To the editor:
The public health threat posed by the coronavirus disease 2019 (COVID-19) may negatively impact on mental wellbeing of the population and significantly increase the risk of mental health problems [1] . In this regard, there are regional differences in mental health which may be affected by sociocultural, economic and environmental factors. In China, the prevalence of mental health problems has been generally higher in the rural areas than their urban counterparts [2, 3] . However, little is known about the urban-rural disparities in the occurrence of mental health problems associated with the COVID-19 pandemic.
. Understanding the regional differences in mental health is essential for planning and implementing targeted intervention and prevention for the general population in the urban and rural areas. Therefore, we conducted a cross-sectional study from Feb 25 to Mar 17, 2020 among the outpatients in West China Hospital of Sichuan University. A semi-structured questionnaire was used to collect information pertaining to socio-demographic and clinical characteristics, with three specific questions to assess the symptoms of anxiety, depression and insomnia related to COVID-19. For those with an affirmative response to any of these items, they were further assessed by the following questionnaires: 7-item Generalized Anxiety Disorder (GAD-7), 9-item Patient Health Questionnaire (PHQ-9), and Insomnia Severity Index (ISI).
J o u r n a l P r e -p r o o f the pandemic was 25.9%, 14.2%, and 27.9%, respectively. Notably, there was a significantly higher prevalence of mental health problems in the urban patients compared to their rural counterparts (anxiety: 27.5% vs. 23.2%, depression: 15.3% vs. 12.4%, insomnia: 29.5% vs.
25.5%, all p<0.05). There were no significant differences between the urban and rural participants in terms of age, sex, marital status, and medical comorbidities, except for higher education level and family income, and being more likely to live alone in the urban participants ( Figure 1 ). There were 369 out of 1,110 participants (33.2%) with mental symptoms who reported not being able to receive timely diagnosis and treatment. In particular, rural patients were more affected by the transportation restriction (53% vs. 29.5%, p<0.001), while urban patients were more likely to express fear of cross-infection in hospitals (48.2% vs. 37.6%, p<0.05). In addition, rural patients were more likely to face the challenges of the drug shortage (9.9% vs. 7.8%, p<0.05; Supplemental Table 1 ). Logistic regression analysis showed that living with others was a risk factor of anxiety in the urban patients, while being married was associated with a reduced risk of depression in the rural patients. Higher family income and drug shortage were significantly associated with the risk of insomnia in the urban patients, while failing to receive timely diagnosis and treatment was a risk factor of insomnia in the rural patients (Supplemental Table 2 