Effective recommendations towards healthy routines to preserve mental health during the COVID-19 pandemic

Pilz, Luísa K.; Couto Pereira, Natividade S.; Francisco, Ana Paula; Carissimi, Alicia; Constantino, Débora B.; Caus, Letícia B.; Abreu, Ana Carolina O.; Amando, Guilherme R.; Bonatto, Fernanda S.; Carvalho, Paula V.V.; Cipolla-Neto, José; Harb, Ana; Lazzarotto, Gabriela; Marafiga, Joseane Righes; Minuzzi, Luciano; Montagner, Francisco; Nishino, Fernanda A.; Oliveira, Melissa A.B.; dos Santos, Bruno G.T.; Steibel, Eduardo G.; Tavares, Patrice S.; Tonon, André C.; Xavier, Nicóli B.; Zanona, Querusche Klippel; Amaral, Fernanda G.; Calcagnotto, Maria Elisa; Frey, Benicio N.; Hidalgo, Maria Paz; Idiart, Marco; Russomano, Thais

doi:10.1590/1516-4446-2021-2109

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Brazilian Journal of Psychiatry

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ORIGINAL ARTICLE • Braz J Psychiatry 44 (2) • Mar-Abr 2022 • https://doi.org/10.1590/1516-4446-2021-2109 copy

Effective recommendations towards healthy routines to preserve mental health during the COVID-19 pandemic

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

To assess the adherence to a set of evidence-based recommendations to support mental health during the coronavirus disease 2019 (COVID-19) pandemic and its association with depressive and anxiety symptoms.

Methods:

A team of health workers and researchers prepared the recommendations, formatted into three volumes (1: COVID-19 prevention; 2: Healthy habits; 3: Biological clock and sleep). Participants were randomized to receive only Volume 1 (control), Volumes 1 and 2, Volumes 1 and 3, or all volumes. We used a convenience sample of Portuguese-speaking participants over age 18 years. An online survey consisting of sociodemographic and behavioral questionnaires and mental health instruments (Patient Health Questionnaire-9 [PHQ-9] and Generalized Anxiety Disorder-7 [GAD-7]) was administered. At 14 and 28 days later, participants were invited to complete follow-up surveys, which also included questions regarding adherence to the recommendations. A total of 409 participants completed the study – mostly young adult women holding university degrees.

Results:

The set of recommendations contained in Volumes 2 and 3 was effective in protecting mental health, as suggested by significant associations of adherence with PHQ-9 and GAD-7 scores (reflecting anxiety and depression symptoms, respectively).

Conclusion:

The recommendations developed in this study could be useful to prevent negative mental health effects in the context of the pandemic and beyond.

COVID-19; pandemic; mental health; adherence; recommendations

Volume/recommendation	Adherence question: Which of the following recommendations did you follow?
1 – COVID-19 prevention
Wash your hands regularly with soap or apply hand sanitizer (70% alcohol).	I washed my hands regularly or applied hand sanitizer (70% alcohol) to clean them.
Avoid going out; if you have to go out, wear a mask.	I avoided leaving home.
	When outside, I wore a mask.^† † Participants could select not applicable (N/A) as a response to these questions.
Keep a safe distance of at least 2 m from others; if you are walking, increase the distance.	I kept a 2-m distance from other people when outside.^† † Participants could select not applicable (N/A) as a response to these questions.
Avoid touching your eyes, nose, and mouth	I avoided touching my eyes, nose, and mouth.
If you need to cough or sneeze, cover your mouth and nose with the inner part of your elbow or a disposable tissue.	-
Stay at home if you feel sick. Viral transmission can occur at least 3 days before symptoms appear.	I stayed at home if I felt any of the COVID-19 symptoms (cough, fever, difficulty breathing...).^† † Participants could select not applicable (N/A) as a response to these questions.
2 – Healthy habits
Avoid listening to the news all the time.	I avoided listening to the news all the time.
Practice body and mind relaxing techniques.	I practiced techniques to relax my mind and body.
Set aside some time for leisure activities.	I set aside some time for leisure activities.
Exercise at home.	I exercised.
Take care of your body posture.	I took care of my body posture.
Maintain good oral hygiene.	I maintained good oral hygiene.
Take care of your nutrition.	I was careful with my meals.
3 – Biological clock and sleep
Expose yourself to sunlight during the day.	I exposed myself to sunlight during the day.
Turn off lights at night.	I turned off lights earlier or avoided white light exposure.
Reduce screen time, especially at night.	I reduced the amount of screen time (computer, TV, cell phone) at night.
Use apps that turn your screen light yellow at night.	I used an app to change the screen color temperature to yellow at night.
Organize your routine according to your chronotype.	I organized my routine according to my chronotype.
Keep your routines regular.	I kept regular routines (sleep, meals, work-leisure).
Avoid long naps.	I avoided taking long naps during the day.
Avoid thinking about problems at bedtime.	I avoided thinking about my problems at bedtime.
Make your bedroom a sleep-inducing environment.	My bedroom was a sleep-inducing environment.
Avoid heavy meals close to bedtime.	I avoided heavy meals before bedtime.
Avoid caffeine and alcohol intake close to bedtime.	I avoided beverages/food containing caffeine before bedtime.
	I avoided alcoholic beverages before bedtime.^† † Participants could select not applicable (N/A) as a response to these questions.
Plan your exercise schedules considering your sleep time.	I avoided doing exercise before bedtime.

Variable	n (%)
Sex
Female	349 (85)
Male	60 (15)
Age (years)
18-29	157 (38)
30-45	179 (44)
46-59	50 (12)
≥ 60	23 (6)
Education
Middle school	1 (< 1)
High school	89 (22)
Bachelor’s degree	158 (39)
Master’s degree	79 (19)
Doctoral degree	82 (20)
Employment situation
Formally employed	149 (36)
Self-employed	46 (11)
Student	146 (36)
Unemployed	21 (5)
Retired	13 (3)
Not available	34 (8)
Marital status
Single	258 (63)
Married	135 (33)
Separated/divorced	14 (3)
Widowed	2 (< 1)
State of origin
Bahia	4 (1)
Ceará	4 (1)
Minas Gerais	14 (3)
Mato Grosso do Sul	9 (2)
Pernambuco	6 (1)
Paraná	9 (2)
Rio de Janeiro	13 (3)
Rio Grande do Sul	166 (41)
Santa Catarina	12 (3)
São Paulo	157 (38)
Alagoas, Distrito Federal, Espírito Santo, Roraima	9 (2)
Outside Brazil	6 (1)
Geographical area
Urban	396 (97)
Rural	13 (3)
Substance use
Alcohol	261 (64)
Tobacco	20 (5)
Illicit drugs	6 (1)
Stimulants (coffee, mate)	301 (74)
Comorbidities
None	240 (59)
Diabetes	7 (2)
Hypertension	24 (6)
Asthma	26 (6)
Depression	50 (12)
Immunodeficiency	5 (1)
Other	104 (25)

Group	Volume 1 14 days	Volume 1 28 days	Volume 2 14 days	Volume 2 28 days	Volume 3 14 days	Volume 3 28 days
1	86.7 (80.0-93.3)	86.7 (80.0-93.3)	-	-	-	-
2	86.7 (80.0-93.3)	86.7 (80.0-93.3)	54.8 (42.8-66.7)	57.1 (42.9-66.7)	-	-
3	91.1 (86.7-100.0)	93.3 (86.7-100.0)	-	-	65.4 (55.8-74.3)	65.4 (51.3-73.8)
4	88.9 (86.7-94.4)	86.7 (80.0-93.3)	52.4 (42.8-66.7)	52.4 (38.1-66.7)	61.5 (53.8-69.2)	61.5 (52.8-71.8)
p-value	0.236	0.211	0.506	0.542	0.135	0.570

	Model Volume 1	Model Volume 2	Model Volume 3	Full
Outcome: PHQ-9 scores (time point 14d/28d)
Age (years)	-0.06 (0.01)^ p < 0.001	-0.05 (0.02)^* † Adherence to Volumes 1, 2, and 3 in the three first columns, respectively.	-0.06 (0.02)^* † Adherence to Volumes 1, 2, and 3 in the three first columns, respectively.	-0.05 (0.01)^ p < 0.001
Sex (male)	-0.01 (0.52)	0.39 (0.68)	0.03 (0.78)	-0.07 (0.50)
Initial PHQ-9	0.70 (0.03)^ p < 0.001	0.63 (0.05)^ p < 0.001	0.65 (0.05)^ p < 0.001	0.68 (0.03)^ p < 0.001
Time point (28d)	-2.97 (1.95)	2.67 (1.70)	-0.03 (1.81)	-0.26 (0.22)
Adherence (%)^† * p < 0.05	0.01 (0.02)	-0.05 (0.02)^* † Adherence to Volumes 1, 2, and 3 in the three first columns, respectively.	-0.06 (0.03)^* † Adherence to Volumes 1, 2, and 3 in the three first columns, respectively.	-
Adherence × time point	0.03 (0.02)	-0.05 (0.03)^* † Adherence to Volumes 1, 2, and 3 in the three first columns, respectively.	-0.00 (0.03)	-
Group 2 × adherence	-	-	-	-1.31 (0.54)^* † Adherence to Volumes 1, 2, and 3 in the three first columns, respectively.
Group 3 × adherence	-	-	-	-1.31 (0.58)^* † Adherence to Volumes 1, 2, and 3 in the three first columns, respectively.
Group 4 × adherence	-	-	-	-2.85 (0.64)^ p < 0.001
Outcome: GAD-7 scores (time point 14d/28d)
Age (years)	-0.02 (0.01)	-0.02 (0.02)	-0.03 (0.02)	-0.02 (0.01)
Sex (male)	0.06 (0.51)	-0.32 (0.74)	-0.14 (0.84)	-0.02 (0.50)
Initial GAD-7	0.66 (0.03)^ p < 0.001	0.61 (0.05)^ p < 0.001	0.60 (0.06)^ p < 0.001	0.66 (0.03)^ p < 0.001
Time point (28d)	0.41 (1.82)	0.56 (1.04)	2.21 (1.38)	-0.16 (0.20)
Adherence (%)^† * p < 0.05	0.03 (0.02)	-0.03 (0.02)^* † Adherence to Volumes 1, 2, and 3 in the three first columns, respectively.	-0.02 (0.02)	-
Adherence × time point	0.00 (0.02)	-0.02 (0.02)	-0.04 (0.02)	-
Group 2 × adherence	-	-	-	-1.02 (0.53)
Group 3 × adherence	-	-	-	-0.74 (0.43)
Group 4 × adherence	-	-	-	-1.84 (0.57)^* † Adherence to Volumes 1, 2, and 3 in the three first columns, respectively.
n entries \| n subjects	624 \| 330	312 \| 169	294 \| 157	624 \| 330

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[1] Correspondence: Luísa K. Pilz, Laboratório de Cronobiologia e Sono, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, CEP 90035-903, Porto Alegre, RS, Brazil. E-mail: luisa.pilz@ufrgs.br