The increase, as predicted in literature, in stress factors and stress consequences of people suffering from mental disorders during the SARS-CoV-2 pandemic, could not be confirmed within the clinical sample. The statistically significant difference between the cohorts before and during the pandemic in terms of occupational problems must be considered not clinically relevant due to the low effect size.
Women and men at psychosomatic rehabilitation clinics do not exhibit a psychosocial burden of varying severities as a result of the pandemic.
During the SARS-CoV-2 pandemic, patients in psychosomatic rehabilitation clinics reported, in the multivariate comparison, a significantly higher psychosocial burden in terms of psychosocial health, activity and participation as well as occupational problems at the beginning of rehabilitation than patients a year before the pandemic. According to Cohen (1988), the effect sizes indicate negligible effects of the pandemic consequences [21].
The univariate analyses for the areas of occupational problems, activity and participation, and psychosocial health also suggest an insignificant effect of the pandemic. With respect to occupational problems, significant differences also with a very small effect size are recognizable in the area of activity and participation as well as psychosocial health, the differences are not to be classified as significant.
Other studies also only reported minimal changes in symptom burden [10] and/or no changes in the mental health [11] of persons suffering from mental disorders. Pan et al. (2020) even identified positive developments in symptom burden [10].
The purely descriptive view of the data indicates a slightly adverse influence of the pandemic on the investigated areas of mental health (tables 1-3). This is an indication of the increased burden of people suffering from mental disorders [1, 3, 5], which had been postulated on multiple occasions by clinical psychology, as well as initial findings involving a deterioration in their psychological state [9, 8].
Table 1
Scale values Health-49 by cohort
Cohort
|
2019
|
2020
|
M
|
SD
|
M
|
SD
|
Total value
|
1.99
|
0.64
|
2.01
|
0.64
|
Somatoform complaintsa
|
1.81
|
0.95
|
1.83
|
0.97
|
Depressivenessa
|
1.93
|
0.97
|
1.97
|
1.00
|
Phobic anxietya
|
0.99
|
1.03
|
1.04
|
1.05
|
Total value mental and somatoform complaintsa
|
1.62
|
0.80
|
1.66
|
0.81
|
Mental well-beingb
|
2.78
|
0.72
|
2.79
|
0.73
|
Interactional difficultiesc
|
2.17
|
0.99
|
2.18
|
1.00
|
Self-efficacyd
|
2.39
|
0.91
|
2.43
|
0.93
|
Activity and participatione
|
2.26
|
0.83
|
2.28
|
0.83
|
Social supportf
|
1.62
|
0.87
|
1.61
|
0.88
|
Social burdenf
|
1.76
|
0.81
|
1.74
|
0.82
|
Comments. M = mean value; SD = standard deviation. a module A. b module B. c module C. d module D. e module E. f module F.
Table 2
Scale values ICF AT-50 Psych by cohort
Cohort
|
2019
|
2020
|
M
|
SD
|
M
|
SD
|
Total ICF value
|
1.65
|
0.81
|
1.70
|
0.82
|
Verbal competencea
|
1.53
|
0.98
|
1.59
|
1.00
|
Fulfill requirementsa
|
2.05
|
0.95
|
2.10
|
0.96
|
Fitness and well-beinga
|
1.78
|
1.00
|
1.82
|
0.99
|
Social relationships and activitiesb
|
1.53
|
0.98
|
1.57
|
1.00
|
Closeness in social relationshipsb
|
1.78
|
1.11
|
1.83
|
1.09
|
Social considerationb
|
0.90
|
0.78
|
0.90
|
0.78
|
Comments. M = mean value; SD = standard deviation; values rounded to two decimal places.
a Scales for documenting activity. b Scales for documenting participation.
Table 3
Occupational problems (SIMBO-C items) by cohort
|
Cohort
|
|
2019
|
2020
|
|
%
|
%
|
Unemployment
|
14.9
|
16.7
|
Incapacity to work / sick leave
|
51.2
|
56.1
|
Sick leave > 26 weeks in the last year
|
32.2
|
43.6
|
Severe occupational impairment
|
49.5
|
53.2
|
Negative subjective RTW forecast a
|
16.7
|
19.4
|
High motivation for MBORb
|
71.0
|
71.8
|
Age < 46
|
26.9
|
25.8
|
Comments. a Return-to-work forecast.
b Medical-professionally oriented rehabilitation
In the study, gender had no effect on the influence of the SARS-CoV-2 pandemic on the psychosocial burden of people suffering from mental disorders. In descriptive, exploratory analyses, there was even a tendency towards an increased burden of men suffering from mental disorders caused by the SARS-CoV-2 pandemic, both for stress factors in the sense of occupational problems and for stress consequences in the area of activity and participation as well as psychosocial health. In research to date on the influence of the pandemic on psychosocial health of the general population, an increased burden on women was frequently described [22, 12, 23]. In most cases, they featured a cross-sectional design; the causal influence of gender on an increased burden during the pandemic therefore could not be investigated. It is possible that women may have already had a greater burden before the pandemic than men. In this paper, differential values were used for the descriptive analysis of the gender effect, which adjusts the difference between men and women during the SARS-CoV-2 pandemic for the gender difference before the pandemic.
With respect to the interpretation of the results, the study exhibits a number of shortcomings. Possible selection effects when filling out the questionnaire or systematic differences in the cohorts cannot be ruled out.
Based on the present investigations, the size of the share of people with new mental disorders and/or people with previous mental illness present in the cohorts cannot be differentiated. Based on the increased stress consequences of the SARS-CoV-2 pandemic for the general population and the postulated increasing need for care, the share of new illnesses may have increased in the pandemic cohort. According to Pan et al. (2020), people suffering from multiple or chronic mental disorders experienced a greater burden as the result of the pandemic [10]. A larger share of persons who developed a new illness present in the cohort of the SARS-CoV-2 pandemic could therefore offer an alternative explanation for the psychosocial stress consequences, which did not increase in the pandemic cohort. The severity of the symptoms is also not recorded in this study. According to Pan et al. (2020), there is a link between the severity of the burden caused by the mental disorder and the extent of the burden experienced in the pandemic [10].
Based on the study design, there are only questionnaire data from routine diagnostics in the study. Even if they provide valid results for the context of rehabilitation, they may not account for the burden situation caused by the pandemic.
Studies show a peak level of the stress during the lockdown in March 2021 [24, 25]. In the present study, data were considered until December 2020, an analysis of the following cohorts could offer further findings regarding the psychosocial burden in the SARS-CoV-2 pandemic.
The limitations of the study arise from the use of data from practice. This also results in the considerable advantage that comparable data from pre-pandemic times can be applied. Cohort studies are well suited to analyzing changes in psychosocial burden caused by the SARS-CoV-2 pandemic given that differences between the study groups can be attributed to the influence of the pandemic situation. However, for causal inferences about the impact of the pandemic to be valid, the comparability of the samples must be ensured.
The large sample of 7335 patients from seven psychosomatic rehabilitation clinics constitutes a representative sample for people suffering from mental disorders in in-patient psychotherapeutic care. With clinic locations in Baden-Württemberg, Thuringia and Saxony, data from different regions in Germany are included, as a result of which different regional infection patterns are included in the study. Inferences as to the population of people suffering from mental disorders cannot be made without further ado.
In order to research the influence of the pandemic on the psychosocial burden of people suffering from mental disorders, in further approaches, the control of relevant confounding variables such as chronicity of the disease or symptom burden are necessary in order to ensure the comparability of the patients before and during the SARS-COV-2 pandemic. Also, the use of a healthy control group is necessary for investigating whether people suffering from mental disorders actually constitute a vulnerable group in the context of the SARS-CoV-2 pandemic. To assess specific stress caused by the pandemic, supplementary direct surveys, which assess pandemic-specific stress or third-party reports from physicians and psychologists regarding the psychosocial burden of their patients would be useful.
In the project "Implikationen der SARS-CoV-2 Pandemie für die psychosomatische Rehabilitation – Eine Kohortenstudie (ISAR-Psych)" (Implications of the SARS-CoV2 pandemic for psychosomatic rehabilitation – a cohort study (ISAR-Psych) – approved by Deutsche Rentenversicherung, the psychosocial stress of further years is analyzed and compared with the values before the pandemic. Furthermore, an indirect measurement of change (pre-post comparisons of psychosocial burden in rehabilitation to determine rehabilitation effectiveness) as well as direct surveys regarding stress caused by the pandemic will be supplemented to be able to derive recommendations for action for future rehabilitation.