F on ie s in Public Heal h 01 on ie sin.o g
COVID-19 go e nmen measu es
and hei impac on men al heal h:
a c oss-sec ional s udy o olde
p ima y ca e pa ien s in Ge many
FelixG.Wi mann
1
*, And eaZülke
1, Alexande Pabs
1,
MelanieLuppa
1, JochenRenéThy ian
2,3,4, AnikaKäs ne
2,
Wol gangHo mann
2,3, HannaKaduszkiewicz
5, JulianeDöh ing
5,
Ca ha inaEscales
5, JochenGensichen
6, IsabelZöllinge
6,
Robe PhilippKosilek
6, Bi gi Wiese
7, AnkeOey
7,
Hans-Helmu König
8, Ch is ianB e schneide
8, ThomasF ese
9†
and S e iG.Riedel-Helle
1†
1 Ins i u e o Social Medicine, Occupa ional Heal h and Public Heal h (ISAP), Uni e si y o Leipzig,
Leipzig, Ge many, 2 Ins i u e o Communi y Medicine, Uni e si y Medicine G ei swald (UMG),
G ei swald, Ge many, 3 Ge man Cen e o Neu odegene a i e Diseases (DZNE), Si e Ros ock/
G ei swald, G ei swald, Ge many, 4 Facul y V: School o Li e Sciences, Uni e si y o Siegen, Siegen,
Ge many, 5 Ins i u e o Gene al P ac ice, Uni e si y o Kiel, Kiel, Ge many, 6 Ins i u e o Gene al P ac ice/
Family Medicine, Uni e si y Hospi al o LMU Munich, Munich, Ge many, 7 Hanno e Medical School,
Ins i u e o Gene al P ac ice, Wo k G oup Medical S a is ics and IT-In as uc u e, Hanno e , Ge many,
8 Depa men o Heal h Economics and Heal h Se ice Resea ch, Uni e si y Medical Cen e Hambu g-
Eppendo , Hambu g, Ge many, 9 Ins i u e o Gene al P ac ice and Family Medicine, Ma in-Lu he -
Uni e si y Halle-Wi enbe g, Halle (Saale), Ge many
Backg ound: Wi h he ou b eak o COVID-19, go e nmen measu es including
social dis ancing and es ic ions o social con ac s we e imposed o slow he
sp ead o he i us. Since olde adul s a e a inc eased isk o se e e disease,
hey we e pa icula ly a ec ed by hese es ic ions. These may nega i ely a ec
men al heal h by loneliness and social isola ion, which cons i u e isk ac o s o
dep essi eness. We aimed o analyse he impac o pe cei ed es ic ion due
o go e nmen measu es on dep essi e symp oms and in es iga ed s ess as
media o in an a - isk-popula ion in Ge many.
Me hods: Da a we e collec ed in Ap il 2020 om he popula ion o he AgeWell.
de-s udy, including indi iduals wi h a Ca dio ascula Risk Fac o s, Aging, and
Incidence o Demen ia (CAIDE) sco e ≥9, using he dep ession subscale o
he B ie Symp om In en o y (BSI-18) and he Pe cei ed S ess Scale (PSS-4).
Feeling es ic ed due o COVID-19 go e nmen measu es was su eyed wi h a
s anda dized ques ionnai e. S epwise mul i a ia e eg essions using ze o-in la ed
nega i e binomial models we e applied o analyse dep essi e symp oms, ollowed
by a gene al s uc u al equa ion model o assess s ess as media o . Analysis we e
con olled o sociodemog aphic ac o s as well as social suppo .
Resul s: We analysed da a om 810 olde adul s (mean age = 69.9, SD = 5). Feeling
es ic ed due o COVID-19 go e nmen measu es was linked o inc eased
dep essi eness (b = 0.19; p < 0.001). The associa ion was no longe signi ican when
adding s ess and co a ia es (b = 0.04; p = 0.43), while s ess was linked o inc eased
dep essi e symp oms (b = 0.22; p < 0.001). A inal model con i ms he assump ion
ha he eeling o es ic ion is media ed by s ess ( o al e ec : b = 0.26; p < 0.001).
OPEN ACCESS
EDITED BY
Lin Yang,
Albe a Heal h Se ices, Canada
REVIEWED BY
Xiaoyu Zong,
Washing on Uni e si y in S . Louis,
Uni edS a es
Junxiang Chen,
Uni e si y o Pi sbu gh, Uni edS a es
*CORRESPONDENCE
Felix G. Wi mann
[email p o ec ed]
†These au ho s sha e las au ho ship
RECEIVED 10 Janua y 2023
ACCEPTED 09 May 2023
PUBLISHED 22 May 2023
CITATION
Wi mann FG, Zülke A, Pabs A, Luppa M,
Thy ian JR, Käs ne A, Ho mann W,
Kaduszkiewicz H, Döh ing J, Escales C,
Gensichen J, Zöllinge I, Kosilek RP, Wiese B,
Oey A, König H-H, B e schneide C,
F ese T and Riedel-Helle SG (2023) COVID-19
go e nmen measu es and hei impac on
men al heal h: a c oss-sec ional s udy o olde
p ima y ca e pa ien s in Ge many.
F on . Public Heal h 11:1141433.
doi: 10.3389/ pubh.2023.1141433
COPYRIGHT
© 2023 Wi mann, Zülke, Pabs , Luppa, Thy ian,
Käs ne , Ho mann, Kaduszkiewicz, Döh ing,
Escales, Gensichen, Zöllinge , Kosilek, Wiese,
Oey, König, B e schneide , F ese and Riedel-
Helle . This is an open-access a icle dis ibu ed
unde he e ms o he C ea i e Commons
A ibu ion License (CC BY). The use,
dis ibu ion o ep oduc ion in o he o ums is
pe mi ed, p o ided he o iginal au ho (s) and
he copy igh owne (s) a e c edi ed and ha
he o iginal publica ion in his jou nal is ci ed,
in acco dance wi h accep ed academic
p ac ice. No use, dis ibu ion o ep oduc ion is
pe mi ed which does no comply wi h hese
e ms.
TYPE O iginal Resea ch
PUBLISHED 22 May 2023
DOI 10.3389/ pubh.2023.1141433
Wi mann e al. 10.3389/ pubh.2023.1141433
F on ie s in Public Heal h 02 on ie sin.o g
Conclusion: We ound e idence ha eeling es ic ed due o COVID-19
go e nmen measu es is associa ed wi h highe le els o dep essi e symp oms
in olde adul s a inc eased isk o demen ia. The associa ion is media ed by
pe cei ed s ess. Fu he mo e, social suppo was signi ican ly associa ed wi h
less dep essi e symp oms. Thus, i is o high ele ance o conside possible
ad e se e ec s o go e nmen measu es ela ed o COVID-19 on men al heal h
o olde people.
KEYWORDS
COVID-19, go e nmen measu es, dep ession, s ess, olde people, social suppo
1. Backg ound
Wi h he ou b eak o he SARS-CoV-2-pandemic, he Wo ld
Heal h O ganisa ion (WHO) has decla ed a global heal h eme gency
in Janua y 2020 (1). Measu es ha e been aken wo ldwide o con ain
he i us and as o Ap il 2020, a hi d o mankind was unde
qua an ine (2). As he go e nmen measu es implemen ac o s ha
po en ially lead o social isola ion and loneliness, hey ha e a
pa icula ole o play o men al heal h. E idence sugges s ha social
isola ion is among he s onges isk ac o s o dep ession and anxie y,
especially in olde people (3, 4). Howe e , since social isola ion,
loneliness and dep essi eness coun as isk ac o s o demen ia
acco ding o Li ings on e al. (5), he e is an u gen need o add ess
he isk o hese ac o s due o go e nmen COVID-19 measu es.
A e he labo a o y con i ma ion o he i s case o COVID in
Ge many on 28 Janua y 2020 (6), he Ge man go e nmen imposed
he i s s ic es ic ions on 22 Ma ch 2020 (7). These included,
among o he s, qua an ine, social and physical dis ancing. Acco ding
o he Ox o d COVID-19 Go e nmen Response T acke o he
Uni e si y o Ox o d, he in oduc ion o he policy measu es in
Ge many mean a s ong, sudden es ic ion. On a scale om 0 o 100,
he index indica es how s ic measu es we e a a gi en poin in ime,
using nine ac o s such as es ic ions on public li e o con ac
es ic ions (8). Wi h he egula ion o 22 Ma ch 2020in Ge many, he
COVID-19 s ingency index ose om 32.9 o 76.7 (9).
Thus a , a e iew o he psychological impac o he COVID-19
pandemic on olde adul s ou lines 18 c oss-sec ional su eys. While
some o hese s udies desc ibe less psychologically dis ess in olde
people han in younge ones, i has been demons a ed ha ,
ne e heless, olde adul s expe ienced mo e se e e symp oms o
dep ession, anxie y and s ess as well as loneliness du ing he
pandemic han p e ious (10). Se e al s udies ha e con i med an
inc ease in dep essi e symp oms compa ing p e-wi h pos -pandemic
da a (11). Robb e al. (12) showed an inc ease in epo ed eelings o
dep ession symp oms (12.8% epo ed eeling wo se), especially o
women (17.3% s. 7.8% o men). Fu he mo e, an associa ion
be ween subjec i e loneliness and wo sened componen s o dep ession
was epo ed. Thy ian e al. only ound a small psychological impac
o he pandemic o olde people li ing a home wi h cogni i e
impai men (13). A sys ema ic e iew by Giebel e al. (14) u he
epo ed an inc ease o dep ession in people li ing wi h demen ia.
A sys ema ic e iew by Röh e  al. (2) ound e idence o
psychosocial consequences o es ic ions due o p e ious co ona i us
ou b eaks. O e all esul s o he 13 included s udies we e ele a ed
isks o dep ession, anxie y, s ess, social isola ion and loneliness.
Compa ing people unde pandemic es ic ions wi h people who a e
no subjec o qua an ine, Liu e al. (15) ounds a i e old inc eased
chance o dep essi e symp oms e en 3 yea s a e he qua an ine.
While a la ge p opo ion o s udies om p e ious pandemics ocuses
on heal h ca e wo ke s, mos s udies in es iga ing SARS-CoV-
qua an ine measu es su e om li le in o ma ion on
sociodemog aphic and –economic ac o s, o example o o e
65-yea -olds (2). E idence sugges s, howe e , ha olde age inc eases
he isk o ad e se men al heal h ou comes in imes o pandemic (16).
Especially isola ion and physical dis ancing h ough lockdowns a e
a ec ing bo h men al and physical heal h in olde adul s (17). Since
dep ession is among he mos common men al heal h condi ions in
olde adul s (18), indica ion o dep essi eness among olde adul s play
a pi o al ole when in es iga ing men al heal h ou comes o
go e nmen al measu es du ing pandemics.
Acco ding o Cohen e al. (19), s esso s and nega i e li e e en s
lead o an inc eased isk o men al illness h ough pe cei ed s ess.
S ess as a esul o social and physical isola ion due o he COVID-19
pandemic has been demons a ed se e al imes (20–22). A high
associa ion be ween s ess and dep ession ega ding he COVID-19
pandemic was ound by B idgland e al. (23) analysing s ess ul li e
expe iences. The possible consequences o he measu es desc ibed,
such as loss o social con ac s, loneliness and dep essi eness, a e
conside ed as isk ac o s o demen ia (5). Since, o ou knowledge,
li le is known abou he impac o he pandemic, espec i ely he
go e nmen measu es, on olde adul s a isk o demen ia, his pape
examines he ela ionship be ween he eeling o es ic ions due o
COVID-19- ela ed go e nmen measu es and dep essi e symp oms.
We u he aim o examine he ole o pe cei ed s ess esul ing om
go e nmen es ic ions and dep essi eness in olde adul s a
inc eased isk o demen ia.
2. Me hods
2.1. Design and da a collec ion
The s udy sample was d awn om pa icipan s o he AgeWell.
de- ial (24). AgeWell.de is a mul i-cen ed, clus e - andomized,
con olled p e en ion ial wi h he p ima y aim o coun e ac ing
cogni i e decline in olde gene al p ac i ione (GP) pa ien s a
inc eased isk o demen ia, applying a mul i-componen in e en ion
(24). Pa icipan s (60–77 yea s; n = 1,030) we e ec ui ed a i e s udy
Wi mann e al. 10.3389/ pubh.2023.1141433
F on ie s in Public Heal h 03 on ie sin.o g
si es ac oss Ge many (Leipzig, G ei swald, Halle, Kiel and Munich)
be ween June 2018 and Oc obe 2019. The mul i-cen ic design has
been conside ed a iable s a egy o enlis ing pa icipan s om
di e se u ban and u al egions. Jus o e hal o he sample (52%) was
emale. A de ailed desc ip ion o he s udy sample can be ound
elsewhe e (25). Pa icipan s had inc eased demen ia isk acco ding o
CAIDE (Ca dio ascula Risk Fac o s, Aging, and Incidence o
Demen ia; (26))—demen ia isk sco e (CAIDE ≥9 poin s). The isk
sco e is composed, among o he s, o ascula o me abolic isk ac o s,
bu also o he p e-exis ing diseases. The in e en ion consis s o
ad ice and mo i a ion on he modi ica ion o li es yle ac o s such as
op imiza ion o die and inc eased physical and social ac i i y (25). To
assess pa icipan s’ pe sonal si ua ion and possible impac s o he
pandemic on s udy pa icipa ion and in e en ion conduc , mailed
pape ques ionnai es we e sen o all pa icipan s in Ap il 2020. A ha
ime, he i s lockdown in Ge many was in o ce (measu es we e
enac ed on Ma ch 22nd las ing 7 weeks).
2.2. Measu es
Ques ions owa ds he pe sonal si ua ion du ing he pandemic,
like pe cep ion o pe sonal isk o suppo o he go e nmen
measu es we e su eyed using newly de eloped s anda dized
ques ions using a 5-poin Like scale (“ o ally disag ee” o” o ally
ag ee”). Feeling es ic ed due o COVID-19 go e nmen measu es
was su eyed by: “I eel se e ely es ic ed by he go e nmen measu es
o slow he sp ead o he co ona i us.”
Dep essi e symp oms we e assessed using he Ge man adap a ion
o he B ie Symp om In en o y 18 (BSI-18; (27)). The BSI-18 cap u es
men al s ess wi hin he las 7 days. Symp oms o soma isa ion,
dep essi eness and anxie y a e each asked o by six ques ions. Fo he
analysis o dep essi e symp oms, he co esponding six i ems we e
combined in o one a iable a e excluding cases wi h missing alues
(C onbach’s α = 0.83; (27, 28)).
The Pe cei ed-S ess Scale-4 (PSS-4), consis ing o ou i ems
e e ing o he expe ience o s ess ul si ua ions wi hin he las mon h
was chosen o iden i y pe cei ed s ess (29). Two ques ions (i em 2&3)
a e ph ased posi i ely and ha e been e e sed by ecoding.
Acco dingly, a highe le el o he espec i e sum sco e sugges s highe
pe cei ed s ess (30). The in e n consis ency o he ou i ems was
C onbach’s α = 0.599. Ing am e  al. (31) discuss he low in e nal
consis ency using a con i ma o y ac o analysis and conclude ha one
i em (i em 2) leads o a p oblema ic s uc u e. Acco ding o he
au ho s, he consis ency o he i ems was checked wi h and wi hou
his p oblema ic i em. The o iginal e sion, including i em 2, howe e ,
led o highe consis ency. The e o e, he o iginal e sion was used in
his s udy. Al hough he e is no o icial cu -o , Wa ig e al. (30)
ecommends compa ing i wi h a no ma i e alue a ound six poin s.
To con ol o sociodemog aphic a iables, da a collec ed du ing
he baseline in e iew we e used. Age was measu ed in yea s and
calcula ed using he di e ence be ween da e o he baseline assessmen
and o comple ion o he add-on ques ionnai e. Educa ion was
ope a ionalized in o h ee ca ego ies acco ding o Compa a i e
Analysis o Social mobili y in Indus ial Na ions (CASMIN)-scale
using in o ma ion on oca ional and p o essional quali ica ions (32).
Also, all analysis we e con olled o gende , alloca ion o con ol (CG)
o in e en ion g oup (IG) and household size. Finally, all models
we e con olled o social suppo , assessed using he En iched Social
Suppo Ins umen (ESSI). The ins umen consis s o i e ques ions,
all o which ocus on pe cei ed emo ional social suppo (33). The i e
i ems we e combined in o one a iable (C onbach’s α = 0.88) wi h
highe sco es indica ing highe social suppo .
2.3. S a is ical analysis
In a i s s ep, desc ip i e analysis we e ca ied ou . In addi ion o
i s esul s and a b oad o e iew o he da a, his p o ides indica ions
o he assump ion o he ollowing mul i a iable analysis. Dep essi e
symp oms we e assumed o inc ease i a pe son el es ic ed due o
COVID-19 go e nmen measu es. To analyse his associa ion, se e al
mul i a ia e models we e calcula ed.
Dep essi e symp oms, ea ed as a dependen a iable o all
models, shows ze o in la ion, i.e., a high p opo ion o pa icipan s
epo ed no symp oms a all. This equi es special conside a ion,
which is why ze o-in la ed nega i e binomial eg ession me hod
(ZINB) was used. ZINB ea s cases ha ha e a high le el o ze o
di e en ly han non-ze o obse a ions. Since no no mal dis ibu ion
is assumed, he e is no bias caused by he ze o in la ion (34). Besides,
o e -dispe sion can be esol ed and ZINB has been ecommended o
in es iga ions o men al heal h like dep essi e symp oms and
espec i e in luencing ac o s (35).
A hie a chical model was calcula ed o analyse he associa ion
be ween eeling es ic ed on dep essi e symp oms adding pe cei ed
s ess in a second and co a ia es in a hi d model. Based on he
assump ion ha s ess may media e he associa ion be ween he
eeling o es ic ion and dep essi eness, a ou h model was calcula ed
as single-media o model o in es iga e s ess as a media o acco ding
o MacKinnon e al. (36). Weused a gene alized s uc u al equa ion
model o he ou h model, as i allows bo h he modelling o a
media o e ec and ze o in la ion which was conside ed using
cons an dispe sion.
Fo he co ec in e p e a ion o he ZINB models, incidence- a e
a ion (IRR) we e calcula ed addi ionally (S a aCo p2019: 2822).
Signi icance le els we e se a he 5% le el o all analysis. Besides,
analysis we e calcula ed using obus s anda d e o s. Da a
managemen and analysis we e pe o med using STATA, Ve sion 16
(S a aCo p, College S a ion, TX, Uni edS a es).
3. Resul s
3.1. Sample cha ac e is ics
Pa icipan cha ac e is ics a e p esen ed in Table1. A o al o 810
esponden s we e included o he analysis. The mean age was 69.93
(SD: 4.99) yea s, while 51.23% o he sample we e emale. 22.60%
ag eed o o ally ag eed o he s a emen , ha hey eel es ic ed due
o he COVID-19 go e nmen measu es. The majo i y s a ed ha hey
eel pa ly (37.41%) es ic ed o a he /s ongly disag eed o he
s a emen o eeling es ic ed (40.00%). A high le el o he alue 0 was
conspicuous o he se e i y o dep essi eness (Figu e1). Wi hin a
angelow-high (0–20), he mean alue was x = 1.66 (SD = 2.63). The mean
alue o he se e i y o dep essi eness is 1.65 (SD: 2.64) wi h a high
le el o ze o epo ed symp oms (49.01%, n = 397). Pe cei ed s ess has
Wi mann e al. 10.3389/ pubh.2023.1141433
F on ie s in Public Heal h 04 on ie sin.o g
a mean sco e o 5.17 (Figu e1), whe eby 69.88% ha e a sco e below
he ecommended e e ence alue o six poin s (30).
3.2. Feeling es ic ed due o COVID-19
measu es and dep essi eness
Reg ession esul s o he impac o eeling es ic ed due o
COVID-19 go e nmen measu es on dep essi e symp oms a e shown
in Table2. Wi h successi e inc ease in he eeling o es ic ion, a
signi ican posi i e inc ease in dep essi e symp oms was eco ded in
model 1 (ß = 0.194; p < 0.001). A high co ela ion was ound o he
in la e g oup, i.e., pa icipan s epo ing ze o dep essi e symp oms.
The nega i e associa ion indica es, ha wi h inc easing eeling o
es ic ion, he odds o a pe son o epo ze o dep essi e symp oms
would dec ease d ama ically (ß = −11.927; p < 0.001).
When adding pe cei ed s ess, he associa ion be ween eeling o
es ic ion and dep essi e symp oms disappea s, while he e is a
signi ican co ela ion be ween pe cei ed s ess and dep essi eness
(model 2; ß = 0.223; p < 0.001). Fo he g oup o pa icipan s wi h ze o
epo ed dep essi e symp oms, he e is a nega i e, signi ican
associa ion wi h pe cei ed s ess (ß = −0.133; p < 0.001). Toge he ,
hese esul s show ha wi h inc easing pe cei ed s ess, he odds o a
pe son o epo dep essi e symp oms inc eases by an IRR o 1.25,
while he odds o epo ze o dep essi e symp oms dec ease by an IRR
o 0.88.
Finally, co a ia es we e added o con ol o ele an ac o s in
model 3. As in model 2, pe cei ed s ess was posi i ely associa ed wi h
dep essi e symp oms (ß = 0.221; p < 0.001), while no associa ion was
de ec ed wi h eeling es ic ed. Pe cei ed s ess was no longe
signi ican in he in la e g oup, i.e., pa icipan s epo ing ze o
dep essi e symp oms. Fu he mo e, social suppo was nega i ely
associa ed wi h dep essi e symp oms (ß = −0.035; p < 0.001) and
TABLE1 Cha ac e is ics o pa icipan s (n = 810).
Missing
alues
(n)
% o
mean
SD Min Max
Age (yea s) – 69.93 4.99 61 80
Gende
( emale)
– 51.23% 0.5 0 1
Educa ion Elemen a y – 21.48% 0.41 0 1
Seconda y – 52.59% 0.5 0 1
Te ia y – 25.93% 0.44 0 1
Feeling
es ic ed
S ongly
disag ee
176 15.19% 0.36 0 1
Ra he
disag ee
24.81% 0.43 0 1
Pa ly
disag ee
37.41% 0.48 0 1
Ag ee 13.09% 0.34 0 1
To ally
ag ee
9.51% 0.29 0 1
Dep essi e
symp oms
192 1.65 2.64 0 20
Pe cei ed
s ess
186 5.17 2.66 0 14
Household
size
– 1.77 0.56 1 6
In e en ion
g oup
– 45.68% 0.5 0 1
Social
suppo
195 21.83 3.73 5 25
FIGURE1
Dis ibu ion o dep essi e symp oms (n = 875) and pe cei ed s ess (n = 881) o he pa icipan s.
Wi mann e al. 10.3389/ pubh.2023.1141433
F on ie s in Public Heal h 05 on ie sin.o g
TABLE2 The e ec o he eeling o es ic ion on dep essi e symp oms using mul iple ze o-in la ed-nega i e binomial eg ession models (model 1–3)
and he media ing ole o pe cei ed s ess using a gene alized s uc u al equa ion model (model 4).
Model 1 (ZINB) Model 2 (ZINB) Model 3 (ZINB) Model 4 (GSEM)
Coe . 95%-CI Coe . 95%-CI Coe . 95%-CI Coe . 95%-CI
Dep essi e symp oms
Feeling
es ic ed
0.194*** (0.091; 0.297) 0.071 (−0.027;
0.170)
0.038 (−0.055;
0.131)
0.072 (−0.002;
0.147)
Pe cei ed s ess 0.223*** (0.191; 0.256) 0.221*** (0.188; 0.254) 0.222*** (0.191; 0.254)
Age (yea s) 0.004 (−0.015;
0.023)
0.004 (−0.012;
0.020)
Women ( e .: men) 0.034 (−0.165;
0.233)
0.036 (−0.144;
0.217)
Educa ion (p ima y; e .) – –
Educa ion (seconda y) 0.175 (−0.090;
0.440)
0.048 (−0.173;
0.269)
Educa ion ( e ia y) 0.084 (−0.191;
0.359)
0.215 (−0.014;
0.443)
Household size −0.087 (−0.282;
0.108)
−0.219*** (−0.394;
−0.044)
Social suppo −0.035*** (−0.058;
−0.013)
−0.062*** (−0.080;
−0.045)
In e en ion G oup 0.217*** (0.024; 0.411) −0.031 (−0.200;
0.139)
In la e (ze o dep essi e symp oms)
Feeling
es ic ed
−11.927*** (−20.681;
−3.174)
−0.129 (−0.409;
0.152)
−0.333 (−0.695;
0.029)
–
Pe cei ed s ess −0.133*** (−0.223;
−0.044)
−0.057 (−0.177;
0.063)
–
Age (yea s) 0.023 (−0.044;
0.090)
–
Women ( e .: men) −0.216 (−0.840;
0.409)
–
Educa ion (p ima y; e .) – –
Educa ion (seconda y) 0.549 (−0.556;
1.654)
–
Educa ion ( e ia y) −0.325 (−1.438;
0.787)
–
Household size 0.607 (−0.054;
1.268)
–
Social suppo 0.329*** (0.090; 0.567) –
In e en ion G oup 1.040*** (0.130; 1.951) –
Pe cei ed s ess
Feeling es ic ed 0.394*** (0.229; 0.559)
To al media ion e ec 0.295*** (0.223; 0.366)
Obs. 810 810 810 810
Nonze o obs. 413 413 413 413
AIC 2755.753 2559.243 2505.604 6393.373
CI, Con idence In e al; AIC, Akaike In o ma ion c i e ion; GSEM, Gene alized s uc u al equa ion model; ZINB, Ze o-in la ed nega i e binomial eg ession; Men (Gende ) and P ima y
educa ion as e e ence ca ego ies; Robus s anda d e o s; Signi icance le el: *p < 0.05, **p < 0.01, ***p < 0.001.

Wi mann e al. 10.3389/ pubh.2023.1141433
F on ie s in Public Heal h 06 on ie sin.o g
posi i ely associa ed wi h epo ing ze o dep essi e symp oms
(ß = 0.329; p < 0.001). A posi i e associa ion be ween he alloca ion o
he in e en ion g oup and dep essi e symp oms was obse ed
(ß = 0.217; p < 0.001), while he e was also a posi i e associa ion
be ween in e en ion g oup alloca ion and epo ing ze o
dep essi e symp oms.
A close look a he Akaike in o ma ion c i e ion (37) shows ha
model 3 i s he da a bes compa ed o he p eceding models.
3.3. The media ing ole o s ess
Ou s udy assumed a media ing e ec o s ess on he ela ion
be ween eelings o es ic ion and dep essi e symp oms. The esul s
indica e a ull media ion o he hypo hesized e ec (Table2; model 4).
Weobse ed a posi i e, signi ican associa ion be ween pe cei ed
s ess and dep essi e symp oms (b = 0.222; p < 0.001), while he e is no
associa ion be ween eelings o es ic ion and dep essi e symp oms
(b = 0.072; p = 0.06). Fu he mo e, an associa ion be ween he eeling
o es ic ion and pe cei ed s ess was obse ed (ß = 0.394; p < 0.001).
The o al e ec o eeling es ic ed due o COVID-19 go e nmen
measu es and pe cei ed s ess on dep essi e symp oms is ß = 0.295
(p < 0.001). Mo eo e , he e we e signi ican co ela ions be ween
household size and dep essi e symp oms (ß = −0.219; p < 0.001) and
social suppo and dep essi e symp oms (ß = −0.062; p < 0.001).
Since he media ing e ec o s ess can be measu ed only in
pa icipan s epo ing a non-ze o le el o dep essi e symp oms, no
esul s o he GSEM a e epo ed o he in la e g oup.
4. Discussion
In he cu en s udy, weaimed o analyse he associa ion be ween
he eelings o es ic ion due o COVID-19 go e nmen measu es and
dep essi e symp oms in a sample o olde adul s a inc eased isk o
demen ia in Ge many. We u he in es iga ed he e ec o s ess and,
las ly, he ole o s ess as media o be ween eelings o es ic ion due
o COVID-19 go e nmen measu es and dep essi e symp oms.
In ou s udy, abou a hal o he pa icipan s epo ed some le el
o dep essi e symp oms. O he s udies ound somewha lowe le els
o dep essi eness. Pe owski e al. epo a mean o he dep ession
subscale o 1.56(SD = 2.9) o people be ween 65 and 69yea s p io o
he pandemic si ua ion (38). Ge ha ds e al. (39) epo a mean alue
o 1.36(SD = 0.44) in a ep esen a i e sample o olde people om
Ge many, whe eby he da a we e collec ed du ing he i s lockdown,
co e ing he same imespan as ou da a. An inc ease du ing he
ou b eak o COVID-19 has been epo ed in many s udies, Bueno-
No i ol e al. (40) epo e en a se en- ime highe p e alence o
dep essi eness (3.44% s. 25%) in a me a-analysis including 12 s udies
compa ed wi h p e alence o dep essi eness in 2017.
We ound a signi ican associa ion be ween he eelings o
es ic ion due o COVID-19 go e nmen measu es and dep essi e
symp oms. The associa ion pe sis s e en when con olling o
co a ia es (sociodemog aphic cha ac e is ics, household size, social
suppo and belonging o in e en ion g oup; esul s no shown).
These esul s a e in line wi h o he in es iga ions analysing
dep essi eness du ing COVID-19 (10, 11, 40–44). While mos s udies
analysing dep essi eness du ing pandemic si ua ions solely ocus on
impac s o he pandemic i sel , o ou knowledge, only ew
in es iga ions concen a ed on he go e nmen measu es and hei
espec i e impac on men al heal h (45, 46). As ou lined abo e,
ocussing on pandemic- ela ed es ic ions is impo an due o he
aspec o in olun a y social isola ion (47). Fu he , i is impo an o
ake a close look on subjec i e eelings linked o he espec i e
measu es since hey a e o pa icula impo ance o he ela ionship
be ween social isola ion and men al heal h (48). The esul s o his
s udy unde line he impo ance o he isk o dep essi eness due o
he COVID-19 es ic ions, especially agains he backg ound ha ,
acco ding o Li ings on e al. (5), dep essi eness cons i u es a isk
ac o o demen ia.
In se e al mul i- a iable eg ession models, we ound ha eelings
o es ic ion due o COVID-19 go e nmen measu es a e associa ed
wi h inc eased dep essi eness, bu only i pe cei ed s ess is no
accoun ed o . Pe cei ed s ess i sel was independen ly associa ed
wi h highe le els o dep essi e symp oms, ende ing he posi i e
associa ion wi h eelings o es ic ion insigni ican . This is in
ag eemen wi h o e whelming e idence ha s ess is closely associa ed
wi h dep essi e symp oms (49–52), especially du ing pandemic
pe iods (53–56). Ne e heless, mos o he s udies ela ing s ess and
dep ession du ing pandemic si ua ions e e o popula ions like
s uden s o heal h ca e wo ke s. Ou esul s add o he e idence ha
a s ong associa ion o pe cei ed s ess ela ed o COVID-induced
es ic ions wi h dep ession poses a subs an ial heal h bu den
especially in olde people.
We u he ound ha he associa ion o eeling es ic ed by
go e nmen al measu es and dep essi e symp oms was ully media ed
by pe cei ed s ess. This esul is in line wi h ano he s udy epo ing
s ess due o es ic ions (45). A possible explana ion o he
associa ion be ween he eeling o es ic ed and s ess migh bea
s ong co ela ion be ween s ess and loneliness in ou da a ha is in
line wi h o he s udies (57, 58).
Social suppo was nega i ely associa ed wi h dep essi e
symp oms in ou s udy, and posi i ely associa ed wi h he absence o
dep essi e symp oms, espec i ely. Al hough he esul is in line wi h
p e ious indings (59–61), i is o in e es o he con ex o pandemic
si ua ion and go e nmen es ic ions. As Liu e al. (62) epo s, social
suppo can media e he ela ion be ween loneliness and dep essi e
symp oms in olde adul s, which highligh s he impo ance o social
suppo . In excep ional si ua ions, such as in pandemic pe iods, he
social en i onmen is conside ed o bea p o ec i e ac o o men al
heal h (63, 64). Acco dingly, as an indica o o social en i onmen ,
household size was nega i ely associa ed wi h dep essi e symp oms in
ou analysis (model 4).
Belonging o he in e en ion g oup o he AgeWell.de- ial was
associa ed wi h highe le els o dep essi e symp oms. Since baseline
in e iews we e conduc ed be ween June 2018 and Oc obe 2019,
in e en ion du a ion a ied conside ably be ween pa icipan s a he
ime o da a collec ion (Ap il 2020). Acco dingly, he obse ed
associa ion o g oup alloca ion and dep essi e symp oms canno
bein e p e ed as a causal in e en ion e ec a he gi en poin in ime.
Analysis o in e en ion e ec s on dep essi e symp oma ology a
ollow-up a e cu en ly pending. Howe e , a signi ican di e ence was
ound be ween pa icipan s who d opped ou be ween he baseline
in e iew and dis ibu ion o he add-on ques ionnai e. The mean
alue o dep essi e symp oms was signi ican ly highe in con ol
g oup-pa icipan s who d opped ou o he s udy han among
Wi mann e al. 10.3389/ pubh.2023.1141433
F on ie s in Public Heal h 07 on ie sin.o g
in e en ion g oup d opou s (mean IG: n = 32, ß = 1.21 s. CG: n = 32;
ß = 2.34; p = 0.034; see Supplemen a y Figu e S1).
5. Limi a ion and s eng hs o he
s udy
Being limi ed o c oss-sec ional da a, his s udy canno make
conclusions abou changes in dep essi e symp oms om
p e-pandemic due o he es ic ions. I is he e o e no possible o
make causal in e p e a ions ega ding he associa ion o
go e nmen al es ic ions o con ain he sp ead o COVID-19 and
dep essi e symp oms. In addi ion, i mus bes essed ha a he ime
o he da a collec ion, he go e nmen measu es had only been in
e ec o a ew weeks. Based on he esul s o his s udy, i would
be ele an o examine he ex en o which s ess and dep essi eness
and hei espec i e associa ion may ha e inc eased u he wi h
ime. Pe sis en s a es o unusual si ua ions o nega i e li e e en s a e
pa icula ly ele an o he ela ionship be ween s ess and
dep ession, since he leng h and se e i y o ci cums ances ma e s
(49). Fu he mo e, he sensi i i y analysis e ealed ha pa icipan s
wi h highe le els o baseline dep essi eness we e less likely o
comple e he add-on ques ionnai e o he COVID su ey
(p = 0.026).
Since he sample o his in es iga ion is cha ac e ised by inc eased
isk o demen ia due o he CAIDE-sco e, ou sample may demons a e
a highe p e alence o p e-exis ing disease. Wi h a gene aliza ion o
he gene al popula ion is he e o e only possible o a limi ed ex en .
No wi hs anding hese limi a ions, he s udy sugges s esul s o olde
p ima y ca e pa ien s as a ele an g oup.
Finally, i mus bes essed ha his s udy ocused on dep essi e
symp oms. In es iga ing dep essi e symp oms in olde adul s is o
pa icula impo ance due o he high p e alence and como bidi y.
Ne e heless, an issue ha was no add essed in his s udy was he
e ec o es ic ions due o COVID-19 go e nmen measu es on o he
men al heal h ou comes. I would beo in e es , o u he in es iga e
anxie y, soma isa ion o o he men al heal h ou comes as an ou come
o pandemic es ic ions.
6. Conclusion
This s udy se ou o analyse he e ec o eeling es ic ed due o
go e nmen measu es o slow he sp ead o COVID-19 on dep essi e
symp oms in a sample o olde adul s a isk o demen ia in Ge many.
The second aim o his s udy was o u he in es iga e he e ec o
s ess on he espec i e associa ion. Ou indings suppo he need o
a gene al discussion o e ec s o go e nmen measu es du ing
pandemics on men al heal h o olde adul s. Res ic ions p o ec he
heal h o people and p e en dea hs, bu hey also ha bou s isk o
loneliness, lack o social suppo , inc easing s ess and inally highe
dep essi e symp oms. Wi h ega d o como bidi y wi h o he ele an
diseases, such as demen ia, hese isks a e o pa icula impo ance o
olde adul s. The ele ance o social suppo is clea ly suppo ed by
he cu en indings, whe eby adequa e isk communica ion and
men al heal h ecommenda ions could be easonable app oaches o
ackle eelings o es ic ion and pe cei ed s ess and he eby educe
he isk o dep essi e symp oms.
Da a a ailabili y s a emen
The da ase s a e no publically a ailable due o p i acy
es ic ions: Indi idual pa icipan da a unde lying he esul s o his
a icle, a e de-iden i ica ion, is a ailable o esea che s who submi
a me hodologically sound p oposal o he AgeWell.de s ee ing
commi ee (co espondence: s[email p o ec ed].
de) o use o da a in he app o ed p oposal. Reques s o access he
da ase s should be di ec ed o SR-H, s e i. iedel-helle @medizin.
uni-leipzig.de.
E hics s a emen
The s udies in ol ing human pa icipan s we e e iewed and
app o ed by E hical Commi ee a he Medical Facul y, Leipzig
Uni e si y; E hical Commi ee a he Medical Facul y, Ch is ian-
Alb ech s-Uni e si y, Kiel; E hical Commi ee a Uni e si ä smedizin
G ei swald; E hical Commi ee a he Medical Facul y, Ludwig-
Maximilian-Uni e si y, Munich; E hical Commi ee a he Medical
Facul y, Ma in-Lu he -Uni e si y Halle-Wi enbe g; Rup ech -
Ka ls-Uni e si y, Heidelbe g. The pa ien s/pa icipan s p o ided
hei w i en in o med consen o pa icipa e in his s udy.
Au ho con ibu ions
JG, WH, HK, H-HK, JT, BW, and SR-H: concep ualiza ion o
he AgeWell.de- ial. FW: analysis and in e p e a ion o da a and
w i ing he o iginal d a . JG, WH, HK, H-HK, JT, BW, and SR-H:
unding acquisi ion. ML, AZ, AP, TF, JG, WH, HK, H-HK, JT, BW,
and SR-H: supe ision. ML, AZ, AP, JT, AK, WH, HK, JD, CE, JG,
IZ, RK, BW, AO, H-HK, CB, TF, and SR-H: e iew and edi ing. All
au ho s con ibu ed o he a icle and app o ed he
submi ed e sion.
Funding
Open Access unding enabled and o ganized by he Open Access
Publishing Fund o Leipzig Uni e si y suppo ed by he Ge man
Resea ch Founda ion wi hin he p og am Open Access Publica ion
Funding. This publica ion is pa o he s udy “AgeWell.de – a mul i-
cen ic clus e - andomized con olled p e en ion ial in p ima y ca e”
and was unded by he Ge man Fede al Minis y o Educa ion and
Resea ch (BMBF; g an s: 01GL1704A, 01GL1704B, 01GL1704C,
01GL1704D, 01GL1704E, and 01GL1704F).
Acknowledgmen s
Membe s o he AgeWell.de-s udy g oup: P incipal In es iga o :
SR-H. Co-P incipal In es iga o s: WH, JG, Wal e E. Hae eli, HK,
H-HK, TF, Da id Czock, JT, F anziska Be g, And ea Bischho , CB,
Mandy Claus, JD, Alexande Eße , Co inna G äble, S ephanie
Hings , Ca oline Jung-Sie e s, Ke s in Klaue -Tied ke, Ke s in
K ebs-Hein, Flo a Wendel, Sebas ian Lange, Paula Liege , Dagma
Lochmann, Tobias Luck, ML, Silke Mamone, Lea Ma kg a ,
Wi mann e al. 10.3389/ pubh.2023.1141433
F on ie s in Public Heal h 08 on ie sin.o g
And eas Meid, Michael Me zne , Lydia Neube , AO, Susanne Röh ,
F anziska-An onia Zo a Samos, Ka in Schumache , The esa
Te s egen, Anne Hen ike Wagne , La s Wamsiedle , Tanja Weh an,
Ma ina Weißenbo n, Ines Winkle , IZ, AZ, Ina Zwingmann. The
au ho s wan o hank all pa icipa ing GP p ac ices and s udy
pa icipan s o he AgeWell.de- ial. The au ho s acknowledge
suppo om Leipzig Uni e si y wi hin he p og am o Open
Access Publishing.
Con lic o in e es
The au ho s decla e ha he esea ch was conduc ed in he
absence o any comme cial o inancial ela ionships ha could
becons ued as a po en ial con lic o in e es .
Publishe ’s no e
All claims exp essed in his a icle a e solely hose o he au ho s
and do no necessa ily ep esen hose o hei a ilia ed
o ganiza ions, o hose o he publishe , he edi o s and he
e iewe s. Any p oduc ha may be e alua ed in his a icle, o
claim ha may be made by i s manu ac u e , is no gua an eed o
endo sed by he publishe .
Supplemen a y ma e ial
The Supplemen a y ma e ial o his a icle can be ound online
a : h ps://www. on ie sin.o g/a icles/10.3389/ pubh.2023.1141433/
ull#supplemen a y-ma e ial
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