Introduction

COVID-19, which had led to a national pandemic and rapid global transmission to many countries worldwide [1], and stringent public health measures have been implemented to curtail the spread of COVID-19. In China, the government had taken effective measures to prevent further dispersal, including lockdowns, closing entertainment venues, extending the Chinese New Year holidays, forcing people to wear masks in public, and limiting the number and frequency of outings per household [2]. The lockdown was an emergency measure, meaning that people should stay where they are and not allow anyone to enter or leave, which greatly reduces social activity. These measures had been proved to be a huge success in the fight against COVID-19 [3], but have also created economic and psychological burdens [4].

The outbreak itself and the measures taken to combat the epidemic could lead to widespread fear and panic, which might escalate into further negative psychological reactions, including psychological distress, depression, anxiety, and post-traumatic stress symptoms, as well as sleep disturbance, palpitations and suicidality [5–8]. With the closure of schools and businesses, the negative emotions experienced by individuals become more complicated [9]. One recent study pointed to an increase in psychological problems during this epidemic, including anxiety, depression, and stress [10]. A study of 3480 participants from Spain during an outbreak found that 21.6% had anxiety and 18.7% had depression [11]. Studies had shown that young people, women, low socioeconomic status, mental illness, and chronic health problems are risk factors for depression [12]. The COVID-19 pandemic led a serious impact on people ’s economic levels, which was also an important reason for the rise in depressive symptoms among adults [13]. At the same time, as most residents were restricted to their homes, they tended to face too much negative news at home every day, and those with higher education and those who pay more attention to the epidemic news show higher levels of anxiety and depression [14]. Furthermore, the pandemic also affected specific populations. A recent systematic review found that compared with the general population, the COVID-19 patients showed high levels of post-traumatic stress symptoms and higher depressive symptoms [15]. And two studies noted an increase in psychological problems during the epidemic and emphasized that we should pay attention to the mental health of specific groups, such as children, older adults, patients, and medical staffs [16–18].

The COVID-19 pandemic has also changed people’s lifestyles, which may affect mental health. A study in Italy suggested that during the COVID-19 lockdown, 48.6% of people felt weight gain, whereas a slight increased physical activity has been reported in 38.3% of respondents, and 15% of respondents turned to farmers or organic purchasing groups for fruit and vegetables [19]. Regular exercise may reduce depression and anxiety [20]. Evidence from a review showed that diet, physical activity, sleep, and mental stress levels have been altered during the pandemic. The decline of sleep quality also affects mental health [21]. Changes in dietary habits than usual and weight gain were observed. It also found that the prevalence of any kind of mental stress, especially anxiety, is the highest [22].

One of the results from the Indian epidemic period showed that with the increase in isolation time, the psychological status of the population gradually decreased, which may be due to the relatively few mental health interventions made by the government [23]. Therefore, the psychological status of people should be concerned in many aspects, as it is closely related to a healthy body and healthy life of population. However, there was no data available to assess the impact of the COVID-19 pandemic on the mental health of the general population in China one month after the Wuhan lockdown. Therefore, we conducted a survey to investigate the residents’ changes in life and psychological conditions. This might assist government agencies and healthcare professionals in safeguarding the psychological well-being of the community in the face of the COVID-19 outbreak expansion in China and different parts of the world.

Materials and methods

Results

Table 1 described the sociodemographic distribution of the study participants. During the study period, a total of 3803 residents participated in the study (34.4% male and 63.6% female), 432 (11.44%) people were in quarantine, and 718 (18.9%) said that people they knew were diagnosed with COVID-19.

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Table 1. Factors affecting anxiety, depression, and stress in the survey (n = 3803; X±S; n/%).

https://doi.org/10.1371/journal.pone.0274696.t001

Multivariable analyses were then performed to identify these variables with a significantly independent impact on the changes in psychological status (Table 2). The scores of anxiety, depression, and stress were dependent variables, and the independent variables of the models were age (≥50 as reference), gender (male as reference), place of living (urban as reference), city of residence (other areas in China as reference), education (middle school or below as reference), marital status (single as reference), occupation (medical staff as reference), monthly income (<2,000 yuan as reference), number of cohabitants (0 as reference), quarantine or not (yes as reference), confirmed infection in the personal network (yes as reference), level of attention (increased as reference), self-assessed infection risk (increased as reference), mental health help-seeking (not found yet as reference) and satisfaction with community work (dissatisfied as reference). The anxiety (B = -1.27, 95% CI = -1.71 to -0.82), depression (B = -1.47, 95% CI = -2.06 to -0.88), and stress (B = -0.79, 95% CI = -1.13 to -0.46) scores of people in rural areas were lower than those of people in urban areas. In addition, compared with people living in Hubei Province, people in other parts of China have lower anxiety and stress scores. In terms of education, the mental health status of people with higher education is better than people with middle school education and below. Married persons had lower anxiety, depression, and stress scores than single persons did; that is, their mental health was relatively better. People with monthly incomes above 10,000 yuan have higher anxiety, depression, and stress scores than those with monthly incomes below 2,000 yuan. Taking people who had sought mental health help but not yet as a reference, people who had tried to adjust their mental state in some way and those who thought they did not need to adjust their mental state had lower scores of anxiety, depression, and stress. In addition, people who had received psychological help had lower anxiety and stress scores. Gender, age, occupation, confirmed infection in personal networks and satisfaction with community work did not appear to be significant correlates of anxiety, depression, or stress scores.

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Table 2. Multivariate regression model for factors associated with anxiety, depression, and stress.

https://doi.org/10.1371/journal.pone.0274696.t002

Discussion

Since the COVID-19 outbreak sparked a global public health crisis by spreading across China and other countries, various mandatory precautions have been taken by governments and individuals [27]. Studying residents’ psychological conditions at this time point could benefit government agencies and healthcare professionals to protect the mental health of the community as their measures will be conducted in a more humanized way.

In multivariable analyses, we found that urban residents were more likely to gain anxiety, depression and stress than rural counterparts. In densely populated urban areas, well-planned efficient public transportation systems can facilitate residents’ travel [28]. The disruption of daily life and the absence of entertainment or recreation made it impossible to release the excess inner pressure of urban residents. A more important reason is that due to the high density of the urban population and the greater mobility of people than rural areas, the risk of disease infection is greater. High population density increases people’s exposure to infectious diseases [29], which may lead to increased negative emotions among urban residents. Besides, people who were married reported greater mental health status, indicating that family support is of great importance [30], especially in coping with the stress caused by the COVID-19 pandemic. Some studies documented that low-income groups are more likely to suffer from depression and anxiety [31]. In Hubei Province, Li et al. have found that workers with income losses during the COVID-19 have a high risk of developing unfavorable mental health symptoms [32]. However, our study showed that the epidemic had a greater impact on high-income groups; people with monthly incomes above 10,000 have higher anxiety, depression, and stress scores than those with monthly incomes below 2,000, and their concerns about delays in working hours and subsequent deprivation of expected income may explain the high level of stress [33].

Another noteworthy finding of this study is that the subjective indicators of changes in daily life played an important role in the scores of people’s anxiety, depression and stress. Our study found that the greater the level of attention to COVID-19, the greater the negative emotions, which is in agreement with previous research [34]. And a lack of editorial control in social media can also bring incorrect information, fake news, misconception, and rumor, which are possibly intensifying psychological fear and rumination about contracting disease with an effect on behavior and social interactions [35]. Therefore, the content of health information provided during the epidemic needs to be based on evidence to avoid adverse psychological reactions.

Our findings also revealed that the level of self-assessed infection risk also influenced participants’ mental state. Anxiety, depression and stress outcomes were elevated with the increase in self-assessed infection risk. This may have resulted from actual conditions; respondents received signals from the surrounding environment and are supposed to make corresponding assessments of their risk of infection. The respondents who felt severely affected by the lockdown exhibited more obvious anxiety, depression, and stress than the rest of them, which indicates that guaranteeing day-to-day lives for residents will be beneficial for mental health [36].

In addition, people who had tried to adjust their mental state in some way and those who thought they did not need to adjust their mental state had lower scores of anxiety, depression, and stress. This is consistent with the previous result: the use of positive coping strategies was found to be associated with lower depressive symptoms and with less distress during the COVID-19 pandemic [37, 38]. During the COVID-19 epidemic, online mental health services have become the mainstream mental health services, including online cognitive behavioral therapy for depression, anxiety, and insomnia (e.g., on WeChat) [39]. Studies have shown that active coping and social support could be beneficial for dealing with a decrease in mental health due to the COVID-19 pandemic [40]. Therefore, for people with psychological problems, it is also a good choice to seek help from professionals on the Internet.

Not only does this study supplement knowledge of the psychological status of residents during the lockdown period, but it also helps to clarify the groups of people who are more likely to experience negative emotions when the disease is epidemic, which is especially helpful for China and other countries. Even so, it has some limitations. It is limited by its sample size, which is insufficient. And a cause-effect relationship cannot be established due to the inherent nature of cross-sectional design. Besides, in the data collection process, sources of bias include the potential selection bias of respondents. Because respondents were asked if they were willing to participate in the survey, resulting in volunteer bias and may not represent the general population. Some unknown and omitted confounding factors may exist in this study, instrumental variable analysis was used to control these confounding factors.

Conclusions

The life and psychological state of the urban population had produced negative changes after the Wuhan shutdown on January 23. City of residence, education, marital status, monthly income, level of attention, self-assessed infection risk, the impact of daily life and mental health help-seeking are important correlates of the scores of anxiety, depression, and stress. At present, China has achieved great success in the fight against epidemics, but the epidemic situation in some parts of the world has not improved. Most residents are still in a state of quarantine at home. Awareness of these relevant factors could help the government and related personnel prevent more severe psychological trauma in the later period.

Supporting information

Acknowledgments

We thank the staff at School of Health Sciences, Wuhan University and School of Public Health for their input and collaboration on this investigation.