memberslockdown

ArticleMentalHealth,SenseofCoherence,andInterpersonalViolenceduringtheCOVID-19PandemicLockdowninGermanyStefanieJung1,JonasKneer1andTillmannH.
C.
Krüger1,2,*1DepartmentofPsychiatry,SocialPsychiatryandPsychotherapy,DivisionofClinicalPsychologyandSexualMedicine,HannoverMedicalSchool,Carl-Neuberg-Str.
1,30625Hannover,Germany;jung.
stefanie@mh-hannover.
de(S.
J.
);kneer.
jonas@mh-hannover.
de(J.
K.
)2CenterforSystemsNeuroscience,Bünteweg2,30559Hannover,Germany*Correspondence:krueger.
tillmann@mh-hannover.
de;Tel.
:+49-511-532-2407Received:27October2020;Accepted:16November2020;Published:18November2020Abstract:PreliminarydataindicatesthattheCoronavirusSARS-CoV-2disease(COVID-19)pandemicmayhaveasubstantialimpactonmentalhealthandwell-being.
WeassessedmentalhealthinresponsetothelockdowninGermanybetween1April2020and15April2020usingacross-sectionalonlinesurvey(n=3545)withamixed-methodsapproach.
Wefoundincreasedlevelsofpsychosocialdistress(PatientHealthQuestionnaire(PHQ)stressmodule),anxiety,depressivesymptoms(PHQ-4),irritability,andadecreaseinoverallwell-being(WHO-FiveWell-BeingIndex(WHO-5)),senseofcoherence(ShortFormoftheSenseofCoherenceScale(SOC-L9)),sexualcontentment,andsleepquality.
Thefour-week-prevalenceofinterpersonalviolencewasyetat5%andincludedverbal,physical,andsexualviolence.
Participantsreportedndingcomfortinfamily,friends,conversation,exercise,andactivity.
Findingsarealsoinlinewithresearchshowingthatwomenseemtohavemoretroublecopingwiththepandemicandlockdownmeasures.
OurobservationsdemonstratethattheCOVID-19pandemicandrelatedmeasuresleadtoamentalhealthburdeneveninahighlydevelopedWesterncountryandshould,therefore,betakenseriously.
Thendingsforinterpersonalviolencearealarming.
Thus,weshouldsharpenourfocusonthematterandactivateandenhancesupportingsystemstohelpprotectthoseaected.
Keywords:COVID-19;coronavirus;lockdown;mentalhealth;depression;interpersonalviolence;senseofcoherence1.
IntroductionThenovel,highlycontagiouscoronavirusSARS-CoV-2iscurrentlyspreadingallovertheworld.
FirstcasesofCoronavirusSARS-CoV-2disease(COVID-19)werereportedinWuhan,China,inearlyDecember2019.
Symptomsmainlyincluderespiratorydistress,fever,coughing,andfatigue.
Asof13November2020,53,126,651casesofCOVID-19and1,312,170COVID-19relateddeathshavebeenconrmedworldwide(forGermany:771,976casesofCOVID-19and12,270COVID-19-relateddeaths)(JohnHopkinsUniversity)[1].
Thediseases'coursehas,thus,proventobepotentiallyfatal.
Inordertoattenthecurve,measureslikesocialdistancing,wearingofaprotectivemask,enhancedhygieneconcepts,andtemporarylockdownhavebeentakeninmostcountriesworldwide.
ThecurrentfocusonCOVID-19infections,however,mightdistractattentionfrommentalhealthissuesrelatedtotheoutbreakandthemeasurestakeninordertopreventfurtherspreading[2].
Infact,besidesitsimpactonphysicalhealthforthoseinfected,thepandemicandthemeasurestakenseemtohaveasubstantialimpactonmentalhealthandwell-being.
PreliminarydatafromChinaindicatedincreasedlevelsofpsychologicaldistress,anxiety,depressivesymptoms,andinsomnia[3,4].
AnotherChinesesurveyJ.
Clin.
Med.
2020,9,3708;doi:10.
3390/jcm9113708www.
mdpi.
com/journal/jcmJ.
Clin.
Med.
2020,9,37082of12foundthatmorethanhalfofthegeneralpopulationratedtheoutbreak'spsychologicalimpactasmoderateorsevere[5].
StudiesrelatedtomentalhealthduringtheCOVID-19pandemicarestillscarce,butmoreresultsindicatethatanxietyanddepressionincreasewithanoveralldecreaseinpsychologicalwell-being[6].
Increasingfeelingsofisolation,fear,worry,andsadnessmaycausedepressionandabuseofalcohol,drugs,andprescriptionmedicationandmayalsoleadtoviolencetowardtheselforothers[7].
Someauthorsevengosofarastodescribethecurrentsituationasapublicmentalhealthcrisis[8],thenextmentalhealthpandemic[9],oramentalhealthemergency[10].
Factorsassociatedwithacurrentdecreaseinmentalhealthincludefemalegender,lowersocioeconomicstatus,lowereducation,andpoorsleepquality[6].
Pandemic-relatedsymptomsofdepressionandpost-traumaticstressdisorder(PTSD)havealsobeenfoundtobelinkedtofemalegenderandlowersocioeconomicstatus[11].
InMarch2020,theGermangovernmentagreeduponasubstantialcatalogueoflockdownmeasuresincludingcontactbansthatcameintoeecton22March2020.
Suchmeasureswereunprecedentedforthemajorityofpeopleandmayaecttheirlivestremendously.
Asfornow,fewstudiesfromEuropehavebeenpublished[6]andyetitseemsofvitalimportancetosurveilthepsychosocialconsequencesofthecurrentpandemic.
Here,wepresentdatathatwastakenduringtheheightoflockdownmeasuresinGermanyfrom1April2020to15April2020.
Forone,weassumeanincreaseindepression,anxiety,impairedsleep,anddomesticviolenceaswellaschangesinalcoholandfoodconsumption.
Measurestakenagainstthespreadingofthecoronavirusincludedastrictsocialdistancingprotocolthatalsomeantanationwidelockdownwithpeoplebeingadvisedtostayathomeandtoonlyleavethehouseforessentialactivitiessuchaswork,shoppingforessentialgoods,andcareofpets.
Thesemeasuresleadtoaninvoluntarydecreaseinsocialcontact.
Lackofcontactwithotherhumanscancausefeelingsofloneliness,whichmayleadtodepression[12],negativeself-esteem,anxiety,feelingunsafe[13],andimpairedsleep[14,15].
Moreover,perceivedlonelinessimpairsthecapacitytoself-regulate[16],whichcouldleadtodysfunctionalbehavioralchangessuchasanincreaseinalcoholorfoodconsumption[17,18].
Inaddition,whencombinedwithconneddomesticcircumstances,adecreaseinself-regulationcouldleadtoanincreaseindomesticviolence.
Second,weassumethatthesenseofcoherencedecreased,leavingtheGermanpopulationvulnerabletostress.
Senseofcoherenceisatheoreticalconceptthatoersaframeworkforoverallcopinginlife.
Itcombinesthreekeyaspects:comprehensibility,manageability,andmeaningfulness[19].
Whetherweunderstandthethingshappeningtous,whetherwebelievethatwehavethenecessaryresourcesandskillstomanage,andwhetherthingsinlifeareworthwhileandhaveapurpose,greatlydeneshowwecopewithandhowweperceivestressfulevents.
Webelievethatthepandemicandthemeasurestakenagainstitconstitutesuchastressfulevent.
Atthebeginningofthepandemic,therewaslittleunderstandingconcerningwhyandhowthevirusspreadorwhichmeasureswereuseful.
Theuncertaintyandthelockdownmayhaveincreasedfeelingsofpowerlessnessand,thus,reducedfeelingsofmanageability.
Thecurrentsurveywasdevelopedinordertosystematicallyassessmentalhealthinresponsetothepandemicandthemeasurestakeninordertocontainit.
WesoughtouttoreplicateandexpandndingsfromChinafortheGermanpopulationandtoexploreperceivedrisksandremediesinordertoderivemuch-neededimplicationsforpoliticsandhealthcare.
2.
ExperimentalSectionThedevelopmentofthecurrentstudystartedastheCOVID-19pandemicgatheredspeedandanimplementationoflockdownmeasuresinGermanywasstartingtobecomeconceivable.
Sincethepopulationwasadvisedtostayathome,weagreeduponconductinganonlinesurvey.
Weputtogetheratestbatteryincludingquantitativeaswellasqualitativemeasurements.
Apartfromdemographics,quantitativeinstrumentsincludedthePatientHealthQuestionnaire-4(PHQ-4),thePatientHealthQuestionnairestressmodule(PHQstressmodule),theWHO-5Well-beingIndex(WHO-5),andtheJ.
Clin.
Med.
2020,9,37083of12SenseofCoherenceScale–shortformLeipzig(SOC-L9).
Moreover,usingcomparativequestionson3-pointand5-pointLikertscales,weaskedparticipantstoindicatechangestopre-lockdowntimes(workplacechanges,feelingsofaggression,sleepquality,qualityandquantityofnutritionalintake,qualityandquantityofsexualactivity,availabilityoftime,andexperienceofviolence).
Weconstructedthecomparativequestionsusingamulti-stepprocedure.
AfterreviewingcurrentresearchfromChinathatalreadypointedtowardthepsychosocialareasthatmightbeaectedbythepandemicandthemeasurestaken,webroughttogethertherstsetofitems.
Initialitemsweresubsequentlyrevisedbyexpertsandmembersofourdepartmentuntilwereachedagreementupontheadditionalitemsconcerningchangestopre-lockdowntimes.
Additionally,weincludedamultipleselectionquestionconcerninghowparticipantsspendtheirtimeandtwoopen-endedquestionsconcerningwhathelpedparticipantsduringthistimeandwhichopportunitiestheyexpectedtostemfromtheCOVID-19pandemicandthemeasurestakenagainstit.
2.
1.
PatientHealthQuestionnaire-4(PHQ-4)ThePHQ-4brieymeasuresanxietyanddepression.
ItconsistsofthersttwoitemsoftheGeneralizedAnxietyDisorder-7scale(GAD-7)andthePatientHealthQuestionnaire-8(PHQ-8)andshowsgoodreliability[20].
2.
2.
PatientHealthQuestionnaireStressModule(PHQStressModule)ThePHQstressmoduleisa15-itemquestionnairemeasuringpsychosocialriskfactorsthatcontributetothedevelopmentofpsychiatricdisease.
ItconsistsofthePHQitems12a–12jandshowsgoodreliability[21].
2.
3.
WHO-5Well-BeingIndex(WHO-5)TheWHO-5isave-itemscalemeasuringcurrentmentalwell-beingwhilereferencingtheprevioustwoweeks.
Itshowshighclinometricvalidity[22].
2.
4.
SenseofCoherenceScale—ShortFormLeipzig(SOC-L9)TheSOC-L9isanine-itemshortformscalederivedfromtheoriginal29-itemquestionnaire.
Itmeasuressenseofcoherence,whichisaconstructreferringtoaperson'sattitudeorcondencethatintrapsychicandenvironmentaleventsarepredictableandmanageable.
Senseofcoherenceisbelievedtobeaprotectivefactorformentalhealth.
Thescaleshowsgoodreliabilityandvalidity[23].
Accesstotheonlinesurveywasspreadandmadeavailablethroughsocialmedia(Instagram,Facebook),mailinglists,theHannoverMedicalSchools'website,andTVaswellasradioappearancesbyT.
H.
C.
Krüger.
Participantsfrom18yearsupwereinvitedtoparticipate.
Deliberately,therewerenofurtherinclusionandexclusioncriteriaaswesoughtouttoreachasmanycitizensaspossible.
2.
5.
StatisticalAnalysisDatawasanalyzedusingSPSSStatistics26(IBMCorporation,Amonk,NY,USA)andtestedfornormaldistributionandnon-violenceofassumptions,whichwereapplicablepriortofurtheranalysis.
Wemainlyreportmeansandstandarddeviations,groupcomparisons(usingt-testsandMann-Whitney-U-testswithBonferroni-Holmadjustment),andfrequencies(inpercent).
2.
6.
AnalysisofQualitativeDataOurqualitativedataanalysiswasguidedbyqualitativecontentanalysis[24].
Aftersiftingthroughrawdatainordertogetanoverview,llerwordslikeand,the,in.
.
.
wereexcludedfromfurtheranalysis.
Afterdatacleansing,weappliedthesummarymethodthataimsatreducingthematerialinawayinwhichessentialcontentisretained.
Usingabstraction,webuildacorpusthatrepresentstherawmaterialandclusteredkeywordsintocontextualthemeblocks.
Ourcodingwasinductive.
J.
Clin.
Med.
2020,9,37084of12Thus,categorieswerederivedfromrawdata.
Sincethesamplesizeformenisrathersmallandthegenderdierenceswefoundshowedonlysmalleectsizes,wewillreportqualitativedataforwomenandmenasonesample.
ThesurveywasapprovedbythelocalethicscommitteeatHannoverMedicalSchool,Germany(Nr.
9002_BO_K_2020).
DatawascollectedduringtheheightoflockdownmeasuresinGermanyfrom1April2020to15April2020.
Participantswereinformedaboutthesurveycontentandconsentedbystartingthequestionnaire.
3.
ResultsDemographics.
Atotalof3545volunteerstookpartinthiscross-sectionalsurvey.
MeanagewasM=40.
36years,standarddeviation(SD)=11.
70,n=2946(83.
1%)female,n=539(15.
2%)male,n=60(1.
7%)diverseormissing),meaneducationalyears15.
87(SD=4.
19),30.
6%heldauniversitydegree,9.
9%wereunemployed,and23.
9%reportedlivingalone.
Acuteorchronicdiseasewasreportedby36.
7%(physical)and24.
7%(mental)ofsubjects.
MeandurationforcompletionofthesurveywasatM=1134.
53seconds(18.
9min)(SD=575.
35seconds,9.
6min).
Duetotheimbalancedgenderdistribution,wewillreportfurtherresultsseparatelyforwomenandmen.
Depression,Anxiety,andDistress.
DepressionandanxietyasassessedbyPHQ-4wasatM=3.
91(SD=3.
05)forwomenandatM=3.
21(SD=2.
86)formen.
ReferencesamplesshowmeanscoresofM=1.
71(SD=2.
19)forwomenandM=1.
31(SD=1.
88)formen[25].
Thus,PHQ-4scoresweresignicantlyhigherinoursampleforbothgenders((t(4254)=23.
66,plockdownthanmen,theyhadtheoccasiontoparticipateinsurveys,(3)thetitleofthesurveyincludedtheterm"mentalhealth,"whichmayhavespokenmoretowomenthantomen,and(4)womenareimpactedbyaectivedisorderstwiceasmuchasmen,sotheymayhavehadahigherincentivetoparticipate.
Second,oursamplewaswelleducated.
While17.
6%oftheGermanpopulationholdauniversitydegree[36],inoursamplewefound30.
6%withaBachelor'sdegree,aMaster'sdegreeordiploma.
TheunemploymentrateinoursamplewashigherthanintheGermanpopulation(9.
9%inoursampleand6.
2%intheGermanpopulation[37]).
Meanage(40.
36yearsinoursampleand44.
5yearsintheGermanpopulation[38])andhouseholdstatus(23.
9%reportedlivingaloneinoursamplevs.
21.
13%singlehouseholdsinGermany[39]),however,didnotseemtodierwidely.
Takentogether,thedemographicdeviationsfromthenormrestrictrepresentativeness.
Moreover,wedidnotinvestigatedepressionandanxietyratesbeforethepandemic.
Thus,wecanonlydrawacomparisonbetweencurrentpandemicvaluesandreferencevalues.
Wedid,however,checkforpre-existingmentalandphysicalillness.
Concerningpre-existingmentalconditions,theoccurrencecorrespondstopointprevalenceinGermany[40].
Thus,aresultingbiascannotbeexpected.
Furtheron,wedidnotexploretheextenttowhichwomenwereinvolvedinchildcareduringthelockdown,whichincludedclosingofdaycareandschools.
Beyondthat,wedidnotcontrolforsocialdesirabilityeects.
Theseaspectsshouldbetakenintoaccountforfuturestudies.
Yet,usingamixed-methodsapproach,wepresentcomprehensiveEuropeandatathatgivesavaluableinsightintopotentialchallengesandprotectivefactorsformentalhealthduringtheheightoflockdownmeasuresinGermany.
5.
ConclusionsAlthoughthereisreasontoexpectthatmentalhealthwillincreasewiththesuccessfulcontainmentoftheCOVID-19pandemic[41],thespreadingcourseofthecoronavirusseemstobecomingandgoinginwaves.
Thepopulations'mentalhealthcan,thus,beassumedtobeequallydynamic.
ThelatestJ.
Clin.
Med.
2020,9,370810of12numbersfromtheU.
S.
,forexample,demonstratethat,relatedtothepandemic,40%ofrespondentsshowedsignsofanxiety,depression,orincreaseduseofsubstanceswith25%evenreportingsymptomsoftrauma-relatedandstressor-relateddisorders[42].
Bynow,COVID-19casenumbersworldwidehavegoneupagainandmeasuresarebeingintensiedglobally.
Therefore,itisofvitalimportancetocontinuouslymonitorthementalhealthofthegeneralpublicduringthispandemicanditsaftermathtoidentifyassociatedprotectivefactorsandtocarefullyscreenforIPVanditsriskfactorssuchasstress,sleepproblems,andanger[43].
SupplementaryMaterials:Thefollowingareavailableonlineathttp://www.
mdpi.
com/2077-0383/9/11/3708/s1,TableS1:Mann-Whitney-U-testsforgroupdierencesbetweenparticipantswithandwithoutpre-existingphysicalhealthconditions,TableS2:MeansandstandarddeviationsforPHQ-4,WHO-5,SOC-L9andPHQstressmoduleforparticipantswithandwithoutpre-existingphysicalhealthconditions.
,TableS3:Answersforitem"coping"(percentage)forparticipantswithandwithoutpre-existingphysicalhealthconditions.
AuthorContributions:Conceptualization,S.
J.
,J.
K.
andT.
H.
C.
K.
;methodology,S.
J.
,J.
K.
andT.
H.
C.
K.
;validation,S.
J.
,J.
K.
andT.
H.
C.
K.
;formalanalysis,S.
J.
andJ.
K.
;investigation,S.
J.
;resources,S.
J.
andT.
H.
C.
K.
;datacuration,S.
J.
andJ.
K.
;writing—originaldraftpreparation,S.
J.
;writing—reviewandediting,S.
J.
,J.
K.
andT.
H.
C.
K.
;visualization,S.
J.
andJ.
K.
;supervision,T.
H.
C.
K.
;projectadministration,S.
J.
andT.
H.
C.
K.
Allauthorshavecontributedtothescienticworkandhavereadandagreedtothepublishedversionofthemanuscript.
Funding:Thisresearchreceivednoexternalfunding.
ConictsofInterest:Theauthorsdeclarenoconictofinterest.
References1.
JohnsHopkinsUniversity.
JohnsHopkinsCoronavirusResourceCenter.
JHU.
Availableonline:https://coronavirus.
jhu.
edu/map.
html(accessedon13November2020).
2.
Torales,J.
;O'Higgins,M.
;Castaldelli-Maia,J.
M.
;Ventriglio,A.
TheoutbreakofCOVID-19coronavirusanditsimpactonmentalhealth.
Int.
J.
Soc.
Psychiatry2020,66,317–320.
[CrossRef][PubMed]3.
Lai,J.
;Ma,S.
;Wang,Y.
;Cai,Z.
;Hu,J.
;Wei,N.
;Wu,J.
;Du,H.
;Chen,T.
;Li,R.
;etal.
Factorsassociatedwithmentalhealthoutcomesamonghealthcareworkersexposedtocoronavirusdisease2019.
JAMANetw.
Open2020,3,e203976.
[CrossRef][PubMed]4.
Huang,Y.
;Zhao,N.
Generalizedanxietydisorder,depressivesymptomsandsleepqualityduringCOVID-19outbreakinChina:Aweb-basedcross-sectionalsurvey.
PsychiatryRes.
2020,288,112954.
[CrossRef][PubMed]5.
Wang,C.
;Pan,R.
;Wan,X.
;Tan,Y.
;Xu,L.
;Ho,C.
S.
H.
;Ho,R.
C.
M.
Immediatepsychologicalresponsesandassociatedfactorsduringtheinitialstageofthe2019coronavirusdisease(COVID-19)epidemicamongthegeneralpopulationinChina.
Int.
J.
Environ.
Res.
Public.
Health2020,17,1729.
[CrossRef][PubMed]6.
Vindegaard,N.
;Benros,M.
E.
COVID-19pandemicandmentalhealthconsequences:Systematicreviewofthecurrentevidence.
BrainBehav.
Immun.
2020.
[CrossRef]7.
Lieberman,J.
A.
;Olfson,M.
MeetingthementalhealthchallengeoftheCOVID-19pandemic.
PsychiatricTimes.
Availableonline:https://www.
psychiatrictimes.
com/view/meeting-mental-health-challenge-covid-19-pandemic(accessedon12August2020).
8.
Dong,L.
;Bouey,J.
PublicmentalhealthcrisisduringCOVID-19pandemic,China.
Emerg.
InfectDis.
2020,26,3201.
[CrossRef]9.
Parrish,E.
Thenextpandemic:COVID-19mentalhealthpandemic.
Perspect.
Psychiatr.
Care2020,56,485.
[CrossRef][PubMed]10.
Kelly,B.
D.
Coronavirusdisease:Challengesforpsychiatry.
Br.
J.
Psychiatry.
2020,217,352–353.
[CrossRef]11.
Mowbray,H.
InBeijing,coronavirus2019-nCoVhascreatedasiegementality.
BMJ2020.
[CrossRef]12.
Cacioppo,J.
T.
;Hughes,M.
E.
;Waite,L.
J.
;Hawkley,L.
C.
;Thisted,R.
A.
Lonelinessasaspecicriskfactorfordepressivesymptoms:Cross-sectionalandlongitudinalanalyses.
Psychol.
Aging2006,21,140–151.
[CrossRef]13.
Cacioppo,J.
T.
;Hawkley,L.
C.
;Ernst,J.
M.
;Burleson,M.
;Berntson,G.
G.
;Nouriani,B.
;Spiegel,D.
Lonelinesswithinanomologicalnet:Anevolutionaryperspective.
J.
Res.
Pers.
2006,40,1054–1085.
[CrossRef]J.
Clin.
Med.
2020,9,370811of1214.
Cacioppo,J.
T.
;Hawkley,L.
C.
;Crawford,L.
E.
;Ernst,J.
M.
;Burleson,M.
H.
;Kowalewski,R.
B.
;Malarkey,W.
B.
;VanCauter,E.
;Berntson,G.
G.
Lonelinessandhealth:Potentialmechanisms.
Psychosom.
Med.
2002,64,407–417.
[CrossRef][PubMed]15.
Mahon,N.
E.
Lonelinessandsleepduringadolescence.
Percept.
Mot.
Ski.
1994,78,227–231.
[CrossRef][PubMed]16.
Hawkley,L.
C.
;Cacioppo,J.
T.
Lonelinessmatters:Atheoreticalandempiricalreviewofconsequencesandmechanisms.
Ann.
Behav.
Med.
2010,40,218–227.
[CrossRef][PubMed]17.
Lauder,W.
;Mummery,K.
;Jones,M.
;Caperchione,C.
Acomparisonofhealthbehavioursinlonelyandnon-lonelypopulations.
Psychol.
HealthMed.
2006,11,233–245.
[CrossRef][PubMed]18.
Akerlind,I.
;Hornquist,J.
O.
Lonelinessandalcoholabuse:Areviewofevidencesofaninterplay.
Soc.
Sci.
Med.
1992,34,405–414.
[CrossRef]19.
Antonovsky,A.
UnravelingtheMysteryofHealth—HowPeopleManageStressandStayWell;Jossey-BassPublishers:SanFrancisco,CA,USA,1987.
20.
Kroenke,K.
;Spitzer,R.
L.
;Williams,J.
B.
W.
;Lwe,B.
Anultra-briefscreeningscaleforanxietyanddepression:ThePHQ–4.
Psychosomatics2009,50,613–621.
21.
Grfe,K.
;Zipfel,S.
;Herzog,W.
;Lwe,B.
Screeningpsychischerstrungenmitdem"GesundheitsfragebogenfürPatienten(PHQ-D)".
Diagnostica2004,50,171–181.
[CrossRef]22.
Topp,C.
W.
;stergaard,S.
D.
;Sndergaard,S.
;Bech,P.
TheWHO-5well-beingindex:Asystematicreviewoftheliterature.
Psychother.
Psychosom.
2015,84,167–176.
[CrossRef]23.
Lin,M.
;Bieda,A.
;Margraf,J.
Shortformofthesenseofcoherencescale(SOC-L9)intheUS,Germany,andRussia:Psychometricpropertiesandcross-culturalmeasurementinvariancetest.
Eur.
J.
Psychol.
Assess.
2019.
[CrossRef]24.
Mayring,P.
QualitativeInhaltsanalyse.
GrundlagenundTechniken,11thed.
;Beltz:Weinheim,Germany,2010.
25.
Kroenke,K.
;Spitzer,R.
L.
;Williams,J.
B.
;Monahan,P.
O.
;Lowe,B.
Anxietydisordersinprimarycare:Prevalence,impairment,comorbidity,anddetection.
Ann.
Intern.
Med.
2007,146,317–325.
[CrossRef][PubMed]26.
WellbeingMeasuresinPrimaryHealthCare/theDepcareProject;ReportonaWHOMeeting:Stockholm,Swedish,1998.
27.
Brhler,E.
;Mühlan,H.
;Albani,C.
;Schmidt,S.
Teststatistischeprüfungundnormierungderdeutschenversionendeseurohis-qollebensqualitt-indexunddesWHO-5wohlbendens-index.
Diagnostica2007,53,83–96.
[CrossRef]28.
Singer,S.
;Brhler,E.
Die"SenseofCoherenceScale";Vandenhoeck&Ruprecht:Gttingen,Germany,2007.
29.
Makaroun,L.
K.
;Brignone,E.
;Rosland,A.
M.
;Dichter,M.
E.
Associationofhealthconditionsandhealthserviceutilizationwithintimatepartnerviolenceidentiedviaroutinescreeningamongmiddle-agedandolderwomen.
JAMANetw.
Open2020,3,e203138.
[CrossRef][PubMed]30.
Schnell,R.
;Hill,P.
B.
;Esser,E.
MethodenderEmpirischenSozialforschung,2nded.
;Oldenbourg:München,Germany,1989.
31.
StatistischesBundesamt.
Availableonline:https://www.
destatis.
de/DE/Themen/Gesellschaft-Umwelt/Bevoelkerung/Bevoelkerungsstand/_inhalt.
html;jsessionid=DE922D7E04B48DCE2930CF8398773356.
internet8742(accessedon20October2020).
32.
Moore,D.
L.
;Tarnai,J.
Surveynonresponse.
InEvaluatingNonresponseErrorinMailSurveys;Groves,R.
M.
,Dillman,D.
A.
,Eltinge,J.
L.
,Little,R.
J.
A.
,Eds.
;JohnWiley&Sons,Inc.
:NewYork,NY,USA,2002;pp.
197–211.
33.
DiRenzo,L.
;Gualtieri,P.
;Cinelli,G.
;Bigioni,G.
;Soldati,L.
;Attinà,A.
;Bianco,F.
F.
;Caparello,G.
;Camodeca,V.
;Carrano,E.
;etal.
Psychologicalaspectsandeatinghabitsduringcovid-19homeconnement:ResultsofEHLC-COVID-19Italianonlinesurvey.
Nutrients2020,12,2152.
[CrossRef][PubMed]34.
Ho,H.
-Y.
;Chen,Y.
-L.
;Yen,C.
-F.
DierentimpactsofCOVID-19-relatedinformationsourcesonpublicworry:Anonlinesurveythroughsocialmedia.
InternetInterv.
2020,22,100350.
[CrossRef]35.
Perrin,A.
"SocialNetworkingUsage:2005–2015"PewResearchCenter.
Availableonline:http://www.
pewinternet.
org/2015/10/08/2015/Social-Networking-Usage-2005-2015/(accessedon15February2016).
36.
StatistischesBundesamt.
Availableonline:https://www.
destatis.
de/DE/Themen/Gesellschaft-Umwelt/Bildung-Forschung-Kultur/Bildungsstand/_inhalt.
html(accessedon20October2020).
37.
Arbeitsagentur.
Availableonline:https://www.
arbeitsagentur.
de/news/arbeitsmarkt-2020(accessedon20October2020).
J.
Clin.
Med.
2020,9,370812of1238.
StatistischesBundesamt.
Availableonline:https://de.
statista.
com/statistik/daten/studie/723069/umfrage/durchschnittsalter-der-bevoelkerung-in-deutschland-nach-staatsangehoerigkeit/(accessedon20October2020).
39.
StatistischesBundesamt.
Availableonline:https://de.
statista.
com/statistik/daten/studie/156951/umfrage/anzahl-der-einpersonenhaushalte-in-deutschland-seit-1991/(accessedon20October2020).
40.
DGPPN.
BasisdatenPsychischeErkrankungen.
Availableonline:https://www.
dgppn.
de/_Resources/Persistent/a2e357dac62be19b5050a1d89ffd8603cfdb8ef9/20201008_Factsheet.
pdf(accessedon27October2020).
41.
Snderskov,K.
M.
;Dinesen,P.
T.
;Santini,Z.
I.
;stergaard,S.
D.
Increasedpsychologicalwell-beingaftertheapexoftheCOVID-19pandemic.
ActaNeuropsychiatr.
2020.
[CrossRef]42.
Czeisler,M.
.
;Lane,R.
I.
;Petrosky,E.
;Wiley,J.
F.
;Christensen,A.
;Njai,R.
;Weaver,M.
D.
;Robbins,R.
;Facer-Childs,E.
R.
;Barger,L.
K.
;etal.
Mentalhealth,substanceuse,andsuicidalideationduringtheCOVID-19pandemic—UnitedStates,June24–30,2020.
MMWR.
Morb.
Mortal.
Wkly.
Rep.
2020,69,1049–1057.
[CrossRef]43.
DeWolfe,D.
J.
TrainingManualforMentalHealthandHumanServiceWorkersinMajorDisasters,2nded.
;FederalEmergencyManagementAgency:Washington,DC,USA,2000.
Publisher'sNote:MDPIstaysneutralwithregardtojurisdictionalclaimsinpublishedmapsandinstitutionalaliations.
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LicenseeMDPI,Basel,Switzerland.
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0/).