Epidemiology and Psychiatric Increase in prevalence of current mental

Sciences
disorders in the context of COVID-19: analysis
cambridge.org/eps of repeated nationwide cross-sectional surveys
P. Winkler1,2, * , T. Formanek1, * , K. Mlada1,3, A. Kagstrom1, Z. Mohrova1,
Original Article P. Mohr1,4 and L. Csemy1
1
*Contributed equally. National Institute of Mental Health, Topolová 748, 250 67, Klecany, Czech Republic; 2Health Service and
Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London,
Cite this article: Winkler P, Formanek T, Mlada David Goldberg Centre, De Crespigny Park, London SE5 8AF, UK; 3Faculty of Medicine in Pilsen, Charles University,
K, Kagstrom A, Mohrova Z, Mohr P, Csemy L Husova 3, 301 00 Pilsen, Czech Republic and 4Third Faculty of Medicine, Charles University, Ruska 87, 100 00
(2020). Increase in prevalence of current Prague, Czech Republic
mental disorders in the context of COVID-19:
analysis of repeated nationwide cross-
sectional surveys. Epidemiology and Psychiatric Abstract
Sciences 29, e173, 1–8. https://doi.org/10.1017/
S2045796020000888
Aims. The United Nations warned of COVID-19-related mental health crisis; however, it is
unknown whether there is an increase in the prevalence of mental disorders as existing studies
Received: 22 June 2020 lack a reliable baseline analysis or they did not use a diagnostic measure. We aimed to analyse
Revised: 9 September 2020 trends in the prevalence of mental disorders prior to and during the COVID-19 pandemic.
Accepted: 24 September 2020
Methods. We analysed data from repeated cross-sectional surveys on a representative sample
Key words: of non-institutionalised Czech adults (18+ years) from both November 2017 (n = 3306;
Anxiety; depression; COVID-19; mental 54% females) and May 2020 (n = 3021; 52% females). We used Mini International
disorders; prevalence; SARS-CoV-2; suicide risk Neuropsychiatric Interview (MINI) as the main screening instrument. We calculated descrip-
tive statistics and compared the prevalence of current mood and anxiety disorders, suicide risk
Author for correspondence:
Petr Winkler, E-mail: petr.winkler@nudz.cz and alcohol-related disorders at baseline and right after the first peak of COVID-19 when
related lockdown was still in place in CZ. In addition, using logistic regression, we assessed
the association between COVID-19-related worries and the presence of mental disorders.
Results. The prevalence of those experiencing symptoms of at least one current mental dis-
order rose from a baseline of 20.02 (95% CI = 18.64; 21.39) in 2017 to 29.63 (95% CI =
27.9; 31.37) in 2020 during the COVID-19 pandemic. The prevalence of both major depres-
sive disorder (3.96, 95% CI = 3.28; 4.62 v. 11.77, 95% CI = 10.56; 12.99); and suicide risk (3.88,
95% CI = 3.21; 4.52 v. 11.88, 95% CI = 10.64; 13.07) tripled and current anxiety disorders
almost doubled (7.79, 95% CI = 6.87; 8.7 v. 12.84, 95% CI = 11.6; 14.05). The prevalence of
alcohol use disorders in 2020 was approximately the same as in 2017 (10.84, 95% CI = 9.78;
11.89 v. 9.88, 95% CI = 8.74; 10.98); however, there was a significant increase in weekly binge
drinking behaviours (4.07% v. 6.39%). Strong worries about both, health or economic conse-
quences of COVID-19, were associated with an increased odds of having a mental disorder
(1.63, 95% CI = 1.4; 1.89 and 1.42, 95% CI = 1.23; 1.63 respectively).
Conclusions. This study provides evidence matching concerns that COVID-19-related mental
health problems pose a major threat to populations, particularly considering the barriers in
service provision posed during lockdown. This finding emphasises an urgent need to scale
up mental health promotion and prevention globally.

Introduction
As COVID-19 became a global pandemic, countries responded with nationwide lockdowns in
attempt to slow and prevent further spread of the virus. With over half of the world population
on some form of lockdown in April 2020, mental health of populations became a growing
concern as individuals faced unprecedented levels of established mental health risk factors
including social isolation, stress and anticipated economic hardship (Monroe and Simons,
1991; Mazure, 1998; Hammen, 2004; Ahnquist and Wamala, 2011; Matthews et al., 2016;
© The Author(s), 2020. Published by Herbolsheimer et al., 2018; Economou et al., 2019; Brooks et al., 2020). These risk factors
Cambridge University Press. This is an Open not only disproportionately affect individuals with a history of mental health problems
Access article, distributed under the terms of
(Hao et al., 2020; Yao et al., 2020), high-risk groups such as health care workers
the Creative Commons Attribution licence
(http://creativecommons.org/licenses/by/4.0/), (Kang et al., 2020; Liu et al., 2020; Lu et al., 2020), COVID-19 patients and survivors
which permits unrestricted re-use, (Zhang et al., 2020a), individuals with pre-existing chronic diseases (Ohliger et al., 2020;
distribution, and reproduction in any medium, Wang et al., 2020b) or unemployed individuals (Zhang et al., 2020b), but also could trigger
provided the original work is properly cited. the onset of mental disorders in previously healthy populations. Alarming statements by pub-
lic health experts and the United Nations have expressed the concern that COVID-19 could
contribute towards a major global mental health crisis (Galea et al., 2020; UN, 2020).
Evidence on the prevalence of COVID-19-related mental health problems is emerging. A
nationwide online survey of participants from China recruited through convenience sampling
2 P. Winkler et al.

(n = 1210) reported that 16.5% of individuals exhibited severe emergency lasted from 12th March to the 17th of May, greatly
depressive symptoms, and 28.8% moderate to severe anxiety impacting businesses and workers. During this period, services
symptoms (Wang et al., 2020a). Another nationwide online considered as non-essential by the Government of the Czech
survey using convenient sampling in China estimated that the Republic were limited and citizens were under stay-at-home
prevalence of anxiety disorders, depressive symptoms and orders implemented on 16th March. Restrictions were gradually
reduced sleep quality was 35.1, 20.1 and 18.2%, respectively lifted, with businesses opening in waves according to their size
(Huang and Zhao, 2020). An online study (n = 4872) from and purpose (see the following reference for detailed introduction
Wuhan, China, found a 48.3 and 22.6% prevalence of depression and easing of restrictions as well as for a list of essential services:
and anxiety among the general adult population (Gao et al., Government of the Czech Republic, 2020). Since the psycho-
2020). The largest study conducted in China (n = 52 730) found diagnostic instrument used in this study assess whether the
35% of respondents experienced psychological distress as assessed examined symptoms occurred in the period of last 2 weeks or
by the COVID-19 Peritraumatic Distress Index (Qiu et al., 2020). more (see ‘Measurement’ for details), the obtained data reflect
Nationwide studies from Bangladesh (Al Banna et al., 2020) and the period of the peak of COVID-19-related national emergency
Taiwan (Wong et al., 2020) showed high prevalence of anxiety and the most severe associated restrictions within Czechia. This
and depressive symptoms as well. was the period immediately following the first peak of COVID-19
In Europe, several waves of the UK Household Longitudinal in CZ when stay-at-home orders were not in place anymore.
Study conducted between 2018/2019 and April 2020 (i.e. after
approximately 1 month of lockdown in the UK) were compared,
Data and participants
and it was demonstrated that the prevalence of clinically signifi-
cant levels of mental disorders, as measured by the 12-item Since face-to-face data collection was not feasible during the state
General Health Questionnaire, increased from 18.9 to 27.3% of emergency, we utilised a combination of computer-assisted
(Pierce et al., 2020). A nationwide study from Italy using telephone interviewing (CATI) and computer-assisted web inter-
convenience sampling (n = 500) reported that 19.4 and 18.6% viewing (CAWI). Individuals aged 18 years and older were eligible
of participants experienced mild and moderate-to-severe psycho- to participate. Participants were sampled via randomly emailing
logical distress respectively (Moccia et al., 2020). In Spain, respon- (CAWI) or telephoning (CATI) to individuals registered in the
dents (n = 3480) of an online survey reported high prevalence of online database of a data collection agency, while respecting the
depression (18.7%), anxiety (21.6%) and post-traumatic stress dis- distribution of the Czech non-institutionalised adult population.
order (15.8%) (González-Sanguino et al., 2020). High prevalence While we obtained data from 3021 respondents, 907 of them
of depression (23.6%) and anxiety (45.1%) were also found in were interviewed using CATI (response rate = 43%) and 2114
respondents (n = 343) of an online survey in Turkey (Özdin completed CAWI (response rate = 93%); each of these subsamples
and Özdin, 2020). The nationally representative online survey were representative for the Czech non-institutionalised adult
which reported a baseline comparison comes from Denmark population in terms of gender, age, education, size and region
(n = 2458), where the WHO-5 Well-being Index was utilised find- of residence. As the representativeness was established according
ing that the Danish population, and especially females, reported to the last census that was conducted in 2011, we asked the data-
lower emotional well-being during the pandemic than in 2016 collecting agency to adjust the sample to be in-line with the more
(Sønderskov et al., 2020). In addition, recently published data recent distribution of population as per the latest Demographic
from the United States demonstrated elevated levels of mental Yearbook of the Czech Republic (CZSO, 2019). Thus, post-
health problems among US adults; the presence of both, anxiety stratification weights were applied to the sample. All respondents
or depressive symptoms was about three times higher in June provided oral informed consent and, at the end of the interview,
2020 than in the second quarter of 2019, and substance use and they were informed about the emergency hotline providing
suicidal ideation was elevated as well (Czeisler et al., 2020). psychological aid to Czech residents during the COVID-19 pan-
While the evidence suggests that COVID-19 is affecting demic. This study was approved by the Ethics Committee of the
population health negatively, no existing study has measured National Institute of Mental Health, Czech Republic (registration
the prevalence of COVID-19-related mental illness on a nation- number 127/20).
ally representative sample using an established psycho-diagnostic For our baseline analysis, we used data from the 2017 Czech
instrument, and existing studies lack a reliable baseline analysis Mental Health Study (CZEMS), which is described in detail
against which it compares the prevalence of mental disorders elsewhere (Winkler et al., 2018a; Formánek et al., 2019). Briefly,
to. We aimed to conduct a study aligned with the published eligibility criteria were the same as in 2020 survey, but the data
mental health research priorities for the COVID-19 pandemic were collected using the PAPI method and two-staged sampling,
(Holmes et al., 2020), by assessing differences in the prevalence with a random sample of participants being selected from a
of current affective, anxiety and alcohol use disorders, and suicide random group of voting districts. The response rate was 75%
risk screened using an established psycho-diagnostic instrument and the final sample of 3306 respondents was representative of
among a representative sample of Czech adults in 2017 and 2020. the Czech general population in terms of age, gender, education
and region of residence. The description of the 2017 sample is
provided in online Supplementary Table 1.
Method
Setting Measurement
To assess the prevalence of current mental disorders in the Czech In both the 2017 and 2020 surveys, we assessed the presence of
adult non-institutionalised population during the COVID-19 mental disorders via the fifth version of the Mini International
pandemic, we utilised data collected between 6th and 20th May Neuropsychiatric Interview (M.I.N.I.), a psycho-diagnostic instru-
2020. In Czechia, the COVID-19-related nationwide state of ment which has demonstrated a high concordance with
Epidemiology and Psychiatric Sciences 3

clinician-assessed diagnosis of mental disorders (Sheehan et al., Table 1. Description of the 2017 and 2020 sample (unweighted)
1997, 1998). We focused on the prevalence of current (as opposed
2017 2020
to life-time) mental disorders; i.e. the presence of examined symp-
toms within the past 2 weeks for major depressive episode; the Gender, n (%)
past month for panic, posttraumatic stress disorder, social phobia
Males 1532 (46.34) 1440 (47.67)
and suicide risk (low, medium or high risk); the past 6 months for
generalised anxiety disorder (GAD); and the past 12 months for Females 1774 (53.66) 1581 (52.33)
alcohol use disorders. For agoraphobia, no specific periods are Age, mean (SD) 48.82 (17.19) 46.84 (16.02)
specified in the M.I.N.I.
Education, n (%)
Since the diagnosis of alcohol use disorders require social dis-
functioning (such as not going to work because of alcohol use), Elementary 278 (8.41) 180 (5.96)
the chance of which is limited due to restrictions imposed during Other than elementary 3028 (91.59) 2841 (94.04)
the lockdown, we measured also, usual consumption of alcohol
Marital status, n (%)
(expressed in number of glasses per drinking session and exam-
ined separately for beer, wine and spirits) and the frequency of Other than married/living with a 1314 (39.75) 1243 (41.15)
occurrence of binge drinking (at least five glasses of beer, wine partner
or spirits per drinking session) in the last 12 months. Married/living with a partner 1992 (60.25) 1778 (58.85)
In addition, we assessed the following: consumption of pre- Employment status, n (%)
scription drugs (pain killers, sleeping pills, tranquilisers and sti-
mulants) expressed as the number of drug categories consumed Employed, student, retired, 3194 (96.61) 2917 (96.56)
receiving benefits
on daily basis; professional (i.e. psychiatrist/psychologist/general
practitioner) mental health help-seeking in the last 12 months; Unemployed 112 (3.39) 104 (3.44)
COVID-19 health and economic-related worries (direct and Size of residence, n (%)
indirect, see online Supplementary Appendix for details),
0–4999 1264 (38.23) 1064 (35.22)
expressed as the number of items with strong worries (min 0,
max 2), and the presence of COVID-19 symptoms. All items 5000–19 999 609 (18.42) 573 (18.97)
were self-reported. The exact wording of COVID-19-related 20 000–99 999 725 (21.93) 671 (22.21)
questions and the distribution of responses on these questions
10 000 and more 708 (21.42) 713 (23.6)
is provided in online Supplementary Table 2.
Daily use of prescription drugs – number of drugs categories, n (%)

Statistical analysis 0 3133 (94.77) 2703 (89.47)

1 132 (3.99) 211 (6.98)
First, we calculated descriptive statistics for the sample, expressed
as counts and percentages (%) for non-continuous variables, and 2 28 (0.85) 75 (2.48)
as means with standard deviations (SD) for continuous variables. 3 10 (0.3) 25 (0.83)
Second, we calculated the prevalence of mental disorders for 2017
and 2020. We expressed prevalence as weighted means with 95% 4 3 (0.09) 7 (0.23)
confidence intervals (95% CIs) estimated via bootstrap method COVID-19 health-related worries – number of items with strong worries, n (%)
with 10 000 replicates. To address the slightly higher proportion 0 NAa 2476 (81.96)
(approximately 2%) of women in the 2017 sample, we employed
post-stratification weights for the 2017 dataset. 1 NA 350 (11.59)
Finally, we performed logistic regression to assess whether 2 NA 195 (6.45)
COVID-19-related worries and the self-reported presence of COVID-19 economic worries – number of items with strong worries, n (%)
COVID-19 symptoms were associated with the presence of (1)
any mental disorder, (2) major depressive episode, (3) suicidality, 0 NA 2516 (83.28)
(4) anxiety disorders and (5) alcohol use disorders in our 2020 1 NA 251 (8.31)
sample. We controlled for age, gender, level of education, work 2 NA 254 (8.41)
status, marital status, size of residence and prescription drugs
use in all models. We report results as odds ratios (ORs) with Presence of COVID-19, n (%)
95% CI, considering associations with p < 0.05 as statistically sig- Not tested NA 2961 (98.01)
nificant. We report the crude models adjusted for age and gender Tested negative or positive NA 60 (1.99)
in online Supplementary Table 3. All analyses were performed
using R statistical programming language (version 3.6.0). Received treatment in the last 12 months
No 3122 (94.43) 2725 (90.2)

Results Yes 184 (5.57) 296 (9.8)

a
Detailed characteristics of both November 2017 and May 2020 Not applicable.

samples are provided in Table 1. In 2020, approximately 10% of

the sample reported using at least one type of prescription
drugs on daily basis, while 1% reported using three to four consequences of COVID-19. Additionally, 8.5% of participants
different types. A considerable number of individuals (6.5%) reported strong worries on both questions focused on the
expressed strong worries on both questions regarding the health economic consequences of COVID-19. Approximately 2% of
4 P. Winkler et al.

Table 2. Prevalence of mental disorders per study years However, we found no statistically significant association between
alcohol use disorders and health or economic COVID-19 worries.
2017 2020
Having been tested (either negatively or positively) for COVID-19
Any mental disorder 20.02 (18.64; 21.39) 29.63 (27.9; 31.37) was associated with elevated risk of at least one mental disorder
(2.13, 95% CI = 1.21; 3.73), risk of suicide (2.36, 95% CI = 1.23;
Affective disorders 6.57 (5.71; 7.4) 18.58 (17.09; 20.05)
4.32) and anxiety disorders (2.11, 95% CI = 1.08; 3.95), but not
Anxiety disorders 7.79 (6.87; 8.7) 12.84 (11.6; 14.05) for major depressive episode or alcohol use disorders.
Alcohol use disorders 10.84 (9.78; 11.89) 9.88 (8.74; 10.98)
Affective disorders Discussion
Major depressive 3.96 (3.28; 4.62) 11.77 (10.56; 12.99) Our results confirm that the concerns expressed by experts and
episode previous studies expressing mental health-related consequences
Suicidality 3.88 (3.21; 4.52) 11.88 (10.64; 13.07) of the COVID-19 pandemic pose a major threat to population
Anxiety disorders
health are real and alarming in the context of Czechia. We
found an approximate 10% increase in the proportion of Czech
Panic disorder 0.21 (0.04; 0.36) 0.88 (0.53; 1.18) adults fulfilling the criteria of at least one current mental disorder
Generalised anxiety 3.14 (2.52; 3.72) 5.17 (4.31; 5.95) during the COVID-19 pandemic in May 2020 as compared to the
disorder baseline in November 2017.
Agoraphobia 5.16 (4.4; 5.91) 7.99 (6.99; 9) The prevalence of affective disorders and anxiety disorders
both increased, by 12.5 and 7%, respectively. While the prevalence
Social phobia 1.67 (1.22; 2.09) 2.53 (1.94; 3.07)
of alcohol use disorders remained similar, the consumption
Posttraumatic stress 0.96 (0.61; 1.28) 1.7 (1.23; 2.15) of alcohol measured by both, number of glasses of beer,
disorder alcohol and spirits and binge drinking, was higher during the
Alcohol use disorder COVID-19 pandemics than prior. Strong worries related to health
Alcohol abuse 9.42 (8.39; 10.41) 7.85 (6.85; 8.79)
and economic consequences of COVID-19 were associated with
considerably higher odds for at least one mental disorder, major
Alcohol dependence 6.61 (5.72; 7.48) 4.25 (3.49; 5) depressive episode, suicide risk or anxiety disorders. In addition,
The results are expressed as weighted proportions (%) with weighted 95% CIs. having been tested for COVID-19, irrespective of test result (nega-
tively or positively), was associated with a higher chance of scor-
ing positively for at least one mental disorder and suicidality.
individuals reported having been tested (either positively or The sustained prevalence of alcohol use disorders at baseline
negatively) for COVID-19; and about 10% of the sample had and during the pandemic might partially be explained by limited
visited a health professional regarding their mental health within possibilities of social dis-functioning during the lockdown, which
the last 12 months. is a diagnostic criterion of alcohol use disorders. For other mental
A detailed comparison of prevalence in 2017 and 2020 is disorders, the lockdown and other restrictive measures resulted in
presented in Table 2 and is graphically displayed in Fig. 1. The increased chances of positive scoring, because they had direct
proportion of those experiencing symptoms of at least one current impact on population functioning and might negatively influence
mental disorder increased during the COVID-19 pandemic interest in hobbies or social activities, feelings of detachedness or
by more than 10% (20.02, 95% CI = 18.64; 21.39 v. 29.63, isolation, feelings of tiredness, sleeping habits, or appetite, which
95% CI = 27.9; 31.37) when compared to the baseline in are all symptoms used by M.I.N.I. to identify a presence of current
November 2017. While the prevalence of current affective disor- mental disorder.
ders increased by almost 12.5% (6.57, 95% CI = 5.71; 7.4 v. The sharp increase in the prevalence of current mental disor-
18.58, 95% CI = 17.09; 20.05), the prevalence of current anxiety ders supports the notion that population mental health is highly
disorders increased by approximately 6% (7.79, 95% CI = 6.87; receptive to socio-economic factors. Similar phenomena have
8.7 v. 12.84, 95% CI = 11.6; 14.05). The prevalence of alcohol been researched in the context of the negative influence of the
use disorders in 2020 was approximately the same as in 2017 last financial crisis on completed suicides across Europe
(10.84, 95% CI = 9.78; 11.89 v. 9.88, 95% CI = 8.74; 10.98); how- (Fountoulakis et al., 2014), and seem to be supported by emerging
ever, there was a significant increase in consumption of alcohol evidence related to the COVID-19 pandemics as well (Mamun
as measured by both, the number of glasses per drinking session and Ullah, 2020). The current study demonstrates significantly
for all examined beverages (beer 1.62 v. 1.8, wine 1.41 v. 1.62 and higher odds of current mental disorders among individuals who
spirits 1.24 v. 1.32) as well as the number of individuals who binge expressed health or economic worries associated with the
drank at least once per week (4.07 v. 6.39%). COVID-19 pandemic. This supports a model of mental health
The main results of the logistic regression are provided in problems existing along a continuum (Patel et al., 2018), where
Table 3, and the results containing all associations in online a considerable amount of the population experiences mild symp-
Supplementary Table 4. Both strong worries from health and eco- toms, leaving the population exceptionally vulnerable during
nomic consequences of COVID-19 were associated with an stressful situations.
increased risk for fulfilling the criteria of at least one mental dis- The increase in the prevalence of mental disorders from
order (1.63, 95% CI = 1.4; 1.89 and 1.42, 95% CI = 1.23; 1.63 2017 to 2020 in the Czech context should be interpreted taking
respectively), major depressive episode (1.66, 95% CI = 1.38; into consideration the reform of mental health care and
1.99 and 1.44, 95% CI = 1.21; 1.71), risk of suicide (1.43, 95% national efforts towards the deinstitutionalisation of mental health
CI = 1.19; 1.72 and 1.37, 95% CI = 1.15; 1.62) and anxiety disor- care (Winkler et al., 2017). As this study includes only
ders (1.7, 95% CI = 1.42; 2.02 and 1.43, 95% CI = 1.2; 1.69). community-dwelling participants, it might be argued that some
Epidemiology and Psychiatric Sciences 5

Fig. 1. Prevalence of mental disorders among non-institutionalized adults in the Czech Republic: November 2017 and May 2020.

confounding might occur because of an increased number of indi- were collected after the strictest lockdown measures had loosened,
viduals with mental illness being based in the community. the full extent of COVID-related mental health problems may not
However this is largely unlikely as the target population for be represented. Consequently, it is likely that at the peak of the
deinstitutionalisation are patients with psychosis (Winkler et al., pandemic and associated lockdown, mental health symptoms
2018b), which were not included in the current study, and at were even higher. In China, this was found in a study reporting
most, patients with comorbidities in mental health diagnosis the progression of mental health symptoms at multiple points
could be represented and contribute to the increased prevalence over COVID-19, showing that the highest levels of mental health
of people with mental illness in 2020 as compared to the 2017 problems presented during the peak of virus spread and asso-
baseline sample. ciated lockdowns (Wang et al., 2020a, 2020b). However, the
This study has several limitations. First, since this is not a study benefits from a considerably large number of participants,
cohort study, we could not assess whether the COVID-19 pan- obtained using rigorous sampling, representative of the Czech
demic led to the development of mental disorders in individuals adult general population. Second, we were able to compare our
with no history of mental disorders. In addition, the baseline data results to a baseline dataset collected prior to COVID-19, which
collection was conducted in November 2017, which is about two measured the prevalence of mental illness using the same instru-
and half year before the COVID-19 data collection, and this might ment on a similar population. Third, data collection for this study
increase a chance of confounding. Second, due to the extraordin- was finalised prior to the lifting of the most severe restrictions
ary epidemiological situation caused by the COVID-19 pandemic, imposed by the government in response to COVID-19. Thus,
we were not able to collect data by means of a face-to-face inter- the results of the study should be interpreted with existing con-
viewing, instead relying on CAWI and CATI methods. The use of textual confounders within the Czech context, but are likely not
these methods may have introduced selection bias as some demo- biased by a return to society with new norms and regulations
graphics (i.e. individuals without phone and/or internet access) surrounding distancing and functioning.
could not participate. Third, while assessing a presence of GAD,
the psycho-diagnostic tool M.I.N.I. asks the following question:
Conclusions
‘Is the patient’s anxiety restricted exclusively to, or better
explained by, any disorder prior to this point?’ This question is This study provides data showing that projections and warnings
intended for clinicians, and it makes sense when all of the mod- of COVID-19-related mental health problems are backed by
ules of MINI are used, which was not the case in 2020. Hence, we evidence, and are justified and warrant attention and action.
relaxed this criterion, and this has led to a relatively high preva- Our study was conducted when the Czech government was lifting
lence of GAD in both of our samples. Fourth, since the data up restrictive measures and heading towards the end of
6 P. Winkler et al.

Table 3. Logit regression models: an association of COVID-19-related covariates and the presence of mental disorders

Any mental Major depressive Alcohol use

disorder episode Suicidality Anxiety disorders disorders

COVID-19 health-related 1.63 (1.4; 1.89)*** 1.66 (1.38; 1.99)*** 1.43 (1.19; 1.72)*** 1.7 (1.42; 2.02)*** 1.12 (0.88; 1.41)
worries
COVID-19 economic 1.42 (1.23; 1.63)*** 1.44 (1.21; 1.71)*** 1.37 (1.15; 1.62)*** 1.43 (1.2; 1.69)*** 1.13 (0.91; 1.38)
worries
Presence of COVID-19
Not tested Ref. Ref. Ref. Ref. Ref.
Tested negative or 2.13 (1.21; 3.73)* 1.75 (0.87; 3.34) 2.36 (1.23; 4.32)* 2.11 (1.08; 3.95)* 0.96 (0.39; 2.07)
positive
Models adjusted for age, gender, level of education, marital status, employment status, size of residence and use of prescription drugs. The results are expressed as ORs with 95% CIs.
*p < 0.05; **p < 0.01; ***p < 0.001.

state-of-emergency. This time also corresponds to improving epi- substantial part of the manuscript. Karolina Mlada contributed to both design-
demiological situation in continental Europe. It is possible that ing the study and to the statistical analyses. Anna Kagstrom contributed to the
the prevalence of mental disorders in the general adult population literature review and writing of the manuscript. Zuzana Mohrova contributed
to the statistical analysis. All authors, including Pavel Mohr and Ladislav
could be higher during the culmination of the first peak, since the
Csémy, contributed to the interpretation of the results and to the writing of
confusion and uncertainties were strongest then. However; with
the manuscript.
the threat of a second wave of COVID-19, services will need to
be assessed, adapted and scaled to both meet the increased preva- Financial support. The study was supported by the project the project
lence of individuals with mental health problems, and to adhere ‘Sustainability for the National Institute of Mental Health’, LO1611,
to new societal standards which parallel the pandemic including Ministry of Education, Youth and Sports of the Czech Republic under the
physical distancing measures, and lockdowns. Considering the NPU I programme. The funder had no role whatsoever in study design; in
existing treatment gap for mental disorders in the Czech context the collection, analysis and interpretation of data; in the writing of the report
and in the decision to submit the paper for publication.
ranging from 61% for affective to 93% for alcohol use disorders in
2017 (Kagstrom et al., 2019), the increase in mental health pro- Conflict of interest. Authors declare that they have no conflict of interest.
blems poses additional burden on national efforts for comprehen-
sive service provision and mental health reform initiatives. Ethical standards. Ethical approval was obtained from the ethical commit-
Our findings showing doubling and tripling of the prevalence tee of the National Institute of Mental Health, Czech Republic.
of common mental illnesses, which are in line with findings from
UK (Pierce et al., 2020) and USA (Czeisler et al., 2020) also References
emphasise an urgent need to scale up mental health promotion
and prevention globally, which includes integrating strategies to Ahnquist J and Wamala SP (2011) Economic hardships in adulthood and
change mental health care in the wake of COVID-19 (Moreno mental health in Sweden. the Swedish National Public Health Survey
2009. BMC Public Health 11, 788.
et al., 2020). E-mental health has proved promising in delivering
Al Banna MH, Sayeed A, Kundu S, Christopher E, Hasan MT, Begum MR,
effective care to populations in diverse settings across the globe Dola STI, Hassan MM, Chowdhury S and Khan MSI (2020) The impact
and scalable e-health interventions could be a major tool in meet- of the COVID-19 pandemic on the mental health of the adult population in
ing the surge of people with mental health problems (Wind et al., Bangladesh: a nationwide cross-sectional study. International Journal of
2020). Continued mental health monitoring, early identification of Environmental Health Research, https://doi.org/10.1080/09603123.2020.
at-risk individuals and ensuring accessible treatment for those with 1802409.
mental health problems will be vital aspects in service provision Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N
(Brooks et al., 2020; DePierro et al., 2020). On-going research and Rubin GJ (2020) The psychological impact of quarantine and how
assessing the prevalence, severity and progress in addressing mental to reduce it: rapid review of the evidence. The Lancet 395, 912–920.
health of populations will be necessary to track developments and Czeisler MÉ, Lane RI, Petrosky E, Wiley JF, Christensen A, Njai R, Weaver
MD, Robbins R, Facer-Childs ER, Barger LK, Czeisler CA, Howard ME
inform priorities in mitigating the effects of COVID-19-related
and Rajaratnam SMW (2020) Mental health, substance use, and suicidal
mental health consequences (Moreno et al., 2020). ideation during the COVID-19 pandemic – United States, June 24–30,
Supplementary material. The supplementary material for this article can 2020. MMWR. Morbidity and Mortality Weekly Report 69, 1049–1057.
be found at https://doi.org/10.1017/S2045796020000888. CZSO (2019) Demographic Yearbook of the Czech Republic 2018. Prague:
Czech Statistical Office.
Data. Data are not available publicly because of government regulations; Depierro J, Lowe S and Katz C (2020) Lessons learned from 9/11: mental health
however, data will be made available upon a reasonable request. Similarly, perspectives on the COVID-19 pandemic. Psychiatry Research 288, 113024.
the R code will be made available upon a reasonable request. Economou M, Peppou LE, Souliotis K, Konstantakopoulos G, Papaslanis T,
Kontoangelos K, Nikolaidi S and Stefanis N (2019) An association of eco-
Acknowledgements. None. nomic hardship with depression and suicidality in times of recession in
Greece. Psychiatry Research 279, 172–179.
Author contributions. Petr Winkler initiated, planned and designed the Formánek T, Kagström A, Cermakova P, Csémy L, Mladá K and Winkler P
study, coordinated the study, conducted the literature review and led the writ- (2019) Prevalence of mental disorders and associated disability: results from
ing of the manuscript. Tomas Formanek planned and designed the study, con- the cross-sectional Czech mental health study (CZEMS). European
ducted the statistical analyses, contributed to the literature review and wrote a Psychiatry 60, 1–6.
Epidemiology and Psychiatric Sciences 7

Fountoulakis KN, Kawohl W, Theodorakis PN, Kerkhof AJ, Navickas A, Moccia L, Janiri D, Pepe M, Dattoli L, Molinaro M, De Martin V, Chieffo D,
Höschl C, Lecic-Tosevski D, Sorel E, Rancans E, Palova E, Juckel G, Janiri L, Fiorillo A and Sani G (2020) Affective temperament, attachment
Isacsson G, Korosec Jagodic H, Botezat-Antonescu I, Warnke I, style, and the psychological impact of the COVID-19 outbreak: an early report
Rybakowski J, Azorin JM, Cookson J, Waddington J, Pregelj P, on the Italian general population. Brain, Behavior, and Immunity 87, 75–79.
Demyttenaere K, Hranov LG, Stevovic LI, Pezawas L, Adida M, Monroe SM and Simons AD (1991) Diathesis-stress theories in the context of
Figuera ML, Pompili M, Jakovljević M, Vichi M, Perugi G, Andreassen life stress research: Implications for the depressive disorders. Psychological
O, Vukovic O, Mavrogiorgou P, Varnik P, Bech P, Dome P, Winkler Bulletin 110, 406–425. doi: 10.1037/0033-2909.110.3.406
P, Salokangas RKR, From T, Danileviciute V, Gonda X, Rihmer Z, Moreno C, Wykes T, Galderisi S, Nordentoft M, Crossley N, Cannon M,
Benhalima JF, Grady A, Kloster Leadholm AK, Soendergaard S, Nordt Correll CU, Byrne L, Carr S, Chen EYH, Gorwood P, Johnson S,
C and Lopez-Ibor J (2014) Relationship of suicide rates to economic vari- Kärkkäinen H, Krystal JH, Lee J, Lieberman J, López-Jaramillo C,
ables in Europe: 2000–2011. The British Journal of Psychiatry 205, 486–496. Männikkö M, Phillips MR, Uchida H, Vieta E, Vita A and Arango C
Galea S, Merchant RM and Lurie N (2020) The mental health consequences (2020) How mental health care should change as a consequence of the
of COVID-19 and physical distancing: the need for prevention and early COVID-19 pandemic. The Lancet Psychiatry 7, 813–824. doi: 10.1016/
intervention. JAMA Internal Medicine 180, 817–818. S2215-0366(20)30307-2
Gao J, Zheng P, Jia Y, Chen H, Mao Y, Chen S, Wang Y, Fu H and Dai J Ohliger E, Umpierrez E, Buehler L, Ohliger AW, Magister S, Vallier H and
(2020) Mental health problems and social media exposure during Hirschfeld AG (2020) Mental health of orthopaedic trauma patients during
COVID-19 outbreak. PLoS ONE 15, e0231924. the 2020 COVID-19 pandemic. International Orthopaedics, 1–5. doi:
González-Sanguino C, Ausín B, Ángelcastellanos M, Saiz J, López-Gómez 10.1007/s00264-020-04711-w.
A, Ugidos C and Muñoz M (2020) Mental health consequences during Özdin S and Özdin BŞ (2020) Levels and predictors of anxiety, depression
the initial stage of the 2020 coronavirus pandemic (COVID-19) in Spain. and health anxiety during COVID-19 pandemic in Turkish society: the
Brain, Behavior, and Immunity 87, 172–176. importance of gender. International Journal of Social Psychiatry 66, 504–
Government of the Czech Republic (2020) Measures adopted by the Czech 511. doi: 0020764020927051
Government against the coronavirus. Available at https://www.vlada.cz/en/ Patel V, Saxena S, Lund C, Thornicroft G, Baingana F, Bolton P, Chisholm
media-centrum/aktualne/measures-adopted-by-the-czech-government- D, Collins PY, Coope JL, Eaton J and Herrman H (2018) The lancet com-
against-coronavirus-180545/ (Accessed 3 June 2020). mission on global mental health and sustainable development. The Lancet
Hammen C (2004). Stress and depression. Annual Review of Clinical 392, 1553–1598.
Psychology 1, 293–319. Pierce M, Hope H, Ford T, Hatch S, Hotopf M, John A, Kontopantelis E,
Hao F, Tan W, Jiang L, Zhang L, Zhao X, Zou Y, Hu Y, Luo X, Jiang X, Webb R, Wessely S, McManus S and Abel KM (2020) Mental health
McIntyre RS and Tran B (2020) Do psychiatric patients experience more before and during the COVID-19 pandemic: a longitudinal probability sam-
psychiatric symptoms during COVID-19 pandemic and lockdown? A ple survey of the UK population. The Lancet Psychiatry 7, 883–892. doi:
case-control study with service and research implications for immunopsy- 10.1016/S2215-0366(20)30308-4
chiatry. Brain, Behavior, and Immunity 87, 100–106. Qiu J, Shen B, Zhao M, Wang Z, Xie B and Xu Y (2020) A nationwide sur-
Herbolsheimer F, Ungar N and Peter R (2018) Why is social isolation among vey of psychological distress among Chinese people in the COVID-19 epi-
older adults associated with depressive symptoms? The mediating role demic: implications and policy recommendations. General Psychiatry 33,
of out-of-home physical activity. International Journal of Behavioral e100213.
Medicine 25, 649–657. Sheehan DV, Lecrubier Y, Sheehan KH, Janavs J, Weiller E, Keskiner A,
Holmes EA, O’Connor RC, Perry VH, Tracey I, Wessely S, Arseneault L, Schinka J, Knapp E, Sheehan MF and Dunbar GC (1997) The validity
Ballard C, Christensen H, Cohen Silver R, Everall I, Ford T, John A, of the Mini International Neuropsychiatric Interview (MINI) according to
Kabir T, King K, Madan I, Michie S, Przybylski AK, Shafran R, the SCID-P and its reliability. European Psychiatry 12, 232–241.
Sweeney A, Worthman CM, Yardley L, Cowan K, Cope C, Hotopf M Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E,
and Bullmore, E (2020) Multidisciplinary research priorities for the Hergueta T, Baker R and Dunbar GC (1998) The Mini-International
COVID-19 pandemic: a call for action for mental health science. The Neuropsychiatric Interview (M.I.N.I.): the development and validation of
Lancet Psychiatry 7, 547–560. a structured diagnostic psychiatric interview for DSM-IV and ICD-10.
Huang Y and Zhao N (2020) Chinese Mental health burden during the Journal of Clinical Psychiatry 59, 22–33.
COVID-19 pandemic. Asian Journal of Psychiatry 51, 102052. Sønderskov KM, Dinesen PT, Santini ZI and Østergaard SD (2020) The
Kagstrom A, Alexova A, Tuskova E, Csajbók Z, Schomerus G, Formanek T, depressive state of Denmark during the COVID-19 pandemic. Acta
Mladá K, Winkler P and Cermakova P (2019) The treatment gap for men- Neuropsychiatrica 32, 226–228.
tal disorders and associated factors in the Czech Republic. European UN (2020) Policy brief: COVID-19 and the Need for Action on Mental Health.
Psychiatry 59, 37–43. Wang C, Pan R, Wan X, Tan Y, Xu L, McIntyre RS, Choo FN, Tran B, Ho R
Kang L, Ma S, Chen M, Yang J, Wang Y, Li R, Yao L, Bai H, Cai Z and Yang BX and Sharma VK (2020a) A longitudinal study on the mental health of gen-
(2020) Impact on mental health and perceptions of psychological care among eral population during the COVID-19 epidemic in China. Brain, Behavior,
medical and nursing staff in Wuhan during the 2019 novel coronavirus disease and Immunity 87, 40–48.
outbreak: a cross-sectional study. Brain, Behavior, and Immunity 87, 11–17. Wang Y, Duan Z, Ma Z, Mao Y, Li X, Wilson A, Qin H, Ou J, Peng K, Zhou
Liu Y, Zhou M, Zhu X, Gu X, Ma Z and Zhang W (2020) Risk and protective F, Li C, Liu Z and Chen R (2020b) Epidemiology of mental health pro-
factors for chronic pain following inguinal hernia repair: a retrospective blems among patients with cancer during COVID-19 pandemic.
study. Journal of Anesthesia 34, 330–337. Translational Psychiatry 10, 263.
Lu W, Wang H, Lin Y and Li L (2020) Psychological status of medical work- Wind TR, Rijkeboer M, Andersson G and Riper H (2020) The COVID-19
force during the COVID-19 pandemic: a cross-sectional study. Psychiatry pandemic: the ‘black swan’ for mental health care and a turning point for
Research 288, 112936. e-health. Internet Interventions 20. doi: 10.1016/j.invent.2020.100317
Mamun MA and Ullah I (2020) COVID-19 suicides in Pakistan, dying off not Winkler P, Krupchanka D, Roberts T, Kondratova L, Machů V, Höschl C,
COVID-19 fear but poverty? – The forthcoming economic challenges for a Sartorius N, Van Voren R, Aizberg O, Bitter I, Cerga-Pashoja A,
developing country. Brain, Behavior, and Immunity 87, 163–166. Deljkovic A, Fanaj N, Germanavicius A, Hinkov H, Hovsepyan A,
Matthews T, Danese A, Wertz J, Odgers CL, Ambler A, Moffitt TE and Ismayilov FN, Ivezic SS, Jarema M, Jordanova V, Kukić S, Makhashvili
Arseneault L (2016) Social isolation, loneliness and depression in young N, Šarotar BN, Plevachuk O, Smirnova D, Voinescu BI, Vrublevska J
adulthood: a behavioural genetic analysis. Social Psychiatry and Psychiatric and Thornicroft G (2017) A blind spot on the global mental health
Epidemiology 51, 339–348. map: a scoping review of 25 years’ development of mental health care for
Mazure CM (1998) Life stressors as risk factors in depression. Clinical people with severe mental illnesses in central and Eastern Europe. The
Psychology: Science and Practice 5, 291–313. Lancet Psychiatry 4, 634–642.
8 P. Winkler et al.

Winkler P, Formánek T, Mladá K and Cermakova P (2018a) The CZEch Yao H, Chen JH and Xu YF (2020) Patients with mental health disorders in
Mental health Study (CZEMS): study rationale, design, and methods. the COVID-19 epidemic. The Lancet Psychiatry 7, e21.
International Journal of Methods in Psychiatric Research 27, e1728. Zhang J, Lu H, Zeng H, Zhang S, Du Q, Jiang T and Du B (2020a) The dif-
Winkler P, Koeser L, Kondrátová L, Broulíková HM, Páv M, Kališová L, ferential psychological distress of populations affected by the COVID-19
Barrett B and McCrone P (2018b) Cost-effectiveness of care for pandemic. Brain, Behavior, and Immunity 87, 49–50.
people with psychosis in the community and psychiatric hospitals in Zhang SX, Wang Y, Rauch A and Wei F (2020b) Unprecedented disruption
the Czech Republic: an economic analysis. The Lancet Psychiatry 5, 1023–1031. of lives and work: health, distress and life satisfaction of working adults in
Wong LP, Hung CC, Alias H and Lee TSH (2020) Anxiety symptoms and China one month into the COVID-19 outbreak. Psychiatry Research
preventive measures during the COVID-19 outbreak in Taiwan. BMC 112958.
Psychiatry 20, pp. 1–9.