This study investigated the difference between the impact of the COVID-19 pandemic on the UK and Germany. The impact was assessed using an online survey including questions on the impact on life circumstances, as well as two psychological questionnaires, the Symptom Check List (SCL-27) and the Schizotypal Personality Questionnaire (SPQ). We found that UK responders reported more infections and symptoms, a stronger financial hardship, and a stronger impact on health and the financial situation of family members. We found that responders of both countries reported an increase in psychological symptoms, especially depressive symptoms and anxieties. The global severity index (GSI) of the SCL was higher in UK responders compared to German responders. An alarming finding was that the percentage of people above clinical cut-off on the SCL-27 compared to a norm population had more than doubled for depressive, dysthymic and agoraphobic symptoms as well as for social phobias, and this increase was stronger in UK responders compared to German responders. We did not find differences in the SPQ or its subscales between the two countries. However, responders reported an increase of symptoms in about 9% with half of those reporting symptoms for the first time. Interestingly, despite the differences, UK responders were still more hopeful for a sooner end of the pandemic in their region, were less concerned about overall life stability and reported more positive changes due to the pandemic (e.g., time with the family, no commute, time for one-self).
In simple associative prediction models, we furthermore identified risk factors for the psychological impact of the pandemic. Being UK resident, female, younger, having a lower education, a worse pre-pandemic mental or physical health, as well as being more concerned about life stability, spending less time outside and reporting a stronger negative impact of the pandemic on the qualities of social contacts predicted higher scores of the GSI, as well as depressive, dysthymic symptoms as well as symptoms of anxiety. Higher scores on the SPQ total-score and its subdimensions were predicted by younger age, lower education, more substance (tobacco, vaping, marihuana) and media (social and video games), less sleep, less time spent outside, worse quality of social contacts, and a worse pre-pandemic mental and physical health.
To the best of our knowledge this is the first study showing a direct comparison of the psychological impact including schizotypy of the pandemic between two countries. There are several large scale studies reporting assessment of levels of depression, anxiety and stress related to COVID-19 comparing multiple countries and regions [15, 24]. This study identified prevalence and risk factors globally, but does not draw direct comparisons between different WHO-regions. Interestingly, however, Plomecka and colleagues (2020) report similar overall risk factors, such as being female, younger, less optimistic, and having worse social relationships and pre-pandemic.
A special focus needs to be drawn on developing and low- or middle-income countries, as those countries historically not only use a fraction of the global resources for mental health care and prevention [25], but also face a much harder impact of the economic consequences of the pandemic [26]; both of these aspects tremendously affect population mental health. In many low- and middle income countries, implementing restrictive measures in order to prevent the spread of the virus has a direct effect on the income of many day laborers, leaving them in direct fear of hunger for themselves and their families [27]. In high-income countries, increased mental health risks are, among other factors, linked to low socioeconomic status, low education, and over-crowed housing [28]. These aspects are highly prominent in low- and middle income countries which might further increase the risk for mental health problems. A recent review on the impact of the COVID-19 pandemic on mental health in low- and middle income countries across Asia and Africa [29] points out that most studies investigating this topic report increased levels of depression, post-traumatic stress disorder, adjustment disorders, addiction problems, sleep disorders, and anxiety disorders; the lack of thorough investigation of mental health in general and the poor quality of infrastructure for prevention and intervention remain pressing problems in low- and middle income countries.
Several studies investigate the psychological impact of the pandemic with a national focus. Two longitudinal studies conducted in UK populations [30, 31] show a general deterioration of mental health in April compared to before the pandemic. Both studies identify similar risk factors such as being female, younger of age and having pre-pandemic mental health conditions. The same is true for research conducted on German populations. A study by Bäuerle and colleagues [32] reports an increase in anxiety, depression and psychological distress with females and younger adults reported a stronger impact. Interestingly, Benke and colleagues [33] report similar effects but dissociate them from the governmental measures taken to control the pandemic. Another recent study [34] compared two countries, Poland and China, that differently enforced mask wearing during the initial stages of the pandemic and compared mental and physical health outcomes. For Poland, the country which less enforced mask wearing, the authors report higher levels of anxiety, depression and stress, as well as physical symptoms related to a COVID-19-infection.
Our study does not contain true pre-pandemic data. However, we assessed subjective measures of change questions on life circumstance and mental health question including the psychological questionnaires, asking participants to either report on that particular question 3 month ago or report whether symptoms had increased, decrease or stayed the same. In the UK population, we found a tripling of the percentage of people lying above cut-off compared to a norm population for depressive, dysthymic and agoraphobic symptoms, and a doubling on symptoms of social phobia and symptoms of mistrust. Similarly, Kwong and colleagues (2020) report a doubling of symptoms of anxiety in a UK sample. In the German responders, we found a doubling for depressive and dysthymic symptoms, for symptoms of social phobia and symptoms of mistrust. The increase in our study compared to Kwong et al. (2020) might be due to the fact that the SCL-27 aims at high sensitivity, but low specificity on the individual symptoms. However, the increase is alarming, and requires actions for interventions.
Overall, our results match those of countries in a global comparison [15], and individual countries such as China [13, 35], Bangladesh [36], Brazil [37], South-Africa [38], Lebanon [39], Greece [40], Iran [41], Japan [42], India [43, 44], Italy [45] or Spain [46, 47]. Here, we provide a unique comparison of two economically and culturally similar countries. However, the governments of both countries followed different strategies in responding to the pandemic, whereas the German government implemented a prompt lock-down [16], the British government first discussed herd-immunity [48], causing a significant delay to implement the lock-down, which according to different predictive models has significantly increased the number of death in the UK [16]. At the time when we started the data collection the rise in cases in Germany was slowing down, whereas the cases in the UK were still increasing quickly, which may have influenced the results. The convenience sample nature of the participants is a limitation as it could also contribute to the observed results. Although our study does include participants with pre-existing mental illness (overall: 14.22%; UK: 20.29%; Germany: 11.59%), it was not designed to specifically address mental health impact of the pandemic on those with severe and enduring mental illness, as this would require a more targeted study design. Although, the comparison of the two countries is still difficult, as both countries vary on a large number of factors not accounted for in this study that might have additionally contributed to the difference, it is likely that the burden of higher death rates and hospitalisations has increased the impact on mental well-being described in this study.
Interestingly, we find this dichotomy between a stronger financial and health impact of the pandemic on UK residents compared to German residents, and still a more optimistic judgment of the overall situation of the UK compared to the German residents. Further research would be needed to further investigate how pre-existing cultural attitudes contribute to these differences. We speculate there could be cultural differences in how likely people are to complain about their personal situation in a questionnaire, also there could be some linguistic difference in how these questions are understood by participants of the two countries. Another line of future enquiry could examine the role of such attitudes as the stereotypes of the British ‘Keep calm and carry on’ way of life [49] compared to the German stereotype of criticism and pessimism [50].
The ultimate question raised by our findings, and those of the many other studies investigating this important topic, is how to establish early interventions for mental health problems during a public health emergency? A number of reviews and opinion articles address this question in detail [4, 51,52,53,54]. The most important aspects proposed to date are psychoeducation and support for health care works, the detection of psychological problems or crises in the general population through online surveys and questionnaires, increased access to online consultations with health care professionals, as well as the development of intervention apps and online tools targeted for specific disorders such as anxiety disorder or depression.
Limitations
This study has potential limitations. First, we used a purely online data collection methods, therefore, people without or with limited access to computers, or less well-versed using these methods would be excluded from the sample. However, in order maximally ease the accessibility of the questionnaire we provided an online version with smart-phone compatible formatting. Second, we used a snowball sampling method, therefore, the sample is not fully representable of the general population. The results of the study should therefore be interpreted considering the sample’s demographics. Third, comparing two countries is problematic as the countries vary on a large number of factors that are not and cannot be accounted for in detail. Therefore, any differences between the countries presented in this study might be linked to baseline differences. However, by specifically asking for a subjective change considering a pre- verses during-pandemic time-point, we minimised this confound. Fourth, we used a self-reporting survey without clinical in-person verifications. Social distancing measures complicate such verification. However, by using a completely voluntary and anonymous format, as well as standardised questionnaires we are minimising potential effects. And fifth, we are presenting simple logistic prediction models without testing for confounds and interactions. Although this approach may not present conclusive results, it does allow for comparison with other studies following the same approach, and to generate hypothesis for future research rather than definitive inference.