Research on psychological distress from the coronavirus disease 2019 (COVID-19) crisis has increased significantly, but the factors that can exacerbate or mitigate such distress have remained underexplored. To address the research gap, this study examined whether two types of rumination and perceived social support predict psychological distress during the pandemic.
Participants were recruited from communities of the greater Daegu area (n=316) where the first massive outbreak in South Korea occurred and most residents underwent substantial disruption of daily life. They completed self-report questionnaires that included measures of psychological distress, event-related rumination, and social support.
The hierarchical regression analysis showed that maladaptive intrusive rumination and perceived social support predicted increases and decreases in psychological distress, respectively, even when subjective severity of COVID-19-related experiences was controlled. Putatively adaptive type of rumination (i.e., deliberate rumination) was not a significant predictor concurrently.
This is among the early endeavors to comprehensively understand risk and protective factors associated with an effective coping strategy against the COVID-19 crisis. Our results indicate that intrusive rumination aggravates but social support mitigates psychological distress during the pandemic, indicating that we can better adapt by differently attending to recent experiences and maintaining perceived social support.
The coronavirus disease 2019 (COVID-19) first appeared in late 2019 and rapidly spread over several countries and continents, leading to an unprecedented global crisis in the 21st century. On March 11, 2020, the World Health Organization (WHO) officially declared it as a global pandemic [
COVID-19 has drastically disrupted every aspect of human life. It has threatened not only the physical health but also the psychological well-being of people [
This problem immediately drew considerable research attention, which resulted in numerous published articles on the COVID-19 crisis [
However, most of the COVID-19-related mental health articles have relied on participants from China, the United States, and India, and data form the South Korean population is still limited. Moreover, not everyone experiencing a sudden stressor like COVID-19 presents negative outcomes. Although existing studies on the mental health consequences of the COVID-19 crisis have contributed to our increased understanding in a timely manner, now there is an increasing call for studies that will inform us on how to adapt to this prolonged stress. To better understand the individual differences in coping with the pandemic, researchers should shift their focus toward factors that can exacerbate or mitigate psychological distress during the COVID-19 crisis.
One such factor is rumination, defined as repetitively and passively focusing on negative thoughts; a substantial body of literature indicated that it is a transdiagnostic risk factor that exacerbates and prolongs the impact of stressors, resulting in various psychological problems, such as depression and anxiety [
Here it is worth noting that rumination is not a unitary construct but rather a multifaceted one that is composed of functionally differential sub-factors [
Social support is another important protective factor that may be associated with psychological distress during the COVID-19 pandemic. Perceived social support is defined as perceived availability and adequacy of the general availability of support and/or global satisfaction with the support provided [
The major aim of this study was to examine whether the two types of event-related rumination and perceived social support influence psychological distress during the COVID-19 crisis. Participants in this study were adults living in greater Daegu area, where the first massive outbreak in South Korea occurred and most residents went through severe restrictions in daily life due to COVID-19. We hypothesized that intrusive rumination and perceived social support would predict increases and decreases in psychological distress, respectively. At this point, there was not enough backgrounds for specifying the concurrent relation between deliberate rumination and distress [
Data were collected from community-dwelling residents of Daegu and Gyeongsangbuk-do Province in South Korea using an online questionnaire in early August 2020. We recruited a representative sample of residents in terms of age and gender to enhance generalizability of this study. The number of participants totaled 316 adults aged 20 years or older; all were included in subsequent analyses. Half (50.6%) were female and participants’ age ranged from 20 to 73 years (M=43.28, SD=12.61). All procedures and materials were approved by the Institutional Review Board of Kyungpook National University (KNU-2020-0054). An online informed consent was obtained from all participants. Sample characteristics are presented in
Two questions, which were originally suggested by García et al. [
The BSI-18 is a self-report questionnaire use for conveniently assessing psychological distress with limited number of items [
The ERRI was developed to separately assess the two types of rumination related to a stressful life event: intrusive and deliberate rumination [
The Perceived Social Support Scale was used to assess the extent to which an individual perceives social support [
After descriptive statistics, we conducted correlational analyses to examine the relationship of the main variables, namely, psychological distress, event-related rumination, and social support. Next, a hierarchical regression analysis was performed to examine the predictors of psychological stress. To demonstrate the incremental variance explained by intrusive rumination, deliberate rumination, and perceived social support in Step 2, two variables of subjective severity were entered as independent variables to be controlled in Step 1. Statistical analyses were carried out using SPSS ver. 24.0 (IBM Corp, Armonk, NY, USA).
On average, participants reported having experienced considerable disruption in daily life (M=3.84, SD=0.78) owing to COVID-19 and rated COVID-19 as a traumatic experience of moderate severity (M=2.94, SD=0.10). One participant (0.3%) was diagnosed with COVID-19 and 31 (9.8%) had family members or close friends who were diagnosed with the disease. About 20% of the participants underwent a screening test or self-quarantine, suggesting a widespread infection within the community at that time.
As can be seen in
As predicted, social support was negatively correlated with psychological distress (r=-0.26, p<0.001). However, it showed a varying pattern of correlation with the two types of event-related rumination. It was significantly negatively associated with intrusive rumination (r=-0.20, p<0.001) but uncorrelated with deliberate rumination (r=0.07, n.s.).
To consider the individual differences at a specific level of COVID-19-related stress, we controlled for two variables of subjective severity (i.e., disruption in daily life and perceived traumatic stress) in Step 1 in a series of hierarchical regression analysis (
For an exploratory purpose, we repeated the hierarchical regression modeling using the same independent variables that predict depression, anxiety, or somatization, instead of the GSI, to see if this relation is robust across specific symptom contents. The results were identical; intrusive rumination was a positive and the strongest predictor, whereas perceived social support was a negative predictor of each psychological symptom in Step 2. These findings indicate the generalizability of the results of the present study irrespective of symptom domain.
The present study explored whether certain factors could explain the individual differences in coping with COVID-19 among residents of Daegu and Gyeongsangbuk-do, who underwent the first massive COVID-19 outbreak in South Korea. Specifically, we investigated how people perceived their COVID-19-related experiences (intrusive versus deliberate rumination) and whether their perceived social support could predict unique variances in psychological distress. Overall, the results supported our hypotheses. Intrusive rumination, or the maladaptive type of ruminative thinking, was positively associated with psychological distress, whereas social support was negatively associated with the latter.
An increasing amount of evidence has shown that the adverse impact of COVID-19 is not confined to physical health but extends to mental health issues [
First, the way people think about their COVID-19-related experiences seemed to matter. Consistent with the previous literature, our study provides converging evidence that rumination may yield an increased level of psychological distress as a response to the COVID-19 crisis. However, different from previous investigations, such as Ye et al. [
A disruption in life and increased stress after the COVID-19 outbreak may naturally lead people to engage in repetitive thinking about what has been going wrong. In this case, the “how,” rather than the “how much,” they think about these stressors is more important. Our results suggest that people with heightened intrusive rumination are susceptible to more psychological distress. From a therapeutic perspective, it may be difficult to divert ruminators from a repetitive thinking pattern particularly when under stress [
In line with previous studies [
Therefore, the next step in addressing the crisis should be to create ways to strengthen social support as psychological resources to effectively cope with this prolonged, global pandemic. Which component of social support (e.g., emotional, material, informational, evaluative social support) is more conducive to maintaining mental health in times of COVID-19? Is social support delivered online or by a virtual technology as effective as that delivered offline and through direct interpersonal contact? What is the active component or mechanism of buffering effect of social support in the face of pandemic? These questions can be a few starting points for future research that will inform mental health care guidelines during the COVID-19 crisis.
Lastly, we would like to emphasize that our results were obtained from a representative sample of adults living in Daegu and adjacent Gyeongsangbuk-do area, where residents underwent severe restrictions in daily life during the first major outbreak in South Korea from early to mid of 2020. Although a complete lockdown has not been executed as a governmental policy, as people who were tested positive for COVID-19 drastically increased specifically within these areas, mobility from and out of these regions was greatly diminished, and economic and social activities were profoundly hampered during that period. Unlike previous studies that used convenience sampling, our sample was stratified by age and gender to increase the ecological validity of the current findings. Additionally, considering that approximately half of the COVID-19-related mental health articles have relied on participants from China, the United States, and India [
Certain limitations should be noted. First, because this is a cross-sectional study, it was not possible to directly examine the causality between variables. Therefore, directionality between rumination, social support, and psychological distress should be investigated in future studies employing longitudinal design. In particular, the impact of deliberate rumination, which did not concurrently predict psychological distress in our results, may vary across time and exert time-lagged protective effect [
Second, although we tried to enhance ecological validity by recruiting community-dwelling residents in a severely affected region, the role of rumination and perceived social support should be examined in other samples as well for generalizability, especially those who are undergoing tremendous stress during the COVID-19 crisis. For instance, health professionals in the front lines are in dire need of mental health support [
Third, reliance on self-report data is also a limitation. Although self-report measures are convenient tools for data collection, especially when participants are adults without literacy difficulty and when research topics deal with internal experiences that cannot be externally observed, which was the case in our study, they are susceptible to issues of certain reporting bias or social desirability. Therefore, subsequent studies would benefit from diversifying methods of data collection.
In summary, the current study extends existing literature regarding rumination and social support by providing evidence that intrusive rumination exacerbates but social support may mitigate psychological distress in reaction to stress caused by the novel pandemic. Although no one can be absolutely free from COVID-19-related stress for the time being, our results suggest that we can still be buffered from psychological distress by differently attending to recent experiences and maintaining or improving perceived social support. In short, the impact of COVID-19 on mental health may not be equal to everyone, despite its ubiquitous presence worldwide. We hope that continued research with a refined focus on plausible risk and/or protective factors will contribute to a better understanding of how we can stay not only physically but also psychologically healthy throughout the prolonged pandemic, which will eventually serve as a sound basis for developing an evidencebased mental health guideline for COVID-19.
None.
The authors have no potential conflicts of interest to disclose.
Author Hyo Shin Kang and Bin-Na Kim jointly participated in conceptualization, data collection, and statistical analysis. In draft writing, author Bin-Na Kim wrote the first draft of Introduction and Methods, and author Hyo Shin Kang wrote the first draft of Results and Discussion. Afterwards, the authors reviewed and edited the draft together, and approved of the final draft.
Sample characteristics (N=316)
Mean | SD | N (%) | |
---|---|---|---|
Age | 43.28 | 12.61 | |
Gender | |||
Male | 156 (49.4) | ||
Female | 160 (50.6) | ||
Residence | |||
Daegu | 220 (69.6) | ||
Gyeonsangbuk-do | 96 (30.4) | ||
Subjective severity | |||
Disruption in daily life | 3.84 | 0.78 | |
Perceived traumatic experience | 2.94 | 0.10 | |
COVID-19-related experience | |||
Diagnosis confirmed | 1 (0.3) | ||
Diagnosis of family or close friends | 31 (9.8) | ||
Screening test | 42 (13.3) | ||
Self-quarantine | 23 (7.3) | ||
Education | |||
University | 239 (75.7) | ||
High school | 74 (23.4) | ||
Middle school | 3 (0.9) | ||
Marital status | |||
Unmarried | 117 (37.0) | ||
Married or cohabiting | 175 (55.4) | ||
Divorced | 20 (6.3) | ||
Bereaved | 4 (1.3) |
Descriptive and correlation analyses (N=316)
K-BSI | K-ERRI |
Social support | ||
---|---|---|---|---|
IR | DR | |||
K-BSI | - | 0.65 |
0.34 |
-0.26 |
K-ERRI | - | |||
Intrusive rumination (IR) | 0.56 |
-0.20 |
||
Deliberate rumination (DR) | - | 0.07 | ||
Mean | 42.86 | 20.69 | 23.05 | 90.56 |
SD | 15.22 | 7.62 | 6.40 | 16.12 |
p<0.001.
K-BSI: Korean-Brief Symptom Inventory, K-ERRI: Korean-Event Related Rumination Inventory
Hierarchical regression predicting psychological distress (N=316)
Step | IV | B | SE | β | t | R2 | ΔR2 |
---|---|---|---|---|---|---|---|
1 | SS 1 | 1.02 | 1.03 | 0.05 | 0.99 | 0.27 |
|
SS 2 | 7.58 | 0.80 | 0.40 | 9.44 |
|||
2 | SS 1 | 0.02 | 0.86 | 0.00 | 0.03 | 0.51 |
0.24 |
SS 2 | 4.67 | 0.72 | 0.31 | 6.47 |
|||
Intrusive rumination | 0.96 | 0.11 | 0.48 | 8.72 |
|||
Deliberate rumination | -0.01 | 0.12 | 0.00 | -0.09 | |||
Social support | -0.16 | 0.04 | -0.17 | -4.12 |
p<0.001.
SS: subjective severity (1=disruption in daily life, 2=perceived traumatic experience)