Impact of the COVID-19 pandemic on mental health among local residents in South of Brazil: during pandemic times, youth sleep matters

Abstract Introduction Social isolation has been associated with poor sleep quality and mental health problems during the COVID-19 pandemic. However, most studies have investigated heterogeneous samples subjected to varying social distancing policies and did not focus on a single local profile subject to homogeneous prevention policies. Objective To evaluate the impact of the COVID-19 pandemic on mental health and sleep quality in a specific region in the South of Brazil where the populations have similar culture and local governments have adopted similar social distancing policies. Methods This study was conducted with 327 individuals aged 18-72 years, living in the Vale do Taquari area, Brazil. We assessed sociodemographic variables with a standardized protocol, symptoms of depression, anxiety, and stress with the Depression, Anxiety and Stress Scale-21 (DASS-21), sleep quality with the Pittsburgh Sleep Quality Index (PSQI), and post-traumatic stress symptoms with the Impact of Event Scale (IES-R), using a web-based online survey. Results Our results showed that sleep dysfunction moderated the effects of age on psychological symptoms, indicating that younger participants who had poorer sleep quality had worse mental health. Furthermore, participants with more perceived stress during the pandemic and more sleep dysfunction reported more symptoms of anxiety and post-traumatic stress. Conclusion Psychological symptoms were not related to social isolation duration but were related to the subjective perception that the pandemic interfered with life and generated stressful situations. These results may help governments make important decisions about protection and isolation measures in future waves of COVID-19 infection.


Introduction
In December 2019, several pneumonia cases caused by a severe acute respiratory syndrome which was later diagnosed as COVID-19 were reported in Wuhan, China, resulting in a worldwide pandemic. 1 In Brazil, the first case of COVID-19 was reported on February 26, 2020.
Due to its complex epidemiological scenario, the country has been severely affected, with 231,534 deaths by the 8th of February, being considered the second most http://dx.doi.org/10.47626/2237-6089-2021-0225 affected nation in the world. 2 This scenario suggests that the responses from the relevant authorities could have been faster and more assertive.
Even when cases started to spike in non-urban areas, the federal government did not support social distancing measures, minimizing the pandemic's importance. 3,4 Therefore, with no national guidelines for prevention of the spread of the virus, decisions were made locally by state and district governments.
On March 19, 2020, a state of public calamity was declared in the South of Brazil. As in many countries, this region adopted social distancing as a public health intervention, restricting movement and closing schools and businesses. However, such measures can also result in physical distancing of people who could provide social support from individuals who need it and, on an individual economic level, the possibility of an impending economic crisis and recession may result in many people losing their jobs and experiencing financial difficulties. 5 Together with the fear of contracting the infection itself, these lifestyle changes have probably generated profound levels of anxiety. 6 Moreover, some studies also suggest that another possible impact of the virus may be to worsen psychiatric conditions and neurological symptoms and that affected patients may be at higher risk of cognitive impairment after overcoming the COVID-19 infection. 7 Several studies have reported the effects of the COVID-19 pandemic on the general population's psychological outcomes in different countries. 8,9 The main findings provide evidence of the negative impact of the COVID-19 pandemic on mental health in different populations.
High rates of symptoms of anxiety, depression, anger, post-traumatic stress disorder (PTSD), and stress, and feelings of horror and apprehension were reported in the general population, especially in younger people, during the COVID-19 pandemic. 10,11 Further, those with preexisting psychiatric disorders reported worsening psychiatric symptoms. 12 Some studies have also reported worsening of quality of sleep in the general population, with an impact of a delay in Bed Time and Wake-Up affecting students in particular. 13  Previous studies have reported findings on the COVID-19 pandemic and its impacts on mental health in the Brazilian population. Two studies included participants from all over the country, and one study included participants from one specific state. 9,18,19 These studies found different results, identifying different social determinants as contributing to greater vulnerability to mental illness in the populations studied. One possible reason for this variability may be that these studies reported results from heterogeneous populations subjected to varying social distancing policies and did not focus on a single local profile subject to heterogenous prevention policies. Brazil is a country of continental dimensions, with significant differences between regions, especially in terms of social behavior, genetics, and economic backgrounds. Due to these marked regional differences, each of the country's regions is at a different stage of the pandemic 20 and mortality is exacerbated by regional disparities that exist within the health system. 21 It is therefore important to evaluate the pandemic's effects on mental health in a specific region in this country. Another important point is that none of these studies evaluated sleep quality using a specific scale. Considering that sleep quality has an important effect on mental health, it would be important to investigate its effects in this sample.
Thus, the purpose of the present study was to evaluate the impact of the COVID-19 pandemic on mental health in a single region in the South of Brazil, specifically the Vale do Taquari region. The region's populations have similar culture and its local governments have adopted similar social distancing policies. More specifically, we first described the study population's characteristics and their levels of stress, anxiety, depression, and sleep quality. Then, we wanted to see whether variables previously described as risk factors in the recent literature were also related to increased psychological distress, such as age, gender, education, and history of mental illness. Also, we investigated whether duration of social isolation and experiencing stressful situations during the pandemic led to increased psychiatric symptoms. Finally, we tested whether sleep quality partly explained the mental distress observed in the participants. The decision to use data from the Vale do Taquari was because this population has very high rates of COVID-19, ranking first in the state in terms of case count in May 2020, 23,24 and also because of the homogeneity of the containment measures adopted to reduce spread of the virus in this region.

Material and methods
The subjects for this study were drawn from an online questionnaire conducted between August and    was more important to anxiety outcomes for younger participants than for older ones ( Figure 1B). Also, we found an interaction between a previous mental illness  Finally, psychological symptoms were not related to duration of social isolation per se, but to the subjective perception that the pandemic interfered with life and generated stressful situations. As far as we know, our study is the first to describe these alarming relationships in the context of the COVID-19 pandemic. These findings are further discussed below.
Our results demonstrated that more than forty percent of the participants scored moderate to severe for symptoms of anxiety, depression, and stress.
Moreover, 28.74% of the subjects reported posttraumatic stress symptoms, while 59.3% considered they had experienced stressful situations during the pandemic. When compared to another study 9 that investigated the prevalence of psychiatric symptoms among the general Brazilian population during the peak of the pandemic, our rates of symptoms of depression and anxiety are lower. However, our finding is worrying because these percentages are higher when compared to other studies, [28][29][30][31][32] but are consistent with findings from a recent meta-analysis. 33 One possible reason for these differences may be the homogeneity of our sample, reflecting the consequences of the pandemic in a specific context, with similar adherence to social distancing recommendations. Additionally, when our study was conducted, this region was suffering from high rates of COVID-19, with new cases and deaths.
By September 2020, the number of confirmed COVID-19 cases in Vale do Taquari was approximately 9,000; in other words, 2.7% of the population. 23 Another critical aspect to consider is that this region has high suicide rates. 34 It is well established that the majority of suicides and suicide behavior worldwide are related to psychiatric diseases and psychiatric symptoms. 35 However, contrary to previous findings, 12 39 We also did not find a significant effect of gender in predicting mental health outcomes, contrary to the high levels of psychological distress among women found in a previous study, 10 but consistent with a recent meta-analysis. 28 However, younger age was associated with anxiety, depression, stress, and PTSD levels, which is supported by the literature. 11,40 Being younger and following COVID-19 news updates seems to be associated with elevated levels of anxiety compared with those who were older and those who were less exposed to COVID-19 news updates, 11  This kind of interaction is not the same as face-to-face social interaction, and the long screen exposure time may affect sleep quality, mainly when use is close to bedtime. 44 As stated by other authors, 45  Moreover, sleep quality also interacted with experiencing stressful situations during the pandemic in prediction of symptoms of anxiety and post-traumatic stress. It is well known that concerns about one's own health or relatives' health, experiencing changes to routines, living with uncertainty and with stress, and worries about the current situation may influence sleep quality and generate or exacerbate fear, depression, and anxiety. 44

Disclosure
No conflicts of interest declared concerning the publication of this article.