COVID-19, social isolation, and psychological distress in a Brazilian sample
Authors: de Mendonça Raíssa Oliveira , de Almeida Mylena Maria Ribeiro , Barroso Talita Garcia , Viana Normando José Queiroz , Maximino Caio 
Published: September 2020

Importance: The global infection outbreak by the new SARS-CoV-2 prompted community containment schedules; however, social isolation is a predictor of psychological distress. Objective: To determine whether social isolation, in Brazil, led to higher signs of psychological distress, and which intra- and inter-psychic variables mediated this effect. The following hypotheses were tested: 1) in isolated individuals, loneliness activates distancing and escape-avoidance coping strategies with intensities that are directly correlated with symptoms of anxiety and common health disorders; 2) in isolated individuals, poor reliance on social support coping strategies increase the effects of loneliness on symptoms of anxiety and common mental disorders; 3) in isolated individuals, External Entrapment moderates the effects of loneliness such that the higher the feelings of entrapment, the higher the effects of loneliness on symptoms of anxiety and common mental disorders. 4) in both isolated and non-isolated individuals, intense reliance on positive reappraisal coping strategies decrease (moderate) the effects of information consumption on symptoms of anxiety and common mental disorders. No a priori hypothesis on the specific nature of the subjective experiences of social isolation were established. We proposed that the semantic field of social isolation should present a complex and multidimensional nature. Design: Two phases of web-based surveys were applied to participants between May 25th 2020 and August 19th 2020. Setting: Brazilian participants responded surveys on the web. Participants: For Phase 1, 440 participants responded to the survey. Participants were a volunteer sample of Brazilian nationality and above 18 years old. For Phase 2, a sub-sample of 55 participants was drawn from the pool of the first phase. Main outcomes and measures: For Phase 1, the primary endpoint was score in the SRQ-20 scale (an instrument to screen symptoms of common mental disorders), and the secondary endpoint was score in an anxiety scale that screened feelings of anxiety related to illness and medical procedures. Results: For Phase 1, 51% of the sample reported leaving the house less than once a week during the period of the research, 27.6% reported leaving the house 1-2 times per week, 9.8% reported leaving the house 3-4 times per week, and 11.6% reported leaving the house every day. Using SRQ-20, we found that 76.9% of the female respondents and 58.0% of the male respondents that reported leaving their houses less than once a week showed clinically significant symptoms, while these proportions fell below 65% for females and 44% for males that reported leaving their houses more than 3 times per week. Reliance on escape/avoidance as well as distancing coping strategies were significant mediators of the effect of isolation-induced loneliness. We did not find support for the hypothesis that reliance on social support coping strategies significantly altered the effects of social isolation-induced loneliness on psychological distress, nor for the hypothesis that external entrapment moderated the effects of loneliness. We also found that the impact of reliance on positive reappraisal coping strategies on the relationship between frequency of media use for COVID-19-related information and psychological distress depended on the type of media, with individuals which sought information from print or online newspapers, social networks, and podcasts at higher frequencies consistently showing more psychological distress; however, higher levels of positive reappraisal coping strategies increased this impact instead of decreasing it. In Phase 2 (qualitative survey), 47.3% of the sample reported leaving the house less than once a week during the period of the research, 21.8% reported leaving the house 1-2 times per week, 10.9% reported leaving the house 3-4 times per week, and 20% reported leaving the house every day. At the qualitative survey we found that individuals interpreted isolation as producing self-assessment with protective and introspective dimensions, but also ruminative and emotional experiences of distress. Conclusions and relevance: Our results reveal that social isolation during the COVID-19 pandemic significantly increased psychological distress at clinically relevant rates, with loneliness being an important predictor of this effect. We also found that escape-avoidance and distancing coping strategies mediated this effect. Psychological distress was also related to high consumption of COVID-19-related information in social networks, print or online newspapers, and podcasts, but that relying on positive reappraisal coping strategies increased this effect instead of decreasing it. Our results suggest the need for policies that diminish the impact of social isolation on mental health; the need to assess and teach alternative coping strategies in clinical settings; and the need to address the impact of Internet-based sources.