Psychology, Health & Medicine

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Study on the public psychological states and its

related factors during the outbreak of coronavirus
disease 2019 (COVID-19) in some regions of China

Yenan Wang , Yu Di , Junjie Ye & Wenbin Wei

To cite this article: Yenan Wang , Yu Di , Junjie Ye & Wenbin Wei (2021) Study on the public
psychological states and its related factors during the outbreak of coronavirus disease 2019
(COVID-19) in some regions of China, Psychology, Health & Medicine, 26:1, 13-22, DOI:
10.1080/13548506.2020.1746817

To link to this article: https://doi.org/10.1080/13548506.2020.1746817

Published online: 30 Mar 2020.

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PSYCHOLOGY, HEALTH & MEDICINE
2021, VOL. 26, NO. 1, 13–22
https://doi.org/10.1080/13548506.2020.1746817

Study on the public psychological states and its related

factors during the outbreak of coronavirus disease 2019
(COVID-19) in some regions of China
a b b c
Yenan Wang , Yu Di , Junjie Ye and Wenbin Wei
a
Department of Ophthalmology, Xuanwu Hospital, Capital Medical University, Beijing, China;
b
Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical
College, Chinese Academy of Medical Sciences, Beijing, China; cTongren Eye Center, Beijing Key
Laboratory of Intraocular Tumor Diagnosis and Treatment, Beijing Ophthalmology& Visual Sciences
Key Lab, Medical Artificial Intelligence Research and Verification Key Laboratory of the Ministry of
Industry and Information Technology, Beijing Tongren Hospital, Capital Medical University, Beijing,
China

ABSTRACT ARTICLE HISTORY

Background: As COVID-19 occurs suddenly and is highly conta- Received 18 March 2020
gious, this will inevitably cause people anxiety, depression, etc. The Accepted 20 March 2020
study on the public psychological states and its related factors KEYWORDS
during the COVID-19 outbreak is of practical significance. COVID-19; public
Methods: 600 valid questionnaires were received. The Self-Rating psychological states; anxiety;
Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS) were depression; related factors
used.
Results: Females’ anxiety risk was 3.01 times compared to males
(95% CI 1.39–6.52). Compared with people below 40 years old, the
anxiety risk of people above 40 years old was 0.40 times
(95% CI 0.16–0.99). SDS results indicated that the difference
between education level and occupation was statistically significant
(p = 0.024, 0.005). Compared to people with a master’s degree or
above, those with a bachelor’s degree group had a depression risk
of 0.39 times (95% CI 0.17–0.87). Compared with professionals,
industrial service workers and other staff had a depression risk of
0.31 times (95% CI 0.15–0.65) and 0.38 times (95% CI 0.15–0.93).
Conclusions: 600 questionnaire participants were psychologically
stable. Non-anxiety and non-depression rates were 93.67% and
82.83%, respectively. There were anxiety in 6.33% and depression
in 17.17%. Therefore, we should pay attention to the psychological
states of the public.

Introduction
The prevention and control of 2019 novel coronavirus pneumonia has entered a critical
stage. This viral infection from Wuhan city, Hubei province, has attracted wide attention
all over the country and even the world (Guan et al., 2020; Huang et al., 2020; Lu et al.,

CONTACT Wenbin Wei weiwenbintr@163.com Beijing Tongren Eye Center, Beijing Key Laboratory of Intraocular
Tumor Diagnosis and Treatment, Beijing Ophthalmology&Visual Sciences Key Lab, Medical Artificial Intelligence Research
and Verification Key Laboratory of the Ministry of Industry and Information Technology, Beijing Tongren Hospital, Capital
Medical University, Beijing 100730, China
© 2020 Informa UK Limited, trading as Taylor & Francis Group
14 Y. WANG ET AL.

2020; The Lancet, 2020). COVID-19 is a new respiratory infection outbreak that started
in China in December 2019. The pathogen is the seventh member of enveloped RNA
coronavirus (subgenus sarbecovirus, Orthocoronavirinae subfamily). The particles are
usually spherical and have certain pleomorphism. More than 85% of 2019-nCoV are
homologous with bat severe acute respiratory syndrome-like coronavirus (bat-SL-
CoVZC45) (Ren et al., 2020; Zhu et al., 2020). It is mainly transmitted through respira-
tory and close contact, which leads to the phenomenon of clustering infection in families
and hospitals. Because of the sudden nature of the outbreak and the infectious power of
the virus, it will inevitably cause people anxiety, depression and other stress reactions. It
is necessary to understand and investigate the public psychological states during this
tumultuous time. The results of the survey are of great practical significance to the
information provision, cognition, behavior guidance and psychological support of gov-
ernments at all levels. Understanding and investigating the public psychological states
during this tumultuous time is of practical significance. Social and family attention and
mental health support are essential.

Methods
Patients
A total of 605 psychological state questionnaires were distributed to the general popula-
tion through online questionnaires from February 6 to 9, 2020. 600 valid questionnaires
were received, and the response rate was 99.17%.600 valid answers, resulting a 100%
effective rate. Inclusion criteria include the following: (1) 18 years old and above and (2)
completed questionnaire. Exclusion criteria include the following: (1) 17 years old and
below and (2) questionnaire responses are not logical.

Procedures
In this study, the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale
(SDS), both developed by William W.K. Zung in 1971 and 1965, receptively, were used
(Zung, 1971, 1965). The Self-Rating Scale questionnaire was completed by the follow-
ing survey items according to the unified guidance methods. The contents include the
following: (1) General information includes name, gender, age, education level, occu-
pation and residence; (2) SAS is used to evaluate the subjective feelings of anxiety;
and (3) SDS is used to measure the degree of depression. The two independent self-
assessment scales mainly assess the frequency of symptoms of the respondents in the
past week, each with 20 items, using a 4-level score (1 for a little of the time, 2 for some
of the time, 3 for a good part of the time and 4 for most of the time). Five items (Nos. 5,
9, 13, 17 and 19) in the SAS scale are stated using positive words, reverse integration in
the order of 4 to 1, and the score is summed up as the total score. Standard
score = 1.25 × total score. Anxiety levels were graded as the following: standard
score below 50 = non-anxiety; 50–59 = mild anxiety; 60–69 = moderate anxiety; and
above 70 = severe anxiety. Ten items in the SDS scale (Nos.
2, 5, 6, 11, 12, 14, 16, 17, 18 and 20) are stated using positive words, reverse integration
in the order of 4 to 1, and the score is summed up as the total score. Standard
 PSYCHOLOGY, HEALTH & MEDICINE 15

score = 1.25 × total score. Depression levels were graded as the following: standard
score below 53 = non-depression; 53–62 = mild depression; 63–72 = moderate depres-
sion; and above 73 = severe depression.

Statistical methods
The data were organized and analyzed using SPSS 23.0 software. The surveyed popula-
tion was divided into anxiety group and non-anxiety group according to the SAS scoring
criteria. According to the SDS scoring standard, the surveyed population was divided
into depression group and non-depression group. Measurement data are expressed as
mean ± standard deviation ( x ± s). Counting data are expressed by the number of people
(%). The analysis of the relationship between gender, age, education level, occupation,
region and anxiety or depression initially used the chi-square test. The variables with
p < 0.1 were entered in the multiple logistic regression analysis model. The correlation
between SAS and SDS standard scores was analyzed by Spearman correlation analysis,
and p < 0.05 on double sides was statistically significant.

Results
General characteristics of the study population
There were 267 males (44.5%) and 333 females (55.5%) among the 600 questionnaires.
Age was 18–72 years old, average 34 ± 12 years old. Among them, 433 people (72.17%)
were aged 18–40 years old and 167 people (27.83%) were above 40 years old. Education
level was as follows: 38 people (6.3%) with a master’s degree or above, 165 people (27.5%)
with a bachelor’s degree, 236 people (39.33%) with a junior college degree and 161 people
(26.83%) with a high school or below. Occupation was as follows: professionals (Doctor/
Teacher/Lawyer/Student) 83 people (13.83%), employees in enterprises and institutions
207 people (34.5%), workers and service workers 240 people (40%) and others (retired/
freelance/jobless) 70 people (11.67%). According to geographical division, there were 254
people (42.33%) in the midwestern regions and 323 people (53.83%) in the eastern
regions.

Investigation results of anxiety and depression during the COVID-19 outbreak

The scores of 600 questionnaires were as follows: the SAS standard score was 36.92 ± 7.33
points; among them, 562 were non-anxious (93.67%), 34 were mildly anxious (5.67%), 4
were moderately anxious (0.67%) and none were severely anxious. The SDS standard
score was 40.50 ± 11.31 points; among them, 497 were non-depressed (82.83%), 86 were
mildly depressed (14.33%), 15 were moderately depressed (2.5%) and 2 were severely
depressed (0.33%) (Figure 1). Correlation analysis of SAS and SDS standard scores
showed a significant positive correlation r = 0.694 (p < 0.001).
SAS questionnaire results indicated the following: In terms of physiological responses,
7.33% of people felt weak and tired easily, 4.5% of people often had to urinate and 3.83%
of people suffered from head, neck and back pain. In terms of emotional responses, 11.7%
of people were more nervous and anxious than usual, 4.67% of people were afraid for no
16 Y. WANG ET AL.

610

590

570

550 Severe
Number

530 Moderate
Mild
510
Non
490

470

450
SAS SDS

Figure 1. The number of people in different degrees of anxiety and depression during the outbreak of
COVID-19.

reason and 4.17% of people were easily upset or panicked. In terms of behavioral
responses, only 2.17% of people thought they might go crazy. In the description of
positive statements, 71.83% of people had no problems falling asleep and slept well
through the night. And 70.17% of people found it easy to breathe. 66% of people felt
calm and at ease and 64.67% of people often had dry and warm hands and feet.
SDS questionnaire results indicated the following: In terms of physiological
responses, 12.17% of people had poor sleep, 6.67% of people feeling tired for no reason
and 6.5% of people were constipated. In terms of emotional response, 5.33% of people
were feeling unhappy and depressed. In terms of behavioral responses, 6.67% of people
were more likely to be angry and excited. In the description of positive statements,
83.83% of people were hopeful for the future, 82.67% of people's minds were as clear as
uaual, and 80% of people were interested in the things they were interested in. 75.83%
of people thought life had been interesting, 75.17% of people thought they were useful
and 72.5% of people thought it is not difficult to do things.

Analysis of related factors of anxiety and depression during the COVID-19

outbreak
This study was based on SAS scoring criteria: 562 people (93.67%) in the non-anxiety
group and 38 people (6.33%) in the anxiety group. Single-factor chi-square test results
showed the anxiety ratio was higher for females than for males (χ2 = 7.118, p = 0.011).
The anxiety ratio was higher in the 40 and below age group than above the above 40 age
group (χ2 = 2.930, p = 0.087). In the multiple logistic regression model, both gender and
age were correlated with anxiety, and the female anxiety risk was 3.01 times that of males
(95% CI 1.39–6.52). Compared with people 40 years old and below, the risk of anxiety in
people above 40 years old was 0.40 times (95% CI 0.16–0.99) (Table 1).
This study was based on SDS scoring criteria: 497 people (82.83%) in the non-
depression group and 103 people (17.17%) in the depression group. Single-factor chi-
 PSYCHOLOGY, HEALTH & MEDICINE 17

Table 1. Multiple logistic regression analysis of anxiety-related factors of the public during the COVID-
19 outbreak.
Multiple logistic
regression analysis
Non-anxiety group Anxiety group
Factors (n = 562) (n = 38) χ2 p Value OR (95% CI) p Value
Gender
Male 258 (96.6%) 9 (3.4%) 7.118 0.011 1.0 -
Female 304 (91.3%) 29 (8.7%) 3.01 (1.39–6.52) 0.005
Age
18–40 401 (92.6%) 32 (7.4%) 2.930 0.087 1.0 -
≥41 161 (96.4%) 6 (3.6%) 0.40 (0.16–0.99) 0.046
Education level
Master or above 34 (89.5%) 4 (10.5%) 3.046 0.386
Bachelor 157 (95.2%) 8 (4.8%)
College 223 (94.5%) 13 (5.5%)
High school or below 148 (91.9%) 13 (8.1%)
Occupation
Professionals 77 (92.8%) 6 (7.2%) 1.765 0.633
Employees in enterprises and 192 (92.8%) 15 (7.2%)
institutions
Workers and service workers 225 (93.8%) 15 (6.3%)
Other 68 (97.1%) 2 (2.9%)
Region
Midwestern region 239 (94.1%) 15 (5.9%) 0.136 0.738
Eastern region 323 (93.4%) 23 (6.6%)

square test results showed that the difference between education level and occupation was
statistically significant (p = 0.024, 0.005). In multiple logistic regression model, both
education level and occupation were correlated with depression. Compared to those with
a master’s degree or above, those with a bachelor’s degree had a depression risk of 0.39
times (95% CI 0.17–0.87). Compared with professionals, industrial service workers and
other staff had a depression risk of 0.31 times (95% CI 0.15–0.65) and 0.38 times (95% CI
0.15–0.93) (Table 2).

Discussion
The emergence of COVID-19 is similar to the outbreak of SARS, which was caused by
another strand of coronavirus in 2003. Although the clinical manifestations of the two
diseases are not the same, the causes of infection, epidemiological characteristics and the
method of rapid transmission are similar. Moreover, the transmission rate of COVID-19
is faster than that of SARS, but the mortality rate is lower than that of SARS. The median
incubation period for the virus is 3.0 days (range 0–24.0 days). People are generally
susceptible (Chen et al., 2020; China National Health Committee; Guan et al., 2020;
Huang et al., 2020). The transmission routes are mainly airborne (respiratory droplets) or
via contact with the virus through conjunctiva, nasal mucosa, mouth or fecal material (Li
et al., 2020). Therefore, close-contact settings, such as gatherings/people-intensive occa-
sions, can lead to cluster infection. Due to the sudden and highly infectious outbreak of
COVID-19, it will inevitably cause anxiety, depression and other stress reactions amongst
the population. With the new limitations on daily life and social activities for an
unknown period of time, the population will inevitably suffer from stress and anxiety
and eventually may lose confidence in life, ultimately taking a toll on the mental health of
18 Y. WANG ET AL.

Table 2. Multiple logistic regression analysis of depression-related factors of the public during the
COVID-19 outbreak.
Multiple logistic
regression analysis
Non-depression Depression
Factors group (n = 497) group (n = 103) χ2 p Value OR (95% CI) p Value
Gender
Male 226 (84.6%) 41 (15.4%) 1.109 0.327
Female 271 (81.4%) 62 (18.6%)
Age
18–40 359 (82.9%) 74 (17.1%) 0.006 0.936
≥41 138 (82.6%) 29 (17.4%)
Education level
Master or above 25 (65.8%) 13 (34.2%) 9.384 0.024 1.0 -
Bachelor 140 (84.8%) 25 (15.2%) 0.39 (0.17–0.87) 0.021
College 201 (85.2%) 35 (14.8%) 0.54 (0.24–1.21) 0.133
High school or below 131 (81.4%) 30 (18.6%) 0.95 (0.40–2.29) 0.916
Occupation
Professionals 62 (74.7%) 21 (25.3%) 12.926 0.005 1.0 -
Employees in enterprises 162 (78.3%) 45 (21.7%) 0.86 (0.47–1.59) 0.862
and institutions
Workers and service 212 (88.3%) 28 (11.7%) 0.31 (0.15–0.65) 0.002
workers
Other 61 (87.1%) 9 (12.9%) 0.38 (0.15–0.93) 0.035
Region
Midwestern regions 209 (82.3%) 45 (17.7%) 0.094 0.827
Eastern regions 288 (83.2%) 58 (16.8%)

society (Shang et al., 2017). The National Health Commission of the People's Republic of
China published guidelines on psychological crisis intervention and guidelines for
psychological adjustment during the outbreak of novel coronavirus pneumonia on
26 January 2020 (China National Health Committee). We should protect ourselves
against the virus and ensure mental health. The psychological condition of the public
during the epidemic is valued with great importance. It is crucial to provide appropriate
mental health care in time.

Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS)

The SAS self-assessment scale used in this study is mainly used to evaluate the subjective
feelings of anxiety. It has been used to screen the people who may be anxious in the
research and clinical settings (Hong X et al., 2009; Samakouri et al., 2012; Zung, 1971). In
the past 40 years, SAS has been translated into many languages and was widely used in
different cultures. Greek scholars Samakouri et al. (2012) evaluated the Greek version of
SAS. The results showed that it had high reliability and validity. It also confirmed the
feasibility of its cross-cultural use. The SDS used in this study has been widely used in
clinical practice. It can screen the recent depressive symptoms of adolescents and adults
and evaluate the severity of the symptoms (Zung, 1965).
The results of the 600 SAS and SDS questionnaires in this study showed that during
the outbreak of COVID-19, 562 people (93.67%) did not have any symptoms of anxiety
and 38 people (6.33%) felt anxiety. 497 people (82.83%) had no symptoms of depression
and 103 people (17.17%) were depressed. In addition, correlation analysis was conducted
 PSYCHOLOGY, HEALTH & MEDICINE 19

for SAS and SDS standard scores and showed a significant positive correlation r = 0.696
(p < 0.001). These results indicated that, in times of emergency, people with anxiety were
prone to depression and depressed people also tend to be anxious.

The mechanism of panic and the expression of stress

In a special period, this kind of panic of the public is called psychological stress in
psychology. Under the effect of the internal and external environment, due to the
imbalance between objective requirements and the subject’s ability, then create a state
of tension that adapts to the environment. We call the stimulants stressors (Craske &
Stein, 2016; Yang et al., 2015). In this outbreak, COVID-19 is the stressor of public panic.
Due to the uncertainty and lack of knowledge of COVID-19, its fast transmission speed
and infectious nature and its serious threat to life safety, COVID-19 is making the
population especially nervous and pushing them into a state of high stress. In the state
of stress, people’s physiology, psychology and behavior will produce corresponding
responses. Generally speaking, the physiological response of stress state is mainly man-
ifested in the changes of the autonomic nervous system and endocrine system. The
specific manifestations include heartbeat acceleration, blood pressure rise, blood sugar
increase, palpitations, appetite disorder, dyspepsia, sleep disorder, headache, body pain,
endocrine disorders, etc. The emotional response caused by stress is mainly a series of
accompanying emotional experiences putting people in a negative emotional state such
as depression, anxiety, panic, disappointment or fear. The main behavioral changes
caused by stress are restlessness, inattention, reduced ability to solve problems, slow
action, frequent anger, forced behavior (blind excessive disinfection and repeated hand-
washing), crying easily, smoking, alcohol abuse, etc. The results of the 600 SAS and SDS
questionnaires in this study showed that during this special period, the main stress state
of people showed physiological and emotional responses, while the behavioral response
was less. In terms of physiological responses, 12.17% of people had poor sleep, 7.33% of
people felt weak and fatigued and 6.5% of people felt constipation. In terms of emotional
response, 11.3% of people were more nervous and anxious than usual and 5.33% of
people were feeling unhappy and depressed. In terms of behavioral responses, 6.67% of
people were more likely to be angry and excited.
These psychosomatic and behavioral responses to stress are a psychological mechan-
ism for self-defense. It is a natural, normal and necessary response when people are facing
dangerous situations. From the perspective of physical and mental health, if the public
responds to COVID-19 properly, it can stimulate the internal drive of the human body to
fight against the challenge of the epidemic. On the contrary, if the reaction is inappropri-
ate or excessive, exceeding the bottom line that the body can tolerate, it will naturally
disrupt the balance of physical and psychological functions of the person and impair
physical and mental health and even cause serious physical and mental illness (Drury
et al., 2019; Lee et al., 2018). Our study found that age and gender are associated with
anxiety. People 40 years old or below had an increased risk of anxiety than those above
40 years old. This indicateed that with more experience, the psychological self-regulation
ability and psychological quality of the crowd will also increase. Females had a higher risk
of anxiety than males. In addition to their professional roles, women take on the social
role of the lead caregiver in the family. Moreover, women’s experience of affairs is more
20 Y. WANG ET AL.

delicate and sensitive than men. Therefore, women are more prone to anxiety. The
investigation results showed that education level and occupation were related to depres-
sion. People with a master’s degree or above had a higher risk of depression than those
with a bachelor’s degree. Professionals had a higher risk of depression than workers in
service industries and other occupations. Highly educated and professional people are
accustomed to busy work and frequent travel. During the outbreak, most people have
been forced to stay at home and have more time to delve into other aspects of life, such as
family health and safety, work status and family income, frequently leading individuals to
worry more. Therefore, their concerns cannot be ignored.

Provide standardized mental health care

The government provides timely and accurate information about the COVID-19 out-
break to the public, especially the curative ratio and mortality. The number of patients
cured can alleviate the public’s uncertainty and fear, and the death toll can remind them
of the importance of preventing infection. The society can strengthen the publicity of
epidemic prevention and control and educate the public by providing specific examples
of scientific methods of prevention, from proper handwashing to wearing masks and
proper precautions to implement when going out, etc. Additionally, by establishing
security services and using electronic devices and applications (examples: smartphones
and WeChat) to provide psychological counseling to the public, the government can help
ease the public psychological disturbance and psychological harm caused by the outbreak
and promote social stability. Anxiety and depression accounted for only 6.33% and
17.17% of people in this study. This is inseparable from the timely prevention and
control measures taken by the state and the determination of the people to work together
to combat the outbreak.

Establish a correct view of the disease

The COVID-19 outbreak has raised a lot of attention to the past and the present disasters.
Humans have faced crisis and disaster on multiple occasions throughout history. There is
no need to panic. Maintaining a daily routine is necessary for dealing with crisis. Some
people can relax and enjoy the time off, while some people can take the opportunity to
study and rest. The public should pay attention to the information that the state media
and the official propaganda presents and avoid absorbing misleading information that
inevitably can lead to panic and depression.
Anxiety and depression are common psychological phenomena in any disaster and
can be a barrier to rational medical and mental health interventions. The public psycho-
logical state needs to be concerned, and appropriate mental health support should be
provided.
The advantage of this study is that we investigated the psychological states of the
public during the outbreak in time. We performed a cross-sectional study to reflect
anxiety and depression in some people and analyzed the related factors. This study has
limitations. First, sampling studies were not possible during the outbreak. Second, this
study adopted the way of network questionnaire. These may bring some information
bias. It is possible the surveys did not reach underdeveloped areas due to limited
 PSYCHOLOGY, HEALTH & MEDICINE 21

technology availability and omitted people who are not comfortable using technology
and the Internet.

Disclosure Statement
No potential conflict of interest was reported by the authors.

ORCID
Yenan Wang http://orcid.org/0000-0003-0450-8680
Yu Di http://orcid.org/0000-0003-3304-1370
Junjie Ye http://orcid.org/0000-0003-3284-4243
Wenbin Wei http://orcid.org/0000-0003-2386-0989

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