Photo Credit: IDF twitter

{Originally posted to the JCPA website}

As the coronavirus pandemic continues and expands across the globe, attention has turned to the behavioral consequences that may result. The implications go beyond narrow clinical concerns for those affected and have widespread social-political and economic repercussions, much of it related to the effects of continued forced restrictions on society. As noted by academics in the business world, mental health may become the next global pandemic.1 In the United States, a study conducted at the end of March 20202 found an increase over the previous few weeks in those who answered “yes” to the question: “Has stress related to coronavirus affected your mental health?” Others have outlined in detail the factors that can affect mental health as Covid-19 spreads and have called for urgent research priorities in the field to be implemented.3 The professional concern for mental health becoming a national crisis in the United States4 and across the world appears to be growing, as indicated by the World Health Organization (WHO).5

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Clearly, there will be cultural and societal differences in how populations react and how psychological consequences will be expressed. In looking at the psychology of the coronavirus pandemic, we need to differentiate between the reactions to the epidemic itself, such as fear and anxiety, and reactions to the consequences of the epidemic, namely, social isolation and economic uncertainty. The stress of the epidemic has spawned a number of efforts, mostly dealing with the clinical results of being directly affected by the virus. Intervention programs have been initiated for healthcare workers who treat Covid-19 patients6 and also specifically for doctors who are on the frontlines of the crisis.7 Live online sessions related to mental health have been conducted for communities that have been hit hard by Covid-19.8 New York State provides a crisis hotline to provide “free and confidential support,” helping callers experiencing increased anxiety due to the coronavirus emergency.9

While the reasons for concern for those needing to confront the virus head-on appear to be clear, the actual data on the mental health effects of social distancing as a result of epidemics in general is sparse.10 The literature on the effects of quarantine, however, can provide insight into what people are experiencing and may continue to experience with social distancing. In general, the professional literature has found that the psychological effects of quarantine can be significant, especially if isolation continues beyond 10 days.11 So while we know what “can” happen, we still don’t fully know much about what has actually happened or what will happen as some continue to experience social isolation or longer periods of quarantine as a result of Covid-19. Older adults, clearly at greater risk and logically those that will experiences longer periods of isolation, appear to pose a unique challenge.12 Others speak to recognizing that the unique threat of Covid-19 is likely to impact countries with high percentages of low wage earners who will likely experience the brunt of the consequences of lockdown measures.13

Gathering empirical data on the psychological effects of restrictions and infection is important and would provide critical data for governments, which must decide on the nature and timing of lifting coronavirus-related restrictions.

The Israeli Experience

Similar to media reports elsewhere, Israeli media have reported on organizations dealing with mental health concerns as a result of the coronavirus14 and experts who speak to the universal trauma likely to be seen.15 However, does the actual situation accurately reflect these understandable concerns?

We would like to report on a preliminary study conducted between April 1 and May 4, 2020, corresponding approximately to the dates during which lockdown-like restrictions were imposed on the general Israeli population. We have some reservations regarding the representativeness of the data since our subjects, while randomly and voluntarily surveyed, were recruited as convenience samples through social media networks. Thus, interpretation of results needs to be done with caution, considering the limitations of the study. The samples include both Jewish (196 in number) and Arab (Muslim, 131 in number) citizens of Israel, and our data is analyzed separately for each group. While both samples are overrepresented by females (63.8% Jewish sample, 75.6% Arab Muslim sample), they are both similar in other demographic qualities. There are no significant differences in the samples in age (average age Jewish sample=41 years, Arab Muslim sample=39 years), gender and years of education (average for both samples of 15+ years). Data related to economic status before and after the start of the pandemic (see below), family (marital) status or number of children below age 18 were all essentially similar with slight, but not socially significant, expected differences that reflect the Israel-Arab sectors in society. As such, the comparisons between the samples would appear to be valid.

The Study’s Structure

Keeping in mind the reservations noted above, we look at our data as providing a window into the psychological functioning and resilience of the Israeli public that may be different from that of other countries. In general, we can say that the data shows that both Jewish and Arab Muslim citizens of Israel demonstrate good levels of psychological resilience, despite being under strict social distancing regulations that included extended periods of quarantine.

General Mental Health

Our major dependent variable was the General Health Questionnaire-12 (GHQ-12),16 a recognized tool that is considered a general measure of overall mental health. The measure was administered along with questions related to fear and concern regarding coronavirus. The Cronbach alpha, a measure of internal validity and consistency, was computed for both samples, with scores of 0.828 for the Jewish sample and 0.856 for the Arab Muslim sample (scores above 0.80 are considered to reflect good validity and consistency).

When we look at both individual and total scores for the GHQ-12, we find slight, but clinically insignificant differences between the two samples. Items were scored as follows on the following scale: First, for one set of items (e.g., Have you recently lost much sleep over worry?): 0 not at all, 1 not more than usual, 2 a little more than usual, 3 much more than usual. For another set of items (e.g., Have you recently been able to concentrate on what you are doing?): 0 better than usual, 1 as usual, 2 a little less than usual, 3 much less than usual. For the first set of questions, scores of between 0 and 1 reflect usual or better than usual behavior, scores between 1 and 2 reflect functioning within the normal or usual range, with scores between 2 and 3 reflecting deviations from normal or usual behavior. On the second set of questions, scores between 0 and 1 reflect normal or usual behavior, with scores between 1 and 2 reflecting normal or slightly less than usual functioning. Scores above 2 tend to the “much less than usual” range.

For both samples, no individual mean item above “2” was recorded (i.e., no item reflected high or strong levels of deviation from normal functioning), with the mean (average) score on any individual item of 1.287 for the Jewish sample and 1.398 for the Arab Muslim sample. The mean total scores for the samples were 15.44 for the Jewish sample and 16.78 for the Arab Muslim sample. These represent differences that are not clinically significant, as both samples showed general “normal” or “usual” to only “slightly less than normal or usual” functioning as measured by the GHQ-12. When plotted, one can see that both Jewish and Arab Muslim citizens of Israel showed almost identical trends, with only slight differences in mean scores, with no score passing “2,” which would indicate a strong (much more than usual) “out of normal” result.

Jewish and Arab Muslim GHQ Scores

Perceived Change in Economic Status as a Result of the Coronavirus Outbreak

When we look at the economic factors. We find that both groups are generally younger, working-age individuals with families, and both experienced a decline in their economic situation during the period of the study. We measured economic integrity on a 3-point scale, ranging from not good=1, to good=2 to very good=3. Prior to the outbreak, both Jewish and Arab Muslim citizens report that they enjoyed better than “good” economic status. Both groups report their status to have deteriorated to somewhere below, but closer to “good” than to “no good.” The following graph illustrates the changes in perceived level of economic status. The differences in both the Jewish and the Arab Muslim samples between their pre-corona perception of their economic status and their perceived status after the outbreak is statistically significant at the p<.001 level.

Economic Status Change

In percentage terms, about 78% of both Jewish and Arab Muslim citizens felt their status was better than “good” prior to the outbreak, with the percentages going down after the outbreak to 63.8% for the Jewish citizens and 52.7% for the Arab Muslim citizens. We thus see the relative stability of psychological health as measured by the GHQ-12, despite the relative decline in perceived economic status in both samples.

Fears Caused by the Coronavirus Outbreak

One other measure we looked at was fear and concern over coronavirus that people felt. We looked at fear and concern for oneself, for one’s family, and for one’s community. Here we found similar trends, but with different levels among the two groups. For both groups, the greatest level of concern was for one’s family. But while 38.8% of the Jewish sample felt a “high” level of concern, in the Arab Muslim sample the percentage was 64.9%. Differences were also noted in concern for one’s community, with only 20.9% of the Jewish sample claiming “high” concern versus 64.1% of the Arab Muslim sample, similar to concern for one’s own family. We also see differences in the levels of fear and concern for oneself (personal), with only 5.6% of the Jewish sample expressing personal concern versus 19.8% of the Arab Muslim sample. These differences are meaningful and show strong statistical significance (p<.001) for all modes of fear and concern.

How much are you fearful or concerned about Coronavirus?

Policy Implications

Despite limitations of the study, the data show a clear and consistent similarity between younger (average age in the 40s) Jewish and Arab Muslim citizens of Israel regarding their perception of their psychological status in the wake of the coronavirus pandemic. Both groups showed overall good mental health and coping ability despite both groups following a similar pattern of reporting a downturn in their personal economic status. While the Jewish sample demonstrated slightly better overall coping, the difference does not appear to be clinically or functionally significant.

An analysis of individual items of the GHQ-12 shows that the better scores, reflecting “usual” or “better than usual” functioning, were seen on items indicative of personal ability to adapt. For example, both groups showed “much better than usual” scores on items related to self-confidence and finding meaning in living. Similarly, both groups showed a generally “better than usual” response when directly asked about their ability to cope at present with their problems.

That is not to say that there was no reported strain or increase in distress. The GHQ-12 items that tapped these behaviors showed, in both groups, that behaviors such as concentration, decision-making, and general satisfaction with daily life all tend to be “less than usual.” However, these negative deviations, seemingly reflective of a new reality, seemed to be reported along with a “better than usual” ability to cope and adapt to the situation. This would be what we have come to call “resilience” or the ability to cope and maintain emotional equilibrium during a crisis.17 Such resilience is usually correlated with less long-term negative effects and, as Israeli sociologist Aaron Antonovsky has noted, comes when there is comprehensible, manageable, and somehow explainable conditions to cope with.18

The relationship between psychological coping and the coronavirus pandemic is seen by some as related to the level of stringency of restrictions imposed by governments. Researchers at the University of Oxford composed a “stringency index”19 described as a ”composite measure based on nine response indicators including school closures, workplace closures, and travel bans, rescaled to a value from 0 to 100 (100 = strictest response). Israel, during the period of this study, gradually raised the stringency level of restrictions to where it eventually settled at a high level of 96.03. Compare this with the United States, where, during the same period, stringency of restrictions did not exceed a level of 71.88.

Understanding the relatively good coping and resilience of Israelis despite the high level of restrictions placed on the society may be a function of Israeli society’s experience with crisis. Repeated wars and exposure to terrorism may have created a “hardiness” that makes resilience in conditions of stress more likely. Indeed, we have shown how adults in one community in Israel who experienced a higher level of terror attacks showed stress levels similar to those in another community that experienced much lower levels of attacks.20 Another study showed how Israeli social workers whose role involved helping terror victims on a daily basis still did not show high levels of stress indicators.21 Another explanation may be rooted in the role that official restrictions play in psychological security by providing predictability and structure. As noted by Kelly and Noonan,22 “Having stable and well-recognized rules of interaction gives a sense of predictability, reliability and legibility to social life, thus reducing the anxiety caused by the ambiguity and openness of many social situations (p. 235).”

In Europe, the discrepancy between societies that have experienced hardships and yet were able to tolerate strict restrictions has been seen in the relatively better results in countries like Croatia and Greece as opposed to the UK, Spain, and Italy.23 Similarly, Israel, with a population similar to New York City, has shown much better results battling coronavirus, with May 11, 2020, showing 16,477 cases and 252 deaths in Israel24 versus 186,656 cases and 19,292 deaths in New York City.25 As illustrated in the bar graph below, the comparison is stark.

Comparison New York City-Israel

Israel is a country whose citizens have long experienced periods of uncertainty that have included multiple wars, ongoing terrorism, and even existential threats such as posed by Iran’s nuclear ambitions. The coronavirus epidemic is characterized by uncertainty, restriction to personal freedom, and economic suffering, all factors that Israelis, both the Jewish majority and the Arab minority, have experienced for years. The ability to successfully tolerate the uncertainty and restrictions of the coronavirus epidemic is but one crisis event in a series of crises that Israelis have experienced throughout their history.

Open Questions

While the relatively efficient coping we found in our study is encouraging, we need to point out several provisos. The effects we found were after less than two months of restrictions and economic difficulty. Continued restrictions and economic hardship may very well likely erode the resilience reflected in our results. Indeed, our data show negative Pearson correlations (r=-.-263 in the Jewish sample and -.288 in the Arab Muslim sample) between concern over economic issues and scores on the GHQ-12 that suggests that this “common sense” relationship, namely, improved well-being with improved economic status, should be considered. Next, our samples consisted of younger people who personally may be carriers and “spreaders” of the virus, but who also are not likely to suffer more than mild symptoms. In fact, most of our sample (85.7% in the Jewish sample; 92.4% in the Arab Muslim sample) either did not know anyone at all or only had a tangential knowledge of someone who was infected with Covid-19.

Moreover, the overwhelming majority of our sample did not experience mandatory quarantine as a result of being exposed to an infected individual or being infected themselves (91.8% of the Jewish sample, 88.5% of the Arab Muslim sample). Increasing infection and death rates may have limited exposure of our sample to the more serious health effects of the coronavirus and may play a role in limiting negative psychological consequences.

We do not know what the level of resilience is in the older population, who are recommended to continue under stricter levels of personal restrictions. We also do not know the resilience levels in the Haredi sectors of Israeli society since, as noted by a recent Ben-Gurion University study, they do not readily make use of communication systems offered by social networks,26 making data gathering more difficult.

Our results also do not take into consideration those individuals who may have had pre-existing psychological issues. In most crisis situations, those with such conditions are likely “at-risk” and it may very well be that this is true with the coronavirus epidemic as well. A study to assess this is currently being conducted in the United Kingdom.27

Conclusions

Contrary to conventional wisdom, our data, despite the limitations, indicates that Israelis we surveyed, including both Jewish and Arab Muslim citizens, showed good coping ability and experienced limited negative psychological consequences to date as a result of the coronavirus epidemic. This is despite a marked sense of worsening personal economic status and significant restrictions imposed by the government during the period of the study. We see these findings as evidence of the resilience of the population as a whole, which is likely related to a hardiness developed over time and repeated exposure to crisis situations. Like reports in other countries, Israel has seen positive results from the relatively stringent restrictions placed on society. If our data are accurate, the fear and concern that such severe restrictions would result in negative mental health consequences in Israel has not materialized. While we cannot say how long-term restrictions and continued economic hardship would affect resilience, the present results seem to justify the efforts of governments, like Israel, that have chosen a more definitive, strict approach in confronting the coronavirus challenge.

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Notes

1 https://www.sun-sentinel.com/opinion/commentary/fl-op-com-quelch-knoop-pandemic-mental-health-crisis-20200420-s6pgcccrnngudap3oaak66nfve-story.html

3 https://www.mdedge.com/rheumatology/article/220224/coronavirus-updates/survey-covid-19-getting-our-heads?ecd=wnl_evn_200407_mdedge_8pm&uac=&oc_slh=f48f649c6a8255aa15ea320cd9b736fd0dfbe39a4046849da8299d24236b0010&utm_source=News_MDedge_eNL_040620_F&utm_medium=email&utm_content=COVID-19%3A%20Survey%20shows%20dire%20PPE%20shortages%20%7C%20Another%20survey%20reveals%20mental%20health%20impact&channel=63993

3 https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30168-1/fulltext

4 https://www.webmd.com/lung/news/20200508/mental-health-emerging-crisis-of-covid-pandemic

5 http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/novel-coronavirus-2019-ncov-technical-guidance-OLD/coronavirus-disease-covid-19-outbreak-technical-guidance-europe-OLD/mental-health-and-covid-19

6 https://www.medscape.com/viewarticle/929325?nlid=135214_3901&src=wnl_newsalrt_200424_MSCPEDIT&uac=24550MR&impID=2359052&faf=1

7 https://www.physiciansupportline.com/

8 https://zoom.us/rec/play/vJwoI-2u_Wo3TIWQ5QSDUfRwW47uJqOs0CJNqfVcz0nmWnRSZFH0b-RDZLCSxdbd2YWqiNPFxk56iK7u

9 https://omh.ny.gov/omhweb/covid-19-resources.html

10 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764404

11 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30460-8/fulltext?dgcid=raven_jbs_etoc_email

12 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2764748?guestAccessKey=d72dd6e6-b310-4a9e-9a68-d3623f07b997&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamainternalmedicine&utm_content=olf&utm_term=041620

13 http://www.psychiatria-danubina.com/UserDocsImages/pdf/dnb_vol32_no1/dnb_vol32_no1_32.pdf

14 https://www.jpost.com/israel-news/worse-than-wartime-coronavirus-takes-toll-on-israelis-mental-health-621955

15 https://www.haaretz.com/israel-news/.premium.MAGAZINE-trauma-is-the-real-threat-of-the-coronavirus-how-to-keep-your-mental-health-1.8753264

16 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1700485/

17 https://www.ncbi.nlm.nih.gov/pubmed/25476960

18 https://archive.org/details/healthstresscopi00antorich

19 https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker

20 https://psycnet.apa.org/record/2014-10487-003

21 https://academic.oup.com/swr/article-abstract/35/1/36/1636682

22 https://journals.sagepub.com/doi/abs/10.1057/jit.2008.15

23 https://www.nytimes.com/2020/05/10/world/europe/coronavirus-europe-resilience.html

24 https://www.worldometers.info/coronavirus/country/israel/

25 https://www.nytimes.com/interactive/2020/nyregion/new-york-city-coronavirus-cases.html

26 https://in.bgu.ac.il/pages/news/culture-compatible-corona-messages.aspx

27 https://www.mentalhealthtoday.co.uk/news/awareness/how-is-coronavirus-pandemic-affecting-those-with-pre-existing-mental-health-conditions-researchers-want-to-know

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