Abstracts

Introduction

The year 2020 was marked by COVID-19, recognized as a pandemic due to its rapid spread worldwide. To halt it, quarantine, isolation, and social distancing measures were enforced to reduce social interactions ¹1. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395:912-20.^,22. Wilder-Smith A, Freedman DO. Isolation, quarantine, social distancing and community containment: pivotal role for old-style public health measures in the novel coronavirus (2019-nCoV) outbreak. J Travel Med 2020; 27:taaa020.. It has been found, however, that social isolation and the instability caused by the COVID-19 pandemic negatively affected mental health ³3. Ficanha EE, Silva EV, Rocha VMP, Badke HR, Cogo SB, Vasconcelos E, et al. Aspectos biopsicossociais relacionados ao isolamento social durante a pandemia de Covid-19: uma revisão integrativa. Research Society and Development 2020; 9:e709986410.^,44. Pancani L, Marinucci M, Aureli N, Riva P. Forced social isolation and mental health: a study on 1,006 Italians under COVID-19 lockdown. Front Psychol 2021; 12:663799.. High contagion rates, fear, and vulnerability to severe illness and death, along with the lack of knowledge about the disease ⁵5. Moreira WC, Sousa AR, Nóbrega MPSS. Adoecimento mental na população geral e em profissionais de saúde durante a COVID-19: scoping review. Texto & Contexto Enferm 2020; 29:e20200215. and social isolation, led to significant psychological impacts, including symptoms of anxiety and depression, sleep problems, stress, fear, guilt, sadness, helplessness, post-traumatic stress, and use of psychoactive substances, particularly among young adults under 35 years of age ³3. Ficanha EE, Silva EV, Rocha VMP, Badke HR, Cogo SB, Vasconcelos E, et al. Aspectos biopsicossociais relacionados ao isolamento social durante a pandemia de Covid-19: uma revisão integrativa. Research Society and Development 2020; 9:e709986410.^,66. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020; 17:1729.^,77. 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..

Various COVID-19-related risks and protective factors have been highlighted. Risk factors for psychological distress included being women, younger age, having a low socioeconomic or educational status, having a higher risk of contracting the disease, being under social isolation, and being a health worker, especially frontline ⁸8. Lee CM, Cadigan JM, Rhew IC. Increases in loneliness among young adults during the COVID-19 Pandemic and association with increases in mental health problems. J Adolesc Health 2020; 67:714-7.^,99. Jeffers A, Meehan AA, Barker J, Asher A, Montgomery MP, Bautista G, et al. Impact of Social Isolation during the COVID-19 Pandemic on Mental Health, Substance Use, and Homelessness: Qualitative Interviews with Behavioral Health Providers. Int J Environ Res Public Health 2022;19:12120.^,1010. Wathelet M, Duhem S, Vaiva G, Baubet T, Habran E, Veerapa E, et al. Factors associated with mental health disorders among university students in France confined during the COVID-19 pandemic. JAMA Netw Open 2020;3:e2025591.^,1111. Young KP, Kolcz DL, O'Sullivan DM, Ferrand J, Fried J, Robinson K. Health Care workers' mental health and quality of life during COVID-19: results from a mid-pandemic, national survey. Psychiatr Serv 2021; 72:122-8.^,1212. Almeida M, Shrestha AD, Stojanac D, Miller LJ. The impact of the COVID-19 pandemic on women's mental health. Arch Womens Ment Health 2020; 23:741-8.^,1313. Özdin S, Bayrak Özdin S. Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: the importance of gender. Int J Soc Psychiatry 2020; 66:504-11.^,1414. González-Sanguino C, Ausín B, Castellanos MA, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun 2020; 87:172-6.^,1515. Vindegaard N, Benros ME. COVID-19 pandemic and mental health consequences: Systematic review of the current evidence. Brain Behav Immun 2020; 89:531-42.^,1616. Yao H, Chen J-H, Xu Y-F. Patients with mental health disorders in the COVID-19 epidemic. Lancet Psychiatry 2020; 7:e21.^,1717. Xiong J, Lipsitz O, Nasri F, Lui LMW, Gill H, Phan L, et al. Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord 2020; 277:55-64.^,1818. Wang Y, Kala MP, Jafar TH. Factors associated with psychological distress during the coronavirus disease 2019 (COVID-19) pandemic on the predominantly general population: a systematic review and meta-analysis. PLoS One 2020; 15:e0244630.. In contrast, access to medical resources, updated information on the disease, and the employment of protective measures have been cited as protective factors ⁷7. 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.. Earlier studies had already highlighted symptoms of anxiety, aggression, and anger in individuals in social isolation due to the Middle East Respiratory Syndrome, which could lead to post-traumatic stress without early intervention ¹⁹19. Jeong H, Yim HW, Song Y-J, Ki M, Min J-A, CHO J, et al. Mental health status of people isolated due to Middle East Respiratory Syndrome. Epidemiol Health 2016; 38:e2016048..

Personality has been shown to be a relevant predictor for predisposition to develop psychopathology ²⁰20. Garcia-Fontanals A, Portell M, García-Blanco S, Poca-Dias V, García-Fructuoso F, López-Ruiz M, et al. Vulnerability to psychopathology and dimensions of personality in patients with fibromyalgia. Clin J Pain 2017; 33:991. and adherence to government policies during a pandemic. Specifically, individuals with higher neuroticism tend to avoid danger ²¹21. Jonason PK, Sherman RA. Personality and the perception of situations: the big five and dark triad traits. Pers Individ Dif 2020; 163:110081., making them more likely to comply with rules and feel safe ²²22. Zajenkowski M, Jonason PK, Leniarska M, Kozahiewicz Z. Who complies with the restrictions to reduce the spread of COVID-19?: Personality and perceptions of the COVID-19 situation. Pers Individ Dif 2020; 166:110199.. Similarly, those with higher agreeableness comply with rules due to their prosocial functioning ²³23. Wilkowski BM, Robinson MD, Meier BP. Agreeableness and the prolonged spatial processing of antisocial and prosocial information. J Res Pers 2006; 40:1152-68., as their behavior aims to protect others ²²22. Zajenkowski M, Jonason PK, Leniarska M, Kozahiewicz Z. Who complies with the restrictions to reduce the spread of COVID-19?: Personality and perceptions of the COVID-19 situation. Pers Individ Dif 2020; 166:110199.. Individuals with greater openness to experiences often engage in artistic and intellectual expressions ²¹21. Jonason PK, Sherman RA. Personality and the perception of situations: the big five and dark triad traits. Pers Individ Dif 2020; 163:110081., which can protect mental health. People with higher conscientiousness, who value cleanliness and order ²⁴24. McCrae RR, Costa Jr. PT. The five-factor theory of personality. In: John OP, Robins RW, Pervin LA, editorts. Handbook of personality: theory and research. 3rd Ed. New York: The Guilford Press; 2008. p. 159-81., may find social isolation less disruptive ²⁵25. Ai P, Liu Y, Zhao X. Big Five personality traits predict daily spatial behavior: Evidence from smartphone data. Personal Indiv Diff 2019; 147:285-91.. Conversely, those with higher extroversion, needing interpersonal contact and mobility, may find isolation challenging ²²22. Zajenkowski M, Jonason PK, Leniarska M, Kozahiewicz Z. Who complies with the restrictions to reduce the spread of COVID-19?: Personality and perceptions of the COVID-19 situation. Pers Individ Dif 2020; 166:110199.. Extroversion and conscientiousness influence compliance with COVID-19 prevention measures: higher extroversion leads to less social distancing, while higher conscientiousness leads to greater adherence to social distancing and norms ²⁶26. Carvalho LF, Pianowski G, Gonçalves AP. Personality differences and COVID-19: are extroversion and conscientiousness personality traits associated with engagement with containment measures? Trends Psychiatry Psychother 2020; 42:179-84..

The COVID-19 pandemic was, in fact, stressful for the entire world population, and each person used coping/confrontation strategies to deal with the situation. In addition, coping strategies and personality are among the most important predictors of psychopathology, accounting for 40% to 50% of the variance, with conscientiousness, extraversion, and neuroticism being the best psychopathology predictors ²⁷27. Mirnics Z, Heincz O, Bagdy G, Surányi Z, Gonda X, Benko A, et al. The relationship between the big five personality dimensions and acute psychopathology: mediating and moderating effects of coping strategies. Psychiatr Danub 2013; 25:379-88.. Furthermore, in a study by Knoll et al. ²⁸28. Knoll N, Rieckmann N, Schwarzer R. Coping as a mediator between personality and stress outcomes: a longitudinal study with cataract surgery patients. Eur J Pers 2005; 19:229-47., coping strategies were a more reliable predictor of stress when compared to personality.

Some inconsistencies in COVID-19 knowledge have fostered the emergence of negative emotions that could quickly evolve into the psychopathological conditions described above ⁵5. Moreira WC, Sousa AR, Nóbrega MPSS. Adoecimento mental na população geral e em profissionais de saúde durante a COVID-19: scoping review. Texto & Contexto Enferm 2020; 29:e20200215.^,2929. Sonoda KC. A escuta clínica em tempos de pandemia. https://acoescovid19.unifesspa.edu.br/images/conteudo/Painel_-_tempos_de_crise_KATERINE_SONODA_maio_2020.pdf (accessed on 20/May/2021).
https://acoescovid19.unifesspa.edu.br/im... . To be able to work on the prevention/treatment of psychological consequences, it is pertinent to enrich the research related to the predictors of psychological distress during the COVID-19 pandemic. Therefore, we administered a set of questionnaires designed to explore various aspects that occurred during the timeframe coinciding with the COVID-19 pandemic.

The present study aimed to examine the relationships between sociodemographic and clinical variables, personality traits, coping strategies, and psychological distress during the COVID-19 pandemic. Specifically, we aimed to:

(1) Compare psychological distress levels across different sociodemographic and clinical groups (gender, age, educational level, profession, and having a psychiatric diagnosis);

(2) Examine the correlations between psychological distress and personality traits (neuroticism and agreeableness), as well as coping strategies (denial, self-blame, self-distraction, positive reinterpretation, and behavioral disengagement);

(3) Predict psychological distress using sociodemographic variables, personality traits, and coping strategies.

Based on these objectives, we formulated the following hypotheses:

(1) Higher levels of psychological distress will be observed among women, younger individuals, those with less formal education, and those with a psychiatric diagnosis;

(2) Psychological distress will be significantly correlated with personality traits (higher neuroticism and lower agreeableness) and coping strategies (greater use of denial, self-blame, and behavioral disengagement; lesser use of self-distraction and positive reinterpretation);

(3) Personality traits (neuroticism and agreeableness) and coping strategies (denial, self-blame, self-distraction, positive reinterpretation, and behavioral disengagement) will be significant predictors of psychological distress, even after controlling for sociodemographic variables.

Method

Participants

The inclusion criteria were individuals aged 18 years or older and of Portuguese nationality. The current study sample comprised 2,402 participants. The age range of the participants was 18-61, with a mean age of 36.80 years (standard deviation [SD] = 11.80 years). Table 1 illustrates the other sociodemographic and clinical characteristics. Some variables were recoded and grouped for subsequent analyses.

Procedures

We used a non-probabilistic convenience sampling approach employing the snowball technique and sharing the study on social networks. This study was approved and shared by the Portuguese Association of Psychologists (06/May/2020), within the scope of the Scientific research support in psychological health and behavioral change in the COVID-19 pandemic sector. The study also received approval from the Ethics Committee of the Miguel Torga Institute of Higher Education (CE-P04-22).

We used Google Forms to collect data due to its ease of access and distribution, following the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines ³⁰30. Eysenbach G. Improving the quality of web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004; 6:e34.:

(1) Development and pre-testing: the survey was pre-tested with a small group of individuals to ensure clarity and functionality.

(2) Recruitment process and sample access: the survey link was posted on Facebook in targeted groups, including health and university groups. Given these groups’ nature, most members were over 18 years old. The survey description also explicitly stated the age requirement to ensure compliance.

(3) Consent: participants received detailed information and provided consent electronically before proceeding.

(4) Data protection: anonymity and confidentiality were guaranteed, with data used solely for research.

(5) Survey administration: participants could complete the survey at their own pace and exit at any time. Data collection took place between 20 March and 29 June 2020.

(6) Response rate calculation: we did not track the number of clicks on the survey link due to the organic nature of distribution on Facebook.

(7) Preventing multiple entries from the same individual: duplicate entries were screened by cross-referencing demographic information and response patterns. No duplicate responses were found.

(8) Data analysis: the data were cleaned and analyzed using appropriate statistical methods to ensure accuracy and reliability.

All procedures performed in studies involving human participants were per the ethical standards of the Miguel Torga Higher Education Institute Ethics Committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Instruments

To characterize participants, a sociodemographic and clinical questionnaire included questions on age, gender, marital status, formal education, profession, and having/not having a psychiatric disorder diagnosis. Professions were categorized into health & service care workers (e.g., Physician, Nurse, Pharmacy technician, Psychologist, Radiology technician, Social worker), administrative, managerial, & commerce workers (e.g., administrator, manager, salesperson, travel agent), education & technical professionals (e.g., engineer, journalist, teacher, student, university professor), manufacturing & service workers (e.g., cleaning staff, factory worker, kitchen assistant), law enforcement, legal, & security (e.g., lawyer, military, police officer), and other (e.g., retired, unemployed). The psychiatric disorder diagnosis was self-reported and based on the current diagnosis status.

We used the Brief Symptom Inventory (BSI) ³¹31. Derogatis LR, Melisaratos N. The brief symptom inventory: an introductory report. Psychol Med 1983; 13:595-605.^,3232. Canavarro MC. Inventário de sintomas psicopatológicos (BSI). Uma revisão crítica dos estudos realizados em Portugal. In: Simões MR, Gonçalves MM, Almeida L, editors. Avaliação psicológica. Instrumentos validados para a população portuguesa. Coimbra: Quarteto; 1999; p. 305-30., a 53-item questionnaire, to assess psychological distress. The BSI evaluates psychopathological symptomatology across nine dimensions (somatization, obsession-compulsive, anxiety, interpersonal sensitivity, depression, hostility, phobic anxiety, paranoid ideation, and psychoticism) and three global indexes. Each item is answered using a five-point Likert scale ranging from 0 (not at all) to 4 (extremely) considering a seven-day timeframe. Our study analyzed the nine dimensions and the Positive Symptom Distress Index (PSDI = the sum of the values of the items receiving non-zero responses/Positive Symptom Total Index) ³²32. Canavarro MC. Inventário de sintomas psicopatológicos (BSI). Uma revisão crítica dos estudos realizados em Portugal. In: Simões MR, Gonçalves MM, Almeida L, editors. Avaliação psicológica. Instrumentos validados para a população portuguesa. Coimbra: Quarteto; 1999; p. 305-30.. The dependent variable was psychological distress (BSI-PSDI). Cronbach’s alpha of the nine dimensions ranged from 0.7-0.85 in the original study ³¹31. Derogatis LR, Melisaratos N. The brief symptom inventory: an introductory report. Psychol Med 1983; 13:595-605., 0.62-0.80 in the Portuguese study ³²32. Canavarro MC. Inventário de sintomas psicopatológicos (BSI). Uma revisão crítica dos estudos realizados em Portugal. In: Simões MR, Gonçalves MM, Almeida L, editors. Avaliação psicológica. Instrumentos validados para a população portuguesa. Coimbra: Quarteto; 1999; p. 305-30., and 0.75-0.88 in the present study.

The NEO-Five Factor Inventory³³33. Costa P, McCrae R. The NEO PI manual supplement. Odessa: Psychological Assessment Resources; 1989. (NEO-FFI, Portuguese version ³⁴34. Magalhães E, Salgueira A, Gonzalez A-J, Costa JJ, Costa P, Lima MP, et al. NEO-FFI: psychometric properties of a short personality inventory in Portuguese context. Psicologia: Reflexão e Critica 2014; 27:642-57.) is a 60-item questionnaire that assesses the major five personality traits (with 11 items each), answered using a five-point Likert scale ranging from 0 (strongly disagree) to 4 (strongly agree). Cronbach’s alphas for the subscales used were adequate in the Portuguese adaptation version and the present study (respectively): conscientiousness (α = 0.81, α = 0.80), neuroticism (α = 0.81, α = 0.85), extraversion (α = 0.75, α = 0.75), agreeableness (α = 0.72, α = 0.65), openness to experience (α = 0.71, α = 0.64). NEO-FFI subscales were independent variables.

The Brief-COPE Inventory³⁵35. Carver CS, Scheier MF, Weintraub JK. Assessing coping strategies: a theoretically based approach. J Pers Soc Psychol 1989; 56:267-83. (BCI, Portuguese version ³⁶36. Ribeiro JLP, Rodrigues AP. Questões acerca do coping: a propósito do estudo de adaptação do Brief Cope. Psicologia, Saúde e Doenças 2004; 5:3-15.) is a 28-item questionnaire that assesses 14 coping strategies with two items for each strategy/subscale. The coping strategies include self-distraction, active coping, denial, substance use, use of emotional support, use of instrumental support, behavioral disengagement, venting, positive reframing, planning, humor, acceptance, religion, and self-blame. Each item is answered on a four-point Likert scale ranging from 0 (I never do this) to 4 (I do this most of the time). Cronbach’s alphas for the subscales were adequate in the original version (0.54-0.71), the Portuguese adaptation (0.62-0.78), and in the present study (0.65-0.79). All BCI subscales were used as independent variables.

Statistical analysis

Data were analyzed using IBM SPSS Statistics (v. 25, https://www.ibm.com/). Since skewness and kurtosis values were < 2 and < 4, parametric tests were used. Preliminarily, sociodemographic-clinical groups were compared using Student’s t-tests for independent samples and analyses of variance (ANOVA) to check for differences in BSI-PSDI scores.

For the first objective, Student t-tests or ANOVA with Tukey’s post-hoc tests were calculated to assess differences in means between groups based on gender, age, education level, and psychiatric disorder diagnosis.

For the second objective, Pearson’s correlations were calculated to examine the relationship between continuous variables, specifically neuroticism and agreeableness, coping strategies (denial, self-blame, self-distraction, positive reframing, and behavioral disengagement), and psychological distress (BSI-PSDI).

For the third objective, multiple linear regression analysis (enter method) was computed to identify independent predictors of psychopathological symptoms (BSI-PSDI) after controlling for the role of sociodemographic variables and personality dimensions. Sociodemographic and clinical variables (gender, age, educational qualifications, and psychiatric diagnosis) were entered in Block 1; neuroticism and agreeableness (NEO-FFI) were added in Block 2; and coping strategies (BCI strategies presenting significant correlation values with BSI-PSDI) in Block 3. Assumptions regarding sample size, normality, linearity, multi-collinearity, homoscedasticity, and the inexistence of outliers were confirmed.

Effect sizes were interpreted as: low/small (r = 0.10-0.29, g = 0.20-0.49, η² = 0.02); moderate/medium (r = 0.30-0.49, g = 0.50-0.79, η² = 0.13); and high/large (r = 0.50-1.0, g = 0.80-1.29, η² = 0.26) ³⁷37. Cohen J. Statistical power analysis for the behavioral sciences. 2nd Ed. Hillsdale: L. Erlbaum Associates; 1988..

For most statistical tests, the significance level was set at p < 0.05. The Bonferroni adjustment was used to correct for multiple post-hoc pairwise comparisons (three groups: p < 0.017; four groups: p < 0.0125; six groups: p < 0.003).

Results

Preliminary analysis showed the global sample BSI scores as follows: somatization (M = 0.65; SD = 0.77), obsession-compulsion (M = 1.12; SD = 0.86), interpersonal sensitivity (M = 0.83; SD = 0.87), depression (M = 0.95; SD = 0.85), anxiety (M = 1.06; SD = 0.86), hostility (M = 0.81; SD = 0.70), phobic anxiety (M = 0.77; SD = 0.88), paranoid ideation (M = 0.96; SD = 0.83), psychoticism (M = 0.69; SD = 0.71), and BSI-PSDI (M = 1.69; SD = 0.57). The global sample had higher mean scores on somatization, depression, anxiety, phobic anxiety, and psychoticism compared to the average reference values of individuals from the general population. Moreover, the global sample’s 1.69 BSI-PSDI score was very close to the 1.71 cut-off point ³²32. Canavarro MC. Inventário de sintomas psicopatológicos (BSI). Uma revisão crítica dos estudos realizados em Portugal. In: Simões MR, Gonçalves MM, Almeida L, editors. Avaliação psicológica. Instrumentos validados para a população portuguesa. Coimbra: Quarteto; 1999; p. 305-30., indicating a high level of psychological distress. Based on the BSI-PSDI cut-off, 42.7% (n = 1,026) of the sample may have experienced severe psychological distress.

In line with our first objective and hypothesis, results showed that BSI-PSDI scores differed according to various sociodemographic and clinical variables. Specifically, higher levels of psychological distress were observed among women, younger individuals, those with less formal education, those with education and technical professions, and those with a psychiatric diagnosis (Table 1).

Regarding our second objective and hypothesis, Table 2 illustrates Pearson’s correlations across the study variables. All BSI dimensions and BSI-PSDI, ranging from 25% to 46.2%, correlated highly and positively with neuroticism (NEO-FFI) and with most coping strategies (self-distraction, denial, self-blame, behavioral disengagement) and negatively with agreeableness (NEO-FFI) and with positive reframing coping strategy. Of note was the highest positive correlation between the depression subscale (BSI) and neuroticism (r ² = 46.2%).

We computed the predictive model of psychopathological symptomatology (BSI-PSDI) using multiple linear regression (enter method) to address our third objective and hypothesis. All variables included in the first block (gender, age, education, and having/not having a psychiatric diagnosis) were shown as predictors, explaining 12% of the total variance, with “having/not having a diagnosed psychiatric disorder” showing the highest predictive value (β = 0.31; p < 0.001). In the second block, after accounting for the previous ones, neuroticism (β = 0.50; p < 0.001) explained 34% of the total variance. Finally, in the third block, 37% of the variance in psychopathological symptomatology was explained by self-distraction, self-blame, and behavioral disengagement, with self-blame being the biggest predictor (β = 0.12; p < 0.001). Finally, agreeableness and positive reframing were not significant predictors of psychopathological symptomatology (Table 3).

Discussion

The COVID-19 pandemic has had profound economic and health consequences. The fear of contagion, uncertainty regarding the financial future, reorganization of daily life, and adoption of new habits have all impacted mental health ³3. Ficanha EE, Silva EV, Rocha VMP, Badke HR, Cogo SB, Vasconcelos E, et al. Aspectos biopsicossociais relacionados ao isolamento social durante a pandemia de Covid-19: uma revisão integrativa. Research Society and Development 2020; 9:e709986410.. However, the manner and intensity of these repercussions varied based on personal characteristics and predispositions. Therefore, this study aimed to investigate whether personality characteristics and coping strategies predicted psychopathological symptoms during the COVID-19 pandemic.

Our preliminary results showed increased mental health symptoms during the early months of the pandemic, including somatization, depression, anxiety, phobic anxiety, and psychoticism. Notably, 42.7% (n = 1,026) of our sample exhibited severe psychological distress. These findings align with other studies reporting anxiety disorders, depression, post-traumatic stress, sleep disturbances, extreme fear of illness, and negative social behaviors due to perceived contagion risk ⁶6. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020; 17:1729.^,1717. Xiong J, Lipsitz O, Nasri F, Lui LMW, Gill H, Phan L, et al. Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord 2020; 277:55-64.^,3838. Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and target populations. Psychiatry Clin Neurosci 2020; 74:281-2.^,3939. Gloster AT, Lamnisos D, Lubenko J, Presti G, Squatrito V, Cosntantinou M, et al. Impact of COVID-19 pandemic on mental health: an international study. PLoS One 2020; 15:e0244809.. At the pandemic’s onset, the Portuguese population showed moderate to severe symptoms of anxiety (27%) and post-traumatic stress and depression (26%) ⁴⁰40. Almeida TC, Heitor MJ, Santos O, Costa A, Virgolino A, Rasga C, et al. Saúde mental em tempos de pandemia - SM-COVID-19: Relatório final. Lisboa: Instituto Nacional de Saúde Doutor Ricardo Jorge; 2020., with less stress and greater well-being than other countries. Our findings, however, indicate a higher prevalence of severe psychological distress, possibly due to differences in assessment instruments, methodological variations, media exposure, and sociodemographic factors ¹⁷17. Xiong J, Lipsitz O, Nasri F, Lui LMW, Gill H, Phan L, et al. Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord 2020; 277:55-64.^,1818. Wang Y, Kala MP, Jafar TH. Factors associated with psychological distress during the coronavirus disease 2019 (COVID-19) pandemic on the predominantly general population: a systematic review and meta-analysis. PLoS One 2020; 15:e0244630.^,4141. Holingue C, Badillo-Goicoechea E, Riehm KE, Veldhuis CB, Thrul J, Johnson RM, et al. Mental distress during the COVID-19 pandemic among US adults without a pre-existing mental health condition: Findings from American trend panel survey. Prev Med 2020; 139:106231.. These results suggest that the mental health impact of the COVID-19 pandemic is a public health concern that requires comprehensive strategies to address.

Regarding the first objective, our study found that younger adults, women, single individuals, and those with lower education experienced higher distress during the pandemic. This finding confirms our hypothesis that these sociodemographic and clinical variables would predict higher levels of psychological distress. Younger individuals faced significant social and educational disruptions, leading to increased distress ⁸8. Lee CM, Cadigan JM, Rhew IC. Increases in loneliness among young adults during the COVID-19 Pandemic and association with increases in mental health problems. J Adolesc Health 2020; 67:714-7.^,99. Jeffers A, Meehan AA, Barker J, Asher A, Montgomery MP, Bautista G, et al. Impact of Social Isolation during the COVID-19 Pandemic on Mental Health, Substance Use, and Homelessness: Qualitative Interviews with Behavioral Health Providers. Int J Environ Res Public Health 2022;19:12120.^,1010. Wathelet M, Duhem S, Vaiva G, Baubet T, Habran E, Veerapa E, et al. Factors associated with mental health disorders among university students in France confined during the COVID-19 pandemic. JAMA Netw Open 2020;3:e2025591.^,1717. Xiong J, Lipsitz O, Nasri F, Lui LMW, Gill H, Phan L, et al. Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord 2020; 277:55-64.^,1818. Wang Y, Kala MP, Jafar TH. Factors associated with psychological distress during the coronavirus disease 2019 (COVID-19) pandemic on the predominantly general population: a systematic review and meta-analysis. PLoS One 2020; 15:e0244630.^,4141. Holingue C, Badillo-Goicoechea E, Riehm KE, Veldhuis CB, Thrul J, Johnson RM, et al. Mental distress during the COVID-19 pandemic among US adults without a pre-existing mental health condition: Findings from American trend panel survey. Prev Med 2020; 139:106231.. Women, potentially due to increased caregiving responsibilities and greater psychological vulnerability during the pandemic, reported higher levels of distress ¹²12. Almeida M, Shrestha AD, Stojanac D, Miller LJ. The impact of the COVID-19 pandemic on women's mental health. Arch Womens Ment Health 2020; 23:741-8.^,1313. Özdin S, Bayrak Özdin S. Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: the importance of gender. Int J Soc Psychiatry 2020; 66:504-11.^,1717. Xiong J, Lipsitz O, Nasri F, Lui LMW, Gill H, Phan L, et al. Impact of COVID-19 pandemic on mental health in the general population: a systematic review. J Affect Disord 2020; 277:55-64.^,1818. Wang Y, Kala MP, Jafar TH. Factors associated with psychological distress during the coronavirus disease 2019 (COVID-19) pandemic on the predominantly general population: a systematic review and meta-analysis. PLoS One 2020; 15:e0244630.^,4141. Holingue C, Badillo-Goicoechea E, Riehm KE, Veldhuis CB, Thrul J, Johnson RM, et al. Mental distress during the COVID-19 pandemic among US adults without a pre-existing mental health condition: Findings from American trend panel survey. Prev Med 2020; 139:106231.. The social isolation experienced by single individuals and the potential support system available to married individuals may explain the differences in distress levels ⁹9. Jeffers A, Meehan AA, Barker J, Asher A, Montgomery MP, Bautista G, et al. Impact of Social Isolation during the COVID-19 Pandemic on Mental Health, Substance Use, and Homelessness: Qualitative Interviews with Behavioral Health Providers. Int J Environ Res Public Health 2022;19:12120.^,1414. González-Sanguino C, Ausín B, Castellanos MA, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun 2020; 87:172-6.. Those with higher education might have had better access to resources and coping strategies, whereas those with lower educational attainment might have faced greater job insecurity, contributing to their distress ¹⁸18. Wang Y, Kala MP, Jafar TH. Factors associated with psychological distress during the coronavirus disease 2019 (COVID-19) pandemic on the predominantly general population: a systematic review and meta-analysis. PLoS One 2020; 15:e0244630.^,4141. Holingue C, Badillo-Goicoechea E, Riehm KE, Veldhuis CB, Thrul J, Johnson RM, et al. Mental distress during the COVID-19 pandemic among US adults without a pre-existing mental health condition: Findings from American trend panel survey. Prev Med 2020; 139:106231.^,4242. Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, et al. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry 2018; 5:357-69..

These sociodemographic factors have significant implications for public health strategies. Targeted mental health support and resources should be developed to mitigate the psychological impact of the pandemic, particularly for younger adults, women, single individuals, and those with lower education.

Interestingly, health and service care workers reported lower distress, which is somewhat surprising given their high-risk exposure and stress. This might be explained by their heightened sense of purpose and strong support structures ¹¹11. Young KP, Kolcz DL, O'Sullivan DM, Ferrand J, Fried J, Robinson K. Health Care workers' mental health and quality of life during COVID-19: results from a mid-pandemic, national survey. Psychiatr Serv 2021; 72:122-8.. However, other studies noted increased mental health challenges among frontline healthcare workers ⁷7. 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.^,4343. Mélo Silva Júnior ML, Sapia AV, Cavalcanti Neto JM, Barbosa NMG, Neiva VBC, Sauaia Filho EN, et al. The first wave of COVID-19 and mental distress of physician residents in Brazil: a comparison between two cohorts. Human Resources for Health 2023; 21:10., possibly because our study did not distinguish between frontline workers and other healthcare professionals. Education and technical professionals, including students, teachers, and engineers, reported higher distress, possibly due to unique occupational stressors. Individuals with pre-existing psychiatric disorders reported higher distress, highlighting their heightened vulnerability during the pandemic, as documented in various studies ¹⁴14. González-Sanguino C, Ausín B, Castellanos MA, Saiz J, López-Gómez A, Ugidos C, et al. Mental health consequences during the initial stage of the 2020 Coronavirus pandemic (COVID-19) in Spain. Brain Behav Immun 2020; 87:172-6.^,1515. Vindegaard N, Benros ME. COVID-19 pandemic and mental health consequences: Systematic review of the current evidence. Brain Behav Immun 2020; 89:531-42.^,1616. Yao H, Chen J-H, Xu Y-F. Patients with mental health disorders in the COVID-19 epidemic. Lancet Psychiatry 2020; 7:e21.. Public health strategies should aim to strengthen support systems for all essential workers, providing resources and interventions to maintain their mental health during crises.

For the second objective, we found significant correlations between psychopathological symptoms and both personality traits and coping strategies. Specifically, high levels of neuroticism were positively associated with all dimensions of psychological distress and the overall BSI-PSDI. This reinforces the literature suggesting neuroticism is a critical predictor of mental health problems ⁴⁴44. Santos Júnior JA, Lima DVB, Tenório SB, Lopes AP, Fermoseli AFO. Relação entre traços de personalidade e ansiedade. Interfaces Científicas - Saúde e Ambiente 2016; 4:51-62.^,4545. Feist J, Roberts T-A, Feist GJ. Teorias da personalidade. 8th Ed. Porto Alegre: McGraw Hill; 2015.. Neuroticism’s strong association with the depression subscale highlights its role in exacerbating depressive symptoms, likely due to the tendency of neurotic individuals to perceive situations negatively and higher emotional reactivity to stress ⁴⁶46. Zunhammer M, Eberle H, Eichhammer P, Busch V. Somatic symptoms evoked by exam stress in university students: the role of alexithymia, neuroticism, anxiety and depression. PLoS One 2013; 8:e84911.. This finding underscores the pathological nature of neuroticism, distinguishing it from other personality dimensions that are more adaptive ⁴⁷47. Panayiotou G, Kokkinos CM, Spanoudis G. Searching for the "Big Five" in a Greek context: the NEO-FFI under the microscope. Personality and Individual Differences 2004; 36:1841-54.. Our results also showed that maladaptive coping strategies, such as self-distraction, denial, self-blame, and behavioral disengagement, were positively correlated with psychological distress. These strategies appear ineffective in managing stress, leading to higher levels of psychological symptoms by preventing individuals from addressing the root causes of their distress and by fostering negative emotional states ³⁵35. Carver CS, Scheier MF, Weintraub JK. Assessing coping strategies: a theoretically based approach. J Pers Soc Psychol 1989; 56:267-83.^,4848. Orzechowska A, Zajaczkowska M, Talarowska M, Galecki P. Depression and ways of coping with stress: a preliminary study. Med Sci Monit 2013; 19:1050-6.. These findings emphasize the need for public health interventions that promote adaptive coping strategies and resilience. Training programs that help individuals develop positive coping mechanisms could mitigate the negative impact of maladaptive strategies. Health professionals should receive specialized training to help individuals develop effective coping strategies, particularly those with high neuroticism levels.

Conversely, we found negative correlations between psychological distress and both agreeableness and positive reframing. Agreeableness, characterized by compassion and cooperativeness, is linked to better social support and lower stress levels ⁴⁹49. Smith MM, Saklofske DH, Keefer KV, Tremblay PF. Coping strategies and psychological outcomes: the moderating effects of personal resiliency. J Psychol 2016; 150:318-32.^,5050. Joshanloo M. Longitudinal relationship between psychological distress and personality traits. Stress Health 2024; 40:e3305.. Positive reframing, a strategy involving viewing stressors positively, is associated with reduced stress and improved mental health outcomes ²²22. Zajenkowski M, Jonason PK, Leniarska M, Kozahiewicz Z. Who complies with the restrictions to reduce the spread of COVID-19?: Personality and perceptions of the COVID-19 situation. Pers Individ Dif 2020; 166:110199.^,5151. Altunan B, Unal A, Bingöl A, Dilek F, Girgin D. Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with Multiple Sclerosis: the relationship between perceived stress and quality of life. Mult Scler Relat Disord 2021; 53:103039.. Thus, these traits and coping strategies may buffer against psychological distress, promoting more resilient responses to stress. Promoting traits such as agreeableness and strategies like positive reframing can be beneficial in public health approaches to mental health. Programs that encourage compassion, cooperation, and positive thinking can enhance social support networks and improve overall mental well-being during crises.

Concerning the third objective, the analysis showed that gender, age, education, and psychiatric diagnosis status predicted 12% of psychopathological symptomatology, with psychiatric diagnosis being the most significant factor. Adding neuroticism increased the explained variance to 34%, indicating its major role in predicting psychopathological distress. Coping strategies, specifically self-distraction, self-blame, and behavioral disengagement, further increased the prediction to 37%, with self-blame being the strongest predictor. These findings confirm our third hypothesis that personality traits and coping strategies are significant predictors of psychological distress, even after controlling for sociodemographic variables. The exception was agreeableness and positive reframing, which were not significant predictors of psychopathological symptomatology.

These findings align with previous research indicating that personality traits, particularly neuroticism, are significant predictors of psychological distress ²⁰20. Garcia-Fontanals A, Portell M, García-Blanco S, Poca-Dias V, García-Fructuoso F, López-Ruiz M, et al. Vulnerability to psychopathology and dimensions of personality in patients with fibromyalgia. Clin J Pain 2017; 33:991.^,2727. Mirnics Z, Heincz O, Bagdy G, Surányi Z, Gonda X, Benko A, et al. The relationship between the big five personality dimensions and acute psychopathology: mediating and moderating effects of coping strategies. Psychiatr Danub 2013; 25:379-88.^,2828. Knoll N, Rieckmann N, Schwarzer R. Coping as a mediator between personality and stress outcomes: a longitudinal study with cataract surgery patients. Eur J Pers 2005; 19:229-47.^,4343. Mélo Silva Júnior ML, Sapia AV, Cavalcanti Neto JM, Barbosa NMG, Neiva VBC, Sauaia Filho EN, et al. The first wave of COVID-19 and mental distress of physician residents in Brazil: a comparison between two cohorts. Human Resources for Health 2023; 21:10.^,4545. Feist J, Roberts T-A, Feist GJ. Teorias da personalidade. 8th Ed. Porto Alegre: McGraw Hill; 2015.^,5252. Carver CS. You want to measure coping but your protocol's too long: consider the brief COPE. Int J Behav Med 1997; 4:92-100.^,5353. Carver CS, Pozo C, Harris SD, Noriega V, Scheier MF, Robinson DS, et al. How coping mediates the effect of optimism on distress: a study of women with early stage breast cancer. J Pers Soc Psychol 1993; 65:375-90.. Neuroticism’s association with emotional instability likely explains its substantial predictive value, supporting the idea that it is a possible pathological dimension of personality, while the remaining dimensions are deemed positive aspects of personality ⁴⁷47. Panayiotou G, Kokkinos CM, Spanoudis G. Searching for the "Big Five" in a Greek context: the NEO-FFI under the microscope. Personality and Individual Differences 2004; 36:1841-54.. Coping strategies such as self-blame, self-distraction, and behavioral disengagement were positively associated with psychopathological symptoms, suggesting these strategies are ineffective for managing stress. Self-blame, in particular, emerged as the strongest predictor of psychological distress, consistent with a study linking self-blame to increased fear of COVID-19, perceived stress, and depressive symptoms ⁵⁴54. Belen H. Self-blame regret, fear of COVID-19 and mental health during post-peak pandemic. International Journal of Psychology and Educational Studies 2021; 8:186-94..

Our findings contrast with some literature emphasizing the protective effects of agreeableness and positive reframing ²²22. Zajenkowski M, Jonason PK, Leniarska M, Kozahiewicz Z. Who complies with the restrictions to reduce the spread of COVID-19?: Personality and perceptions of the COVID-19 situation. Pers Individ Dif 2020; 166:110199.. Although these traits are generally considered beneficial for mental health, they did not significantly predict psychological distress in our study. This aligns with other studies identifying maladaptive coping strategies as the strongest predictors of emotional outcomes such as anxiety and stress ²⁸28. Knoll N, Rieckmann N, Schwarzer R. Coping as a mediator between personality and stress outcomes: a longitudinal study with cataract surgery patients. Eur J Pers 2005; 19:229-47.^,5252. Carver CS. You want to measure coping but your protocol's too long: consider the brief COPE. Int J Behav Med 1997; 4:92-100.^,5353. Carver CS, Pozo C, Harris SD, Noriega V, Scheier MF, Robinson DS, et al. How coping mediates the effect of optimism on distress: a study of women with early stage breast cancer. J Pers Soc Psychol 1993; 65:375-90.. This discrepancy underscores the need for further research to explore the roles of these traits in different populations and circumstances. These findings suggest that public health interventions should focus on identifying individuals with high levels of neuroticism and providing them with targeted support to prevent psychological distress. Addressing maladaptive coping strategies such as self-blame can further reduce distress levels.

Limitations

Some limitations in our study need consideration. First, we acknowledge that common method variance could be a factor, given the use of self-response instruments and online administration. This variance may inflate relationships, so future studies should include a measure of social desirability ⁵⁵55. Kline TJB, Sulsky LM, Rever-Moriyama SD. Common method variance and specification errors: A practical approach to detection. J Psychol 2000;134:401-21. or other sources for these constructs ⁵⁶56. Craighead C, Ketchen D, Dunn K, Hult GTM. Addressing common method variance: guidelines for survey research on information technology, operations, and supply chain management. IEEE Transactions on Engineering Management 2011; 58:578-88..

Second, other risk factors of psychopathological symptoms were not controlled, including socioeconomic status, having a higher risk of contracting the disease, social isolation, and stressful events related to COVID-19 ⁷7. 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.. However, by not limiting our focus to specific risk factors, our study provides a broad perspective on psychological distress and coping strategies during the pandemic, offering valuable insights that remain relevant for understanding the long-term mental health impacts of similar global crises.

Third, a limitation of our study was the inability to track the exact number of clicks on the survey link and, consequently, the response rate relative to the number of accesses. Additionally, as our survey distribution relied on organic reach, we do not have precise metrics on the percentage of the targeted population reached, which is a common limitation in studies using social media for recruitment. Despite these limitations, the high level of participation suggests that our approach effectively reached a diverse and substantial audience.

Fourth, our study did not distinguish between frontline health workers and other healthcare professionals. This lack of distinction may affect our understanding of the psychological distress experienced by healthcare workers, as those on the frontline might face different stressors compared to their non-frontline counterparts. However, this differentiation was not the primary objective of our study, which aimed to broadly assess psychological distress and coping strategies during the COVID-19 pandemic.

Fifth, our study is limited by the overrepresentation of individuals with higher education levels (71.8%), compared to the general Portuguese population. According to Organisation for Economic Co-Operation and Development (OECD) data ⁵⁷57. Organisation for Economic Co-operation and Development. Population with tertiary education. https://www.oecd.org/en/data/indicators/population-with-tertiary-education.html (accessed on 25/Jul/2024).
https://www.oecd.org/en/data/indicators/... , only 23.1% hold a Bachelor’s degree, 9.4% a Master’s, and 0.7% a PhD. This discrepancy may impact the generalizability of our findings. Future research should include a more representative sample to enhance external validity.

Sixth, the variable “psychiatric disorder diagnosis” was self-reported and based on the participants’ current diagnosis and treatment status, including taking medication or undergoing therapy at the time of the survey. This approach may have limitations, such as reliance on self-reporting accuracy and the exclusion of past psychiatric disorders that were not currently being treated. Future studies should consider obtaining more detailed psychiatric histories, including lifetime diagnoses, for providing a comprehensive understanding of participants’ mental health.

Finally, although the analyses suggest causal relationships, the cross-sectional nature of our study does not allow us to establish them. Studies, which have since been carried out in the meantime, should assess the impact of COVID-19 at the level of psychopathological symptomatology to understand the pandemic’s future impact and better identify protective (e.g., self-compassion, resilience) and risk variables (e.g., guilt, shame, self-criticism) of the development of psychopathological symptomatology ⁵⁸58. Lau BH-P, Chan CL-W, Ng S-M. Self-compassion buffers the adverse mental health impacts of COVID-19-related threats: Results from a cross-sectional survey at the first peak of Hong Kong's outbreak. Front Psychiatry 2020; 11:585270.^,5959. Gutiérrez-Hernández ME, Fanjul Rodríguez LF, Díaz Megolla A, Oynadel C, Castro WP. Analysis of the predictive role of self-compassion on emotional distress during COVID-19 lockdown. Social Sciences 2022; 11:151.^,6060. Hatun O, Kurtça TT. Self-compassion, resilience, fear of COVID-19, psychological distress, and psychological well-being among Turkish adults. Curr Psychol 2022; 24:1-11..

Conclusion

In conclusion, our data provide evidence for a link between psychopathological symptomatology, psychological distress, less protective personality characteristics (such as neuroticism), and maladaptive coping strategies (such as self-distraction, denial, self-blame, and behavioral disengagement). Notably, neuroticism and self-blame were the best predictors of psychological distress. When we also considered maladaptive coping strategies like self-blame, our understanding of what contributes to psychological distress became even clearer, highlighting the complex and multifaceted nature of psychological distress.

Given these findings, promoting resilience and adaptive strategies during prolonged pandemic scenarios is essential. Health professionals should receive specialized training to help individuals develop effective coping strategies, particularly planning, positive reframing, acceptance, and use of emotional support. Additionally, it is essential to increase the availability of mental health resources, focusing on individuals with psychological vulnerabilities, such as high levels of neuroticism.

In this context, one promising approach is Acceptance and Commitment Therapy (ACT), which focuses on accepting what is out of one’s control and committing to actions aligned with personal values. ACT helps individuals identify negative habits and manage difficult thoughts and emotions, fostering a more resilient response to stress ⁶¹61. Smith S, Hayes SC. Get out of your mind and into your life: the new acceptance and commitment therapy. Oakland: New Harbinger Publications; 2005.. By integrating these therapeutic approaches, the complex nature of psychological distress can better be addressed, improving mental health outcomes during challenging times like a pandemic.

References

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