated by continued
isolation and loss of social relationships and rewarding activities.
In addition, it should be noted that during this second evaluation,
changes at work occurred in a large part of the population.
All non-essential activities were restricted, thus aggravating the
economic crisis. This could also have had negative consequences
on our psychological health. Some studies point to links between
suicide and the economic recession of their countries, which
played a more important role than fear of contagion (28,29).
The prediction models are comparable to those found in the
first evaluation of the longitudinal study (7). The main protective
variable for the appearance of symptoms was spiritual well-
being, while loneliness reappears as the main predictor. On the
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González-Sanguino et al. Mental Health Consequences Covid-19 Spain
FIGURE 1 | Mixed longitudinal models for depression (PHQ-2), anxiety (GAD-2), and PTSD (PCL-C-2) over time. The mixed longitudinal models presented significant
time effect for the variable Phq2 (B=0.31, p<0.01) but not for the variables Gad2 (B= −0.014, p=0.752) and PCL-C-2 (B= −0.072, p=0.193). The standard
deviations for the random slopes were 1.04, 1.18, and 1.49, respectively.
TABLE 1 | Linear mixed models for depression (PHQ-2), anxiety (GAD-2), and PTSD (PCL-C-2).
T0 T1 PHQ2 GAD2 PCL-C-2
Time 0.284*** −0.053 −0.084
Psychological wellness M(Sd) 15.61 (3.26) 15.54 (3.33) −0.185*** −0.188*** −0.129***
Loneliness M(Sd) 4.43 (1.58) 4.52 (1.65) 0.221*** 0.166*** 0.155***
Age M(Sd) 39.39 (13.02) −0.016*** −0.014***
Gender: male N(%) 200 (19%) – –
Gender: female N(%) 841 (81%) 0.444*** 0.673***
Not aplicable N(%) 413 (40%) 427 (41%) –
Face-to-face work N(%) 156 (15%) 147 (14%) 0.740***
Remote working N(%) 474 (45%) 469 (45%) 0.061
Time:id 1.08 1.31 1.75
Residual 0.38 0.25 0.21
Pseudo-R2 0.42 0.30 0.11
other hand, when taking into account all of the confinement
time, it seems that age as a predictor variable becomes more
important, as pointed out by other studies (8,30). Young students
may have initially suffered more depressive symptoms, as their
lives were more affected when their daily routines were abruptly
interrupted. Moreover, the initial confusion and uncertainty
about the situation meant that the information received was more
important in generating or reducing anxiety (5,31). However,
with the passage of time and normalization of the situation, it
appears that a stronger predictor for depression and anxiety is
a younger age. In addition, the female gender is a predictor
of anxiety and PTSD, and this group may also be identified as
more vulnerable, perhaps due to the greater burden that may
arise from combining work or telework with childcare and other
gender roles during the pandemic (32). The role of gender has
been further studied in detail in this same sample, concluding
that women have shown a greater psychological impact during
confinement and highlighting the need of special attention for
this group (33). On the other hand, in relation to post-traumatic
symptomatology, the variables of working on site vs. teleworking
or not working arise as a predictor in this model. The people who
have had to work on site at their place of work during the state of
emergency are those who have been on the front line of the fight
against the virus, and have probably had to live through situations
that can be categorized as stressful (34).
The limitations of the study include the selection of the
sample using the snowball effect, which may result in an
unrepresentative sample, with a higher proportion of women
and younger people. Furthermore, although this is a longitudinal
study, there is no control group, so the results should
always be taken with caution, as other authors have pointed
out (35).
The present study shows the psychological impact of Covid-19
over time on the Spanish population. The results show how,
after more than 6 weeks living under an emergency situation,
there has been an increase in depressive symptomatology, with
anxiety and PTSD scores remaining the same. Spiritual well-
being and loneliness are confirmed as the main predictors of
psychological health. A younger age is associated with greater
depression and anxiety, and the female gender with greater
anxiety and PTSD. The results underline the importance of
paying special attention to the most vulnerable groups, as well as
promoting interventions to reduce loneliness and foster spiritual
well-being.
DATA AVAILABILITY STATEMENT
The raw data supporting the conclusions of this article will be
made available by the authors, without undue reservation.
Frontiers in Psychiatry | www.frontiersin.org 4November 2020 | Volume 11 | Article 565474

González-Sanguino et al. Mental Health Consequences Covid-19 Spain
ETHICS STATEMENT
The studies involving human participants were reviewed
and approved by Deontological Commission of the Faculty
of Psychology of the Complutense University of Madrid
(pr_2019_20_029). The patients/participants provided their
written informed consent to participate in this study.
AUTHOR CONTRIBUTIONS
CG-S wrote the manuscript and participated in the design and
development of the study. BA and JS reviewed the manuscript
and participated in the design and development of the study.
MC performed the data analysis and participated in the design
and development of the study. AL-G and CU participated in the
design and development of the study. MM participated in the
development of the study and coordination of the group through
his work as director. All authors contributed to the article and
approved the submitted version.
ACKNOWLEDGMENTS
Our acknowledgment to the Anti-Stigma Chair Group 5—
University Complutense of Madrid that supported us in the
collection of the sample.
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
Copyright © 2020 González-Sanguino, Ausín, Castellanos, Saiz, López-Gómez,
Ugidos and Muñoz. This is an open-access article distributed under the terms
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Frontiers in Psychiatry | www.frontiersin.org 6November 2020 | Volume 11 | Article 565474