Healthcare Workers and Patient Loss During the COVID-19 Pandemic: Interaction Between Grief, Viral Anxiety, and Depression

Article information

Psychiatry Investig. 2024;21(10):1076-1082
Publication date (electronic) : 2024 September 11
doi : https://doi.org/10.30773/pi.2024.0172
1Department of Psychiatry, Keyo Hospital, Uiwang, Republic of Korea
2Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
3Department of Psychiatry, Yongin Mental Hospital, Yongin, Republic of Korea
4Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
5Life Care Center for Cancer Patient, Asan Medical Center Cancer Institute, Seoul, Republic of Korea
Correspondence: Seockhoon Chung, MD, PhD Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 86 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea Tel: +82-2-3010-3411, Fax: +82-2-485-8381, E-mail: schung@amc.seoul.kr
Correspondence: Seyoung Seo, MD, PhD Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 86 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea Tel: +82-2-3010-0491, Fax: +82-2-3010-6961, E-mail: syseo@amc.seoul.kr
Received 2024 May 15; Revised 2024 July 5; Accepted 2024 July 14.

Abstract

Objective

Coronavirus disease-2019 (COVID-19) had a significant impact on the mental health of healthcare workers. Related assessments should be included in plans for future pandemics. We investigated the connections between grief, viral anxiety, depression, and preoccupation in the context of COVID-19 in healthcare workers, to determine which factors will need to be incorporated.

Methods

A total of 267 healthcare workers who had experienced the death of at least one patient during the COVID-19 pandemic were asked to respond to questionnaires assessing grief, viral anxiety, depression, loneliness, and preoccupation with COVID-19, based on their emotional state during the 2 weeks immediately after the death. Multivariate linear regression, causal mediation analysis and structural equation modeling were used to examine the psychological processes underlying grief.

Results

Linear regression showed that viral anxiety (β=0.287, 95% confidence interval [CI]: 0.235–0.338, p<0.001) and depression (β=0.157, 95% CI: 0.073–0.241, p<0.001) had independent associations with preoccupation with COVID-19. Causal mediation analysis revealed that both viral anxiety (proportion mediated: 0.51, 95% CI: 0.37–0.66, p<0.001) and depression (proportion mediated: 0.77, 95% CI: 0.50–1.08, p<0.001) were mediators between grief and preoccupation with COVID-19. In a structural equation model, viral anxiety and depression mediated most of the effects of grief on preoccupation with COVID-19, and loneliness was a mediator between grief and depression.

Conclusion

Contingency plans for the next pandemic are being formulated. Effective measures to protect the mental health of healthcare workers should be included, and such measures should consist of assessments for grief, viral anxiety, depression, and loneliness.

INTRODUCTION

During the severe acute respiratory syndrome coronavirus-2 pandemic, the continuous high demand placed on healthcare systems resulted in significant mental health problems in healthcare workers, with serious levels of depressive symptoms and burnout [1]. Prevalence reports of anxiety ranged from 7% to 57%, and 9% to 51% for depression [2]. Loneliness was also prominent in healthcare workers [1].

Persistent exposure to patient deaths in healthcare workers can increase their workload and lead to deep grief and burnout [3], as occurred during the pandemic, as healthcare workers were tasked with comforting patients while coping with high death rates. This denied them the opportunity to process their grief and increased the risk for complicated grief [4].

Complicated grief reactions are characterized by prolonged painful emotions related to bereavement and a significant loss of function (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]), and may affect nearly 60% of nurses [5]. New support systems for healthcare workers will need to consider complicated grief, and also depression and anxiety, as complicated grief is associated with both [6]. Knowledge of the relationship between grief, depression and anxiety will be invaluable when designing such systems.

Preoccupation with the pandemic has been linked to higher levels of functional impairment in healthcare workers [7]. After studying the interactions of viral anxiety and depression in healthcare workers during the pandemic [8,9], we found that both affected preoccupation with coronavirus disease-2019 (COVID-19) [10]. Therefore, grief may be associated with preoccupation with COVID-19, and viral anxiety and depression may mediate this interaction.

Loneliness is a symptom of complicated grief (DSM-5), and a significant predictor of exhaustion and worse mental health [11,12]. A study on young adults undertaken during the pandemic showed that it was associated with depression and anxiety [13]. Thus, loneliness may be a mediator between grief, depression, and anxiety.

As explained above, previous studies have reported that both viral anxiety and depression are associated with complicated grief, preoccupation with COVID-19 and loneliness. These results hint at a wider relationship encompassing all of these factors. Therefore, we aimed to identify this relationship by determining the connections between grief, viral anxiety, depression and preoccupation in the context of COVID-19. We hypothesized that (A) grief would influence preoccupation with COVID-19, and (B) the association between grief and preoccupation with COVID-19 would be mediated by viral anxiety, loneliness and depression.

METHODS

Participants

We conducted an online survey between June 2 and 11, 2022 on healthcare workers of a tertiary hospital situated in Seoul, South Korea. Medical doctors (n=1,769) and nursing professionals (n=4,680) were asked to respond if they had experienced the death of at least one patient during the past 2 years of the COVID-19 pandemic. This period represented the most extreme period of the pandemic, as monthly cases increased from under 100 to nearly 10 million (Korean Disease Control and Prevention Agency). Participation was voluntary, for which a gift coupon worth 5 US dollars was provided. The survey form was developed according to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines [14], and checked by an investigator (S.C.) prior to implementation. The CHERRIES was developed by the Journal of Medical Internet Research to improve the descriptions of web-based surveys and focuses on the sample selection process.

We collected responses from 293 (4.5%) participants, and 26 who had not experienced patients’ deaths during the past 2 years were excluded from the study. The Institutional Review Board of Asan Medical Center (2022-0740) approved the study protocol and waived the requirement of the informed consent form.

Measures

Participants were asked to recall their emotional state during the 2 weeks immediately after experiencing the death of their patient and respond accordingly.

Pandemic Grief Scale for healthcare workers

The Pandemic Grief Scale (PGS) is a self-reported rating scale measuring individuals’ grief reactions during the COVID-19 pandemic [15]. The healthcare worker’s version was revised from the original PGS by the investigator in Korean [16], and consists of 5 items which can be rated on a 4-point scale. The total score reflects the probability of a dysfunctional grief response. We translated the original English version into Korean by translation and back-translation methods. The Cronbach’s alpha for this sample was 0.842.

Fear of COVID-19 Scale

The Fear of COVID-19 Scale (FCV-19S) is a rating scale which measures an individual’s anxiety response related to the viral pandemic [17]. All seven items in the FCV-19S can be rated on a 5-point scale. A higher total score reflects a higher level of viral anxiety. We used the validated Korean version [18]. The Cronbach’ alpha was 0.889 among this sample.

Obsession with COVID-19 Scale

The Obsession with COVID-19 Scale (OCS) measures an individual’s degree of preoccupation with the coronavirus [19]. It consists of four items which can be answered on a 5-point scale. A higher total score reflects a higher level of preoccupation. We used the Korean version which has been validated [20]. The Cronbach’s alpha among this sample was 0.832.

Patient Health Questionnaire-9 items

The Patient Health Questionnaire-9 items (PHQ-9) is a self-report rating scale which measures an individual’s depressive symptoms [21]. It consists of nine items rated on a 4-point scale, and a higher total score indicates a higher level of depression. The validated Korean version was used in this study [22]. The Cronbach’s alpha among this sample was 0.901.

Loneliness and Social Isolation Scale-6 items

The Loneliness and Social Isolation Scale-6 items (LSIS-6) scale is a self-report rating scale developed in English and Korean which can measure an individuals’ social isolation and loneliness [23]. It consists of 6 items rated on a 4-point scale, and a higher score reflects a higher level of loneliness. The Cronbach’s alpha among this sample was 0.747.

Statistical analysis

Demographic data were presented in means and standard deviations, or frequencies with proportions. We constructed linear regression models with the PGS, FCV-19S, LSIS-6, and PHQ-9 scores, each separately, and then altogether, as independent variables and the OCS score as the dependent variable. The relationships determined by the correlations were then used as a framework to construct the causal mediation models. We constructed four separate models. In three models, the direct effect of the PGS score on the OCS score was assessed, with either the FCV-19S, PHQ-9, or LSIS-6 scores as mediators. In the fourth model, the direct effect of the PGS score on the PHQ-9 score was analyzed, with the LSIS-6 score as the mediator. Bootstrapping with 1,000 iterations was used. Finally, based on the causal mediation analysis results, we constructed a structural equation model that included the PGS, FCV-19S, LSIS-6, PHQ-9, and OCS scores. Bootstrapping with 2,000 iterations was used for this analysis. We used R version 4.1.2 (R Core Team, www.r-project.org), with the dplyr, mediation and lavaan packages for analysis.

RESULTS

The participants were 267 healthcare workers who had experienced patient deaths during the past 2 years of the pandemic. About one third (34.1%) were doctors and the rest were registered nursing professionals (65.9%) (Table 1). They were aged 31 years on average and 78.7% were females. All participants had cared for COVID-19 patients, and 62 (23.2%) reported that the patients’ deaths were related to COVID-19.

Clinical characteristics of participants (N=267)

Through linear regression analysis, we found that whereas the PGS, FCV-19S, LSIS-6, and PHQ-9 scores all showed some level of correlation with the OCS, only the associations of the FCV-19S and PHQ-9 with the OCS were independent of the others (estimate: 0.287, p<0.001 for the FCV-19S; estimate: 0.157, p<0.001 for the PHQ-9) (Table 2). The causal mediation analysis showed that the PGS scores had a significant indirect effect on the OCS scores, which was mediated by both the FCV-19S (regression coefficient: 0.324, p<0.001, proportion mediated: 0.51, 95% confidence interval [CI]: 0.37–0.66, p<0.001) and the PHQ-9 scores (regression coefficient: 0.498, p<0.001, proportion mediated: 0.77, 95% CI: 0.50–1.08, p<0.001) (Figure 1 and Table 3). These results show that viral anxiety and depression each mediated 51% and 77% of the effect of grief on obsession with the coronavirus when analyzed separately. Additionally, although LSIS-6 did not influence the OCS scores, it mediated the effect of the PGS scores on the PHQ-9 scores.

Regression analysis for expecting preoccupation with coronavirus

Figure 1.

The effects of various mediators on the relationship between grief and preoccupation with COVID-19. The indirect effects of grief on preoccupation with COVID-19 were mediated by viral anxiety and depression but not loneliness. Grief had an indirect effect on depression which was mediated by loneliness (***p<0.001). Causal mediation analysis models investigating the effect of the PGS score on the OCS score with either the (A) FCV-19S, (B) PHQ-9, or (C) LSIS-6 scores as mediators. The last model (D) examined the effect of the PGS score on the PHQ-9 score, with the LSIS-6 score as the mediator. OCS, Obsession with COVID-19 Scale; PGS, Pandemic Grief Scale; FCV-19S, Fear of COVID-19 Scale; LSIS-6, Loneliness and Social Isolation Scale-6 items; PHQ-9, Patient Health Questionnaire-9 items; ACME, average causal mediation effect; ADE, average direct effect.

The results of direct, indirect, and total effects on mediation analysis (N=154)

Based on these findings, we constructed a structural equation model for a comprehensive comparison of the variables (Figure 2). The FCV-19S and PHQ-9 scores both mediated the effects of the PGS scores on the OCS scores, and the strength of each was comparable at 29% and 22%, respectively (PGS → FCV-19S → OCS, regression coefficient: 0.286, p<0.001; PGS → PHQ-9 → OCS, regression coefficient: 0.220, p=0.003). Furthermore, the direct effect of the PGS scores on the OCS scores was not significant (regression coefficient: 0.138, p=0.128), reconfirming that most effects of the PGS scores on the OCS scores were not direct, but mediated by the PCV-19S and PHQ-9 scores.

Figure 2.

Structural equation model of the effects of grief, viral anxiety, loneliness, depression and preoccupation with COVID-19. The effect of grief on preoccupation with COVID-19 was indirectly mediated by viral anxiety and depression, and the strength of the effects mediated by each factor were comparable. The direct effect of grief on preoccupation with COVID-19 was not statistically significant (**p<0.01; ***p<0.001). OCS, Obsession with COVID-19 Scale; PGS, Pandemic Grief Scale; FCV-19S, Fear of COVID-19 Scale; LSIS-6, Loneliness and Social Isolation Scale-6 items; PHQ-9, Patient Health Questionnaire-9 items.

DISCUSSION

We found that both viral anxiety and depression mediated the effect of grief on preoccupation with COVID-19 in healthcare workers who have recently experienced patient deaths. Loneliness was also a mediator between grief and depression. Furthermore, the indirect effects mediated by viral anxiety and depression were comparable to each other and accounted for most of the effects of grief on preoccupation with COVID-19.

The pandemic has been linked to various mental health problems in healthcare workers, and have caused issues with grieving [4]. Complicated grief has been linked to depression and anxiety [24], and a study reported that loneliness predicted both depression and anxiety symptoms during the pandemic [25]. Our results support these findings and offer a framework with which to approach their interactions, and show that grieving healthcare workers should be assessed for anxiety and depression and help to combat loneliness.

Our structural equation model can be interpreted with regards to the Terror Management Theory (TMT). The TMT stipulates that, when experiencing conscious thoughts of death, we engage in “proximal defenses,” and when those thoughts leave our consciousness, “distal defenses” are applied. The proximal defenses include thought suppression, denial of vulnerability, and measures to prevent death. As our participants had recently experienced the death of a patient, they would have been having conscious thoughts of death, which through anxiety and depression, increased obsessive thoughts and preoccupation with the coronavirus, and led to compulsive measures to prevent contracting COVID-19, and possible death. Although we did not assess such behavior in our participants, obsessive thoughts can lead to compulsive behavior [26], and obsessive-compulsive symptoms in healthcare workers have actually increased after the onset of the pandemic [27], supporting this argument.

This study has several limitations. First, a self-report questionnaire was used to assess depression. However, we used a widely used instrument; therefore, this probably had minimal effect [21]. Second, the age of our subjects was comparatively young. Young healthcare workers with limited work experience or those without proper training are more susceptible to depression or post-traumatic stress [5]. Therefore, the results of this study may be an overestimation of the average experience of a healthcare worker. Third, the participants were not assessed immediately after the death of a patient. Fourth, the participants were not limited to those who experienced COVID-related deaths only. The number of participants with COVID-related deaths was too small to have sufficient statistical power for our study objective. Larger studies will be needed to verify our results.

In conclusion, we found that viral anxiety and depression are associated with preoccupation with COVID-19 and mediate most of the effects of grief on preoccupation with COVID-19 in healthcare workers who have recently experienced the death of a patient. Furthermore, loneliness mediated the effect of grief on depression. Contingency plans for the next pandemic are being formulated by governments and institutions, and effective measures to protect the mental health of healthcare workers will be needed. Such measures should include assessments for grief, viral anxiety, depression, and loneliness.

Notes

Availability of Data and Material

The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.

Conflicts of Interest

Seockhoon Chung, a contributing editor of the Psychiatry Investigation, was not involved in the editorial evaluation or decision to publish this article. All remaining authors have declared no conflicts of interest.

Author Contributions

Conceptualization: Seyoung Seo, Seockhoon Chung. Data curation: Eulah Cho. Formal analysis: Hoyoung An. Writing—original draft: Hoyoung An. Writing—review &editing: Hyejin Seo.

Funding Statement

None

Acknowledgements

None

References

1. Sunjaya DK, Herawati DMD, Siregar AYM. Depressive, anxiety, and burnout symptoms on health care personnel at a month after COVID-19 outbreak in Indonesia. BMC Public Health 2021;21:227.
2. Luo M, Guo L, Yu M, Jiang W, Wang H. The psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public-a systematic review and meta-analysis. Psychiatry Res 2020;291:113190.
3. Redinbaugh EM, Schuerger JM, Weiss LL, Brufsky A, Arnold R. Health care professionals’ grief: a model based on occupational style and coping. Psychooncology 2001;10:187–198.
4. Rabow MW, Huang CS, White-Hammond GE, Tucker RO. Witnesses and victims both: healthcare workers and grief in the time of COVID-19. J Pain Symptom Manage 2021;62:647–656.
5. Rahmani F, Hosseinzadeh M, Gholizadeh L. Complicated grief and related factors among nursing staff during the COVID-19 pandemic: a cross-sectional study. BMC Psychiatry 2023;23:73.
6. Simon NM, Shear KM, Thompson EH, Zalta AK, Perlman C, Reynolds CF, et al. The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief. Compr Psychiatry 2007;48:395–399.
7. Atreya A, Nepal S, Menezes RG, Shurjeel Q, Qazi S, Ram MD, et al. Assessment of fear, anxiety, obsession and functional impairment due to COVID-19 amongst health-care workers and trainees: a cross-sectional study in Nepal. F1000Res 2022;11:119.
8. Ahn MH, Shin YW, Suh S, Kim JH, Kim HJ, Lee KU, et al. High workrelated stress and anxiety response to COVID-19 among healthcare workers: a cross-sectional online survey study in South Korea. JMIR Public Health Surveill 2021;22(7)e25489.
9. Hong Y, Lee J, Lee HJ, Kim K, Cho IK, Ahn MH, et al. Resilience and work-related stress may affect depressive symptoms in nursing professionals during the COVID-19 pandemic era. Psychiatry Investig 2021;18:357–363.
10. Kim HS, Ahn J, Lee J, Hong Y, Kim C, Park J, et al. The mediating effect of reassurance-seeking behavior on the influence of viral anxiety and depression on COVID-19 obsession among medical students. Front Psychiatry 2022;13:899266.
11. Karcz E, Zdun-Ryżewska A, Zimmermann A. Loneliness, complaining and professional burnout of medical personnel of psychiatric wards during COVID-19 pandemic-cross-sectional study. Healthcare (Basel) 2022;10:145.
12. Gustafson DR, Yucel R, Apple SJ, Cirrone G, Gao H, Huang AJ, et al. Mental health of emergency department healthcare workers during COVID-19 in Brooklyn, New York. Med Res Arch 2022;10:2903.
13. Liu CH, Zhang E, Wong GTF, Hyun S, Hahm HC. Factors associated with depression, anxiety, and PTSD symptomatology during the COVID-19 pandemic: clinical implications for U.S. young adult mental health. Psychiatry Res 2020;290:113172.
14. Eysenbach G. Improving the quality of web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004;6e34.
15. Lee SA, Neimeyer RA. Pandemic Grief Scale: a screening tool for dysfunctional grief due to a COVID-19 loss. Death Stud 2022;46:14–24.
16. Kim JH, Park CHK, Ahmed O, Hong Y, Chung S, Park J, et al. Validation of the healthcare workers’ version of the Pandemic Grief Scale among frontline nursing professionals during the COVID-19 pandemic in Korea. Front Psychiatry 2023;14:1121546.
17. Ahorsu DK, Lin CY, Imani V, Saffari M, Griffiths MD, Pakpour AH. The Fear of COVID-19 Scale: development and initial validation. Int J Ment Health Addict 2020;20:1537–1545.
18. Han JW, Park J, Lee H. Validity and reliability of the Korean version of the Fear of COVID-19 Scale. Int J Environ Res Public Health 2021;18:7402.
19. Lee SA. How much “Thinking” about COVID-19 is clinically dysfunctional? Brain Behav Immun 2020;87:97–98.
20. Choi E, Lee J, Lee SA. Validation of the Korean version of the obsession with COVID-19 scale and the Coronavirus Anxiety Scale. Death Stud 2020;46:608–614.
21. Costantini L, Pasquarella C, Odone A, Colucci ME, Costanza A, Serafini G, et al. Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): a systematic review. J Affect Disord 2021;279:473–483.
22. Park SJ, Choi HR, Choi JH, Kim K, Hong JP. [Reliability and validity of the Korean version of the Patient Health Questionnaire-9 (PHQ-9)]. Anxiety Mood 2010;6:119–124.
23. Hwang SJ, Hong JP, An JH, Kim MH, Jeong SH, Chang H. [Development and validation of Loneliness and Social Isolation scale]. J Korean Neuropsychiatr Assoc 2021;60:291–297. Korean.
24. Yan B, Lo RSK, Chow AYM. The role of post-loss anxiety in the development of depressive symptoms and complicated grief symptoms: a longitudinal SEM study. J Affect Disord 2021;281:649–656.
25. Murata S, Rezeppa T, Thoma B, Marengo L, Krancevich K, Chiyka E, et al. The psychiatric sequelae of the COVID-19 pandemic in adolescents, adults, and health care workers. Depress Anxiety 2021;38:233–246.
26. Aouizerate B, Guehl D, Cuny E, Rougier A, Bioulac B, Tignol J, et al. Pathophysiology of obsessive-compulsive disorder: a necessary link between phenomenology, neuropsychology, imagery and physiology. Prog Neurobiol 2004;72:195–221.
27. Juan Y, Yuanyuan C, Qiuxiang Y, Cong L, Xiaofeng L, Yundong Z, et al. Psychological distress surveillance and related impact analysis of hospital staff during the COVID-19 epidemic in Chongqing, China. Compr Psychiatry 2020;103:152198.

Article information Continued

Figure 1.

The effects of various mediators on the relationship between grief and preoccupation with COVID-19. The indirect effects of grief on preoccupation with COVID-19 were mediated by viral anxiety and depression but not loneliness. Grief had an indirect effect on depression which was mediated by loneliness (***p<0.001). Causal mediation analysis models investigating the effect of the PGS score on the OCS score with either the (A) FCV-19S, (B) PHQ-9, or (C) LSIS-6 scores as mediators. The last model (D) examined the effect of the PGS score on the PHQ-9 score, with the LSIS-6 score as the mediator. OCS, Obsession with COVID-19 Scale; PGS, Pandemic Grief Scale; FCV-19S, Fear of COVID-19 Scale; LSIS-6, Loneliness and Social Isolation Scale-6 items; PHQ-9, Patient Health Questionnaire-9 items; ACME, average causal mediation effect; ADE, average direct effect.

Figure 2.

Structural equation model of the effects of grief, viral anxiety, loneliness, depression and preoccupation with COVID-19. The effect of grief on preoccupation with COVID-19 was indirectly mediated by viral anxiety and depression, and the strength of the effects mediated by each factor were comparable. The direct effect of grief on preoccupation with COVID-19 was not statistically significant (**p<0.01; ***p<0.001). OCS, Obsession with COVID-19 Scale; PGS, Pandemic Grief Scale; FCV-19S, Fear of COVID-19 Scale; LSIS-6, Loneliness and Social Isolation Scale-6 items; PHQ-9, Patient Health Questionnaire-9 items.

Table 1.

Clinical characteristics of participants (N=267)

Variables Value
Female sex 210 (78.7)
Job
 Doctors 91 (34.1)
 Nursing professionals 176 (65.9)
Age (year) 31.4±5.4
Years of employment 6.6±5.4
Marital status*
 Single 168 (63.4)
 Married, without kids 35 (13.2)
 Married, with kids 62 (23.4)
Are you a shift worker? 153 (57.3)
Questions on COVID-19
 Are you taking care of COVID-19 infected patients? (yes) 221 (82.8)
 Did you experience being quarantined due to infection with COVID-19? (yes) 155 (58.1)
 Did you experience being infected with COVID-19? (yes) 134 (50.2)
 Did you get vaccinated? (yes) 264 (98.9)
Did you experience deaths of COVID-19 infected patients? (yes) 267 (100)
 Death was related with COVID-19 62 (23.2)
 Death was not related with COVID-19 164 (61.4)
 Unknown 41 (15.4)
Psychiatric history
 Did you have experience or treated depression, anxiety, or insomnia? (yes) 42 (15.7)
 Now, do you think you are depressed or anxious, or do you need help for your mood state? (yes) 19 (7.1)
Rating scales scores
 PGS for healthcare workers 1.3±2.1
 FCV-19S 16.4±5.8
 PHQ-9 3.6±4.5
 Preoccupation with COVID-19 3.5±3.1
 LSIS-6 5.5±3.1

Data are presented as mean±standard deviation or number (%).

*

there were two missing values.

PGS, Pandemic Grief Scale; FCV-19S, Fear of COVID-19 Scale; LSIS-6, Loneliness and Social Isolation Scale-6 items; PHQ-9, Patient Health Questionnaire-9 items

Table 2.

Regression analysis for expecting preoccupation with coronavirus

Dependent variable Included parameters Unadjusted model*
Adjusted model
Estimate 95% CI p Adjusted R2 Estimate 95% CI p Adjusted R2
OCS PGS 0.643 0.486–0.801 <0.001 0.194 0.147 -0.017–0.312 0.078 0.544
FCV-19S 0.369 0.323–0.415 <0.001 0.484 0.287 0.235–0.338 <0.001
LSIS-6 0.257 0.143–0.371 <0.001 0.066 -0.023 -0.115–0.069 0.621
PHQ-9 0.392 0.326–0.459 <0.001 0.333 0.157 0.073–0.241 <0.001
*

unadjusted linear regression models including only one independent variable;

adjusted linear regression model including all 4 parameters (PGS, FCV-19S, LSIS-6, PHQ-9).

OCS, Obsession with COVID-19 Scale; PGS, Pandemic Grief Scale; FCV-19S, Fear of COVID-19 Scale; LSIS-6, Loneliness and Social Isolation Scale-6 items; PHQ-9, Patient Health Questionnaire-9 items; CI, confidence interval

Table 3.

The results of direct, indirect, and total effects on mediation analysis (N=154)

Mediator variable Parameters Standardized estimate 95% CI p
FCV-19S* ACME 0.324 0.22–0.43 <0.001
ADE 0.318 0.18–0.46 <0.001
Total effect 0.643 0.48–0.79 <0.001
Prop. mediated 0.505 0.37–0.66 <0.001
PHQ-9* ACME 0.498 0.32–0.67 <0.001
ADE 0.147 -0.04–0.34 0.120
Total effect 0.651 0.50–0.79 <0.001
Prop. mediated 0.769 0.50–1.08 <0.001
LSIS-6* ACME 0.051 -0.04–0.14 0.260
ADE 0.592 0.41–0.78 <0.001
Total effect 0.643 0.47–0.82 <0.001
Prop. mediated 0.078 -0.06–0.22 0.260
LSIS-6 ACME 0.188 0.09–0.30 <0.001
ADE 1.252 1.06–1.45 <0.001
Total effect 1.440 1.25–1.64 <0.001
Prop. mediated 0.129 0.06–0.21 <0.001
*

causal mediation analysis with the PGS as the independent variable, the OCS as the dependent variable, and either the FCV-19S, PHQ-9, or LSIS-6, as the mediator;

causal mediation analysis with the PGS as the independent variable, the PHQ-9 as the dependent variable, and the LSIS-6 as the mediator.

CI, confidence interval; PGS, Pandemic Grief Scale; FCV-19S, Fear of COVID-19 Scale; LSIS-6, Loneliness and Social Isolation Scale-6 items; PHQ-9, Patient Health Questionnaire-9 items; ACME, average causal mediation effect; ADE, average direct effect; OCS, Obsession with COVID-19 Scale