Psychological consequences of COVID-19 home confinement: The ECLB-COVID19 multicenter study.

BACKGROUND: Public health recommendations and government measures during the COVID-19 pandemic have enforced restrictions on daily-living. While these measures are imperative to abate the spreading of COVID-19, the impact of these restrictions on mental health and emotional wellbeing is undefined. Therefore, an international online survey (ECLB-COVID19) was launched on April 6, 2020 in seven languages to elucidate the impact of COVID-19 restrictions on mental health and emotional wellbeing.
METHODS: The ECLB-COVID19 electronic survey was designed by a steering group of multidisciplinary scientists, following a structured review of the literature. The survey was uploaded and shared on the Google online-survey-platform and was promoted by thirty-five research organizations from Europe, North-Africa, Western-Asia and the Americas. All participants were asked for their mental wellbeing (SWEMWS) and depressive symptoms (SMFQ) with regard to "during" and "before" home confinement.
RESULTS: Analysis was conducted on the first 1047 replies (54% women) from Asia (36%), Africa (40%), Europe (21%) and other (3%). The COVID-19 home confinement had a negative effect on both mental-wellbeing and on mood and feelings. Specifically, a significant decrease (p < .001 and Δ% = 9.4%) in total score of the SWEMWS questionnaire was noted. More individuals (+12.89%) reported a low mental wellbeing "during" compared to "before" home confinement. Furthermore, results from the mood and feelings questionnaire showed a significant increase by 44.9% (p < .001) in SMFQ total score with more people (+10%) showing depressive symptoms "during" compared to "before" home confinement.
CONCLUSION: The ECLB-COVID19 survey revealed an increased psychosocial strain triggered by the home confinement. To mitigate this high risk of mental disorders and to foster an Active and Healthy Confinement Lifestyle (AHCL), a crisis-oriented interdisciplinary intervention is urgently needed.

Introduction

An unexplained severe respiratory infection detected in Wuhan City of Hubei Province of China was reported to the World Health Organization (WHO) office in China on December 31, 2019. The WHO announced that the disease is caused by a new coronavirus, called COVID-19, which is the acronym of “coronavirus disease 2019” [1]. This new virus has quickly spread worldwide. As of 14 April 2020, a total of 1.910.507 confirmed cases globally with 123.348 deaths had been reported by WHO [2]. Considering the challenges imposed by the COVID-19 pandemic to health care systems and society in general, and in order to cut the rate of new infections and flatten the COVID-19 contagion curve, the majority of countries worldwide imposed mass home-confinement directives, with most including quarantine and physical distancing [3, 4]. Quarantine, and the resulting social isolation, can be major stressors that can contribute to widespread emotional distress [5-8], and may aggravate pre-existing disease [9] and cause disease such as sleep disorder or a weakened immune system [10].

Mental health is an essential component of public health and is associated with a reduced risk of several chronic diseases (e.g. dementia, depression, obesity, coronary heart disease), premature morbidity, and functional decline [11, 12]. According to the WHO, mental health is “a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” [13]. There are many important facets to mental health such as personal freedoms, financial security, social stability and individual lifestyle factors (e.g. physical activity).

Unfortunately, many of the social and individual consequences of the COVID-19 pandemic impose upon these facets. For example, the uncertainty of prognosis, seclusion as a result of quarantine, and financial losses associated with a reduction in economic activity likely result in several severe emotional reactions (e.g., distress) and unhealthy behaviors (e.g. excessive substance use). In this context, a recent review by Brooks et al. [14] reported negative psychological effects, including depression, stress, fear, confusion, and anger, in quarantined people during previous epidemic. Specifically, infringement upon personal freedoms, duration of confinement, resulting financial losses, and insufficient medical care have all been suggested to increase risk for psychiatric illness during quarantine [5]. This notion, the negative effects of quarantine on mental health including psychological and emotional problems (e.g., depression and anxiety), is directly supported by earlier studies during several outbreaks of previous infections (e.g., SARS) [15, 16].

In contrast to the above earlier investigation of relatively recent infections, the dimension of the current COVID-19 pandemic drastically exceeds the previous quarantine measures, as well as the financial hardships, on an international scale. In this regard, there resides the chance of a secondary public mental health sequela related to the impact of COVID-19 that extends beyond the immediate physical health crises suggesting the need to investigate the effects of COVID-19 home confinement on mental health in detail. Therefore, an international online survey (ECLB-COVID19) was launched in April 6, 2020 in multiple languages to elucidate the emotional consequences of COVID-19 home confinement. This study is the first translational large-scale survey on mental health and emotional wellbeing in the general population during the COVID-19 pandemic. It can be assumed that the COVID-19 pandemic will have negative implications for individual and collective mental health.

The present paper presents data on mental wellbeing, mood and feeling before and during home confinement. Other parts of the survey evaluate physical activity and diet behaviors [7], social participation and life satisfaction [17] and mental health and general lifestyle [18, 19]; these findings are published elsewhere. All papers share a common method description.

Materials and methods

We report findings on the first 1047 replies to an international online-survey on mental health and multi-dimension lifestyle behaviors during home confinement (ECLB-COVID19). ECLB-COVID19 was opened on April 1, 2020, tested by the project’s steering group for a period of 1 week, before starting to spread it worldwide on April 6, 2020 [6, 7, 17, 18]. Thirty-five research organizations from Europe, North-Africa, Western Asia and the Americas promoted dissemination and administration of the survey. ECLB-COVID19 was administered in English, German, French, Arabic, Spanish, Portuguese, and Slovenian languages. The survey included sixty-four questions on health, mental wellbeing, mood, life satisfaction and multidimension lifestyle behaviors (i.e., physical activity, diet, social participation, sleep, technology-use, need of psychosocial support). All questions were presented in a differential format, to be answered directly in sequence with regard to both “before” and “during” confinement conditions [6, 7, 17, 18]. The study was conducted according to the Declaration of Helsinki. The protocol and the consent form were fully approved (identification code: 62/20) by the Otto von Guericke University Ethics Committee, Magdeburg, Germany.

Survey development and promotion

The cross-sectional ECLB-COVID19 electronic survey was designed by a steering group of multidisciplinary scientists and academics (i.e., human science, sport science, neuropsychology and computer science) at the University of Magdeburg (principal investigator), the University of Sfax, the University of Münster and the University of Paris-Nanterre, following a structured review of the literature. The survey was then reviewed and edited by 50 colleagues and experts worldwide. The survey was uploaded and shared on the Google online survey platform. A link to the electronic survey was distributed worldwide by consortium colleagues via a range of methods: invitation via e-mails, shared in consortium’s faculties official pages, ResearchGate™, LinkedIn™ and other social media platforms such as Facebook™, WhatsApp™ and Twitter™. Public were also involved in the dissemination plans of our research through the promotion of the ECLB-COVID19 survey in their networks. The survey included an introductory page describing the background and the aims of the survey, the consortium, ethics information for participants and the option to choose one of seven available languages (English, German, French, Arabic, Spanish, Portuguese, and Slovenian). The present study focuses on the first thousand responses (i.e., 1047 participants), which were reached on April 11, 2020, approximately one-week after the survey began. This survey was open for all people worldwide aged 18 years or older. People with cognitive decline are excluded [6, 7, 17–19].

Data privacy and consent of participation

During the informed consent process, survey participants were assured all data would be used only for research purposes and data set will not be available for public. Participants’ answers were anonymous and confidential according to Google’s privacy policy [7, 17–19]. Participants did not have to mention their names or contact information. In addition, participants could stop participating in the study and could leave the questionnaire at any stage before the submission process and their responses were not saved. Response were saved only by clicking on “submit” button. By completing the survey, participants were acknowledging the above approval form and were consenting to voluntarily participate in this anonymous study. Participants have been requested to be honest in their responses.

Survey questionnaires

The ECLB-COVID19 is a translational electronic survey designed to assess emotional and behavioral change associated with home confinement during the COVID-19 outbreak. Therefore, a collection of validated and/or crisis-oriented brief questionnaires were included (Ammar et al. 2020a-e). These questionnaires assess mental wellbeing (Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS)) [18-20], mood and feeling (Short Mood and Feelings Questionnaire (SMFQ)) [18, 19, 21], life satisfaction (Short Life Satisfaction Questionnaire for Lockdowns (SLSQL)) [17, 19], social participation (Short Social Participation Questionnaire for Lockdowns (SSPQL) [17, 19), physical activity (International Physical Activity Questionnaire Short Form (IPAQ-SF)) [6, 7, 19, 22], diet behaviours (Short Diet behaviours Questionnaire for Lockdowns (SDBQL)) [6, 7, 19], sleep quality (Pittsburgh Sleep Quality Index (PSQI)) [23], and some key questions assessing the technology-use behaviours (Short Technology-use Behaviours Questionnaire for Lockdowns (STBQL)), demographic information, and the need of psychosocial support [19]. Reliability of the shortened and/or newly adopted questionnaires was tested by the project steering group through piloting, prior to survey administration. These brief crisis-oriented questionnaires demonstrated high to excellent test-retest reliability coefficients (r = 0.84–0.96). A multi-language validated version already existed for the majority of these questionnaires and/or questions. However, for questionnaires that did not already exist in multi-language versions, we followed the procedure of translation and back-translation, with an additional review for all language versions from the international scientists of our consortium. In this manuscript, we report only results on mental wellbeing (SWEMWBS), mood, and feeling (SMFQ). A copy of the complete survey can be found in S1 File.

The Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS)

The SWEMWBS is a short version of the Warwick–Edinburgh Mental Wellbeing Scale (WEMWBS). The WEMWBS was developed to enable the monitoring of mental wellbeing in the general population and in response to projects, programmes and policies focusing on mental wellbeing. The SWEMWBS uses seven of the WEMWBS’s 14 statements about thoughts and feelings, which relate more to functioning than feelings suggesting an ability to detect clinically meaningful change [24, 25]. The seven statements are positively worded with five response categories from ‘none of the time (score 1)’ to ‘all of the time (score 5)’. The SWEMWBS was recently validated for the general population and is scored by first summing the scores for each of the seven items, which are scored from 1 to 5 [20]. The total raw scores are then transformed into metric scores using the SWEMWBS conversion table. Total scores range from 7 to 35 with higher scores indicating higher positive mental wellbeing. Based on scores that were at least one standard deviation below and above the mean, respectively [26], categories for SWEMWBS were considered ‘low’ (7–19.3), ‘medium’ (20.0–27.0) and ‘high’ (28.1–35) mental wellbeing [20].

The Short Mood and Feelings Questionnaire (SMFQ)

The SMFQ is a short version of the Mood and Feelings Questionnaire (MFQ) developed by Costello and Angold [27]. The SMFQ was developed in response to the need for a brief depression measure [28]. The SMFQ is, therefore, suggested as a brief screening tool for depression based on thirteen of the MFQ’s 33 statements about how the subject has been feeling or acting recently [21]. The MFQ is scored by summing together the point values of responses for each item ("not true" = 0 points; "sometimes true" = 1 point; "true" = 2 points) with higher scores on the SMFQ suggesting more severe depressive symptoms. Scores on SMFQ range from 0 to 26. A total score of 12 or higher may indicate the presence of depression in the respondent [18, 21].

Data analysis

Descriptive statistics were used to define the proportion of responses for each question and the distribution of the total score of both questionnaires. All statistical analyses were performed using the commercial statistical software STATISTICA (StatSoft, Paris, France, version 10.0) and Microsoft Excel 2010. Normality of the data distribution in each question was confirmed using the Shapiro-Wilks-W-test. Values were computed and reported as mean ± SD (standard deviation). To assess for significant differences in responses with reference to “before” and “during” the confinement period, paired samples t-tests were used for normally distributed data (responses to the SWEMWBS questionnaire) and the Wilcoxon test was used when normality was not assumed (responses to the SMFQ). Effect size (Cohen’s d) was calculated to determine the magnitude of the change of the score and was interpreted using the following criteria: 0.2 ≤ d < 0.5: small, 0.5 ≤ d < 0.8: moderate, and d ≥0.8: large [29]. Statistical significance was set at α<0.05.

Results

Sample description

The present study focused on the first thousand responses (i.e., 1047 participants). Overall, 54% of the participants were women, and the participants were from Western Asia (36%), North Africa (40%), Europe (21%) and other (3%). Age, health status, employment status, level of education and marital status are presented in Table 1.

Table 1

Demographic characteristics of the participants.

Variables		N	(%)
Gender
	Male	484	(46.2%)
	Female	563	(53.8%)
Continent
	North Africa	419	(40%)
	Western Asia	377	(36%)
	Europe	220	(21%)
	Other	31	(3%)
Age (years)
	18–35	577	(55.1%)
	36–55	367	(35.1%)
	>55	103	(9.8%)
Level of Education
	Master/doctorate degree	527	(50.3%)
	Bachelor’s degree	397	(37.9%)
	Professional degree	28	(2.7%)
	High school graduate, diploma or the equivalent	69	(6.6%)
	No schooling completed	26	(2.5%)
Marital status
	Single	455	(43.4%)
	Married/Living as couple	562	(53.7%)
	Widowed/Divorced/Separated	30	(2.9%)
Employment status
	Employed for wages	538	(51.4%)
	Self-employed	74	(7.1%)
	Out of work/Unemployed	75	(7.2%)
	A student	259	(24.7%)
	Retired	23	(2.2%)
	Unable to work	9	(0.85%)
	Problem caused by COVID-19	59	(5.6%)
	Other	10	(0.95%)
Health state
	Healthy	956	(91.3%)
	With risk factors for cardiovascular disease	81	(7.7%)
	With cardiovascular disease	10	(1%)

The Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS)

Change in mental wellbeing score assessed through the SWEMWBS from “before” to “during” confinement period are presented in Table 2. The total score decreased significantly by 9.4% during compared to before home confinement (t = 18.82, p < .001, d = 0.58). A statistically significant decrease was observed for each of the 7 questions. Particularly, feeling related questions such as feeling optimistic, useful, relaxed and close to others showed a lower score at “during” compared to “before” confinement with |Δ%| ranged from 4% to 13% (3.44 ≤ t ≤ 20.26; p < .001; 0.106 ≤ d ≤ 0.626). Similarly, participants scored lower in thinking related questions “during” compared to “before” confinement period with |Δ%| ranged from 7% to 16% for the capacities to deal well with problems, think clearly and make up own mind about things (10.36 ≤ t ≤ 12.89, p < .001, 0.32 ≤ d ≤ 0.51). For detailed distribution of responses (in %) please see S1 Table.

Table 2

Responses to the Short Warwick-Edinburgh Mental Wellbeing Scale before and during home confinement.

Questions	Before confinement	During confinement	Δ (Δ%)	95% IC	t test	p value	Cohen's d
1. I’ve been feeling optimistic about the future	4.08±0.91	3.54±1.11	-0.54 (-13.2%)	0.49–0.59	20.260	< .001	0.626
2. I’ve been feeling useful	4.05±0.89	3.62±1.13	-0.43 (-10.7%)	0.37–0.49	14.605	< .001	0.451
3. I’ve been feeling relaxed	3.38±0.94	3.25±1.07	-0.13 (-3.9%)	0.06–0.21	3.442	< .001	0.106
4. I’ve been dealing with problems well	3.88±0.81	3.62±0.93	-0.26 (-6.6%)	0.21–0.3	10.749	< .001	0.332
5. I’ve been thinking clearly	3.99±0.77	3.71±0.94	-0.28 (-6.9%)	0.22–0.33	10.368	< .001	0.320
6. I’ve been feeling close to other people	3.88±0.92	3.26±1.16	-0.61 (-15.8%)	0.54–0.69	16.644	< .001	0.514
7. I’ve been able to make up my own mind about things	4.04±0.83	3.72±1.00	-0.32 (-7.9%)	0.27–0.37	12.887	< .001	0.398
Total score	27.3±4.37	24.73±5.18	-2.57 (-9.4%)	2.3–2.84	18.821	< .001	0.582

The Short Mood and Feelings Questionnaire (SMFQ)

Change in mood and feeling score from “before” to “during” confinement period in response to SMFQ depression monitoring tool are presented in Table 3. The SMFQ total score increased significantly by 44.9% “during” compared to “before” home confinement (z = 14.52, p < .001, d = 0.44). For most questions, an increased score was noted with the following exceptions: “I was a bad person” and “I did everything wrong”. Particularly, bad-feeling related questions such as unhappy, unenjoyed, tired, hated himself, no good and lonely, showed higher score at “during” compared to “before” confinement with |Δ%| ranged from 37% to 107% (5.07 ≤ z ≤ 12.60; p < .001, 0.17 ≤ d ≤ 0.47). Similarly, scored responses to questions related to how the subject has been acting (i.e., restless, crying and doing nothing) or thinking (i.e., not properly, not concentrated, unloved and not good as others) in bad way showed higher score at “during” compared to “before” confinement with |Δ%| ranged from 10% to 76% (2.30 ≤ z ≤ 9.82; .45 ≤ p ≤ .001, 0.07 ≤ d ≤ 0.46). For detailed distribution of responses (in %) please see S2 Table.

Table 3

Responses to the Short Mood and Feelings Questionnaire before and during home confinement.

Questions	Before confinement	During confinement	Δ (Δ%)	z values	95% IC	p value	Cohen's d
1. I felt miserable or unhappy	0.49±0.57	0.79±0.72	0.30 (61.2%)	z = 12.124	-0.34–0.26	< .001	0.458
2. I didn’t enjoy anything at all	0.29±0.51	0.6±0.7	0.31 (107.7%)	z = 12.609	-0.35–0.27	< .001	0.468
3. I felt so tired I just sat around and did nothing	0.46±0.6	0.81±0.78	0.35 (76.2%)	z = 12.456	-0.39–0.3	< .001	0.460
4. I was very restless	0.46±0.6	0.66±0.75	0.20 (44%)	z = 7.762	-0.25–0.16	< .001	0.271
5. I felt I was no good anymore	0.34±0.53	0.55±0.71	0.21 (62.3%)	z = 9.822	-0.25–0.18	< .001	0.351
6. I cried a lot	0.39±0.6	0.43±0.67	0.04 (10.1%)	z = 1.997	-0.07–0.01	0.045	0.071
7. I found it hard to think properly or concentrate	0.53±0.58	0.77±0.74	0.24 (45.1%)	z = 9.370	-0.28–0.20	< .001	0.336
8. I hated myself	0.23±0.49	0.32±0.6	0.09 (37.3%)	z = 5.074	-0.12–0.06	< .001	0.175
9. I was a bad person	0.15±0.39	0.17±0.44	0.01 (8.6%)	z = 1.121	-0.04–0.01	0.262	0.037
10. I felt lonely	0.39±0.58	0.59±0.73	0.2 (52.2%)	z = 8.740	-0.24 - -0.16	< .001	0.308
11. I thought nobody really loved me	0.26±0.52	0.29±0.57	0.03 (10.2%)	z = 2.296	-0.05–0.01	0.021	0.080
12. I thought I could never be as good as other people	0.23±0.49	0.26±0.54	0.04 (16.4%)	z = 3.152	-0.06–0.02	< .001	0.108
13. I did everything wrong	0.27±0.49	0.27±0.49	0.0 (0.3%)	z = 0.080	-0.02–0.02	0,936	0.002
Total score	4.49±4.41	6.5±5.63	2.01 (44.9%)	z = 14.520	-2.29 - -1.73	< .001	0.436

Discussion

The present study reports results from the first 1047 participants who responded to our ECLB-COVID19 multiple languages online survey. Findings indicate significant negative effects of the current COVID-19 pandemic on mental health, especially mental wellbeing, mood, and feeling. There, mental wellbeing (estimate with the total score in SWEMWBS) decreased significantly by 9.4% “during” compared to “before” home confinement with more individuals (+12.89%) reporting a very low to low mental wellbeing. The largest effects of the current COVID-19 pandemic were observed in questions related to optimistic feeling, closed to others, useful, and thinking. Furthermore, results from the mood and feelings questionnaire showed significant increase by 44.9% in SMFQ total score, indicating negative effects with more people (+10%) showing depressive symptoms at “during” compared to “before” home confinement. Especially, questions related to unhappiness, unenjoyment, bad feeling, unclear thinking and loneliness showed highest effect sizes.

The present findings support previous reports suggesting several psychological perturbations and mood disturbances such as stress, depression, irritability, insomnia, fear, confusion, anger, frustration, boredom, and stigma during quarantine periods of earlier infection [14, 30, 31]. Regarding the COVID-19 related research, first results from Chinese studies indicate that the COVID-19 outbreak engendered anxiety, depression, sleep problems, and other psychological problems [32, 33]. The significantly lower total SWEMWBS score and higher total SMFQ score “during” compared to “before” confinement, observed in a sample of more than one thousand participants from Western Asian, North Africa and Europe, support the negative effects of the current COVID-19 pandemic on mental wellbeing and emotional state. Taken together, findings from China and from our survey provide insight into the risk of worldwide emotional distress and mental functioning (e.g., low wellbeing, anxiety, depression) during the COVID-19 home confinement period.

Weakening of physical and social contacts with the disruption of normal lifestyles (e.g., lower freedoms, financial losses, sedentariness, sleep disorder, unhealthy diet) during the COVID-19 outbreaks, have been suggested as major risk factors for lower emotional wellbeing and mental disorders [8, 34]. Furthermore, research indicates that some groups may be more vulnerable to the psychosocial effects of the COVID-19 pandemic. Particularly, people with risk factors for COVID-19 infection (e.g., diabetes, chronic heart failure, COPD, immune deficiency), people living in congregate settings (e.g., Hospice) and people with a predisposition and/or pre-existing psychiatric or substance use problems are at increased risk for mental health problems [5].

Since mental disorders have been previously identified as risk factors for several chronic diseases (e.g. hypertension; obesity, dementia) [11, 35–37] and showed to be associated with increased mortality [38, 39] a crisis-oriented interdisciplinary intervention approach to promote wellbeing and mitigate the negative effects of the COVID-19 pandemic on mental health is urgently needed [6, 40–42].

An active lifestyle, including physical and social activity, is an important modifiable factor for mental health across the lifespan [43]. Taking into-consideration that psychosocial tolls of the COVID-19 pandemic appears to be significantly associated with unhealthy lifestyle behaviours including physical and social inactivity, poorer sleep quality as well as unhealthy diet [19, 44], it seems important that this intervention should focus on fostering social communication, physical activity, sleep quality and healthy dietary behaviours [6, 7, 14, 17, 45]. This multidisciplinary intervention can be supported and delivered to the general populations through technology-based solutions such as fitness and nutritional apps, sleep monitoring device, video streaming, exergames, social network, gamification and/or virtual coach.

Furthermore, considering the more vulnerable population to the psychosocial strain, supportive intervention should include “need-oriented” psychosocial services (e.g., psychoeducation, cognitive behavioural techniques, and/or consulting with specialists) delivered by means of telemedicine.

However, to ensure a sustainable intervention approach, future research should investigate the long-term impact of the COVID-19 pandemic on mental health and identify which component(s) of psychosocial strain may persist after the quarantine.

Strengths, limitations and perspective

The strength of this study is that the data was collected very quickly during the restrictions using a fully anonymous cross-disciplinary survey provided in multiple language and widely distributed in several continents. However, most participants (90.2%) were 55 years old or younger, healthy (90.5%), and educated with a degree beyond high school (90.9%). These demographic characteristics may influence the results, thus the present findings need to be interpreted with caution. Additionally, as cultural differences were previously suggested as relevant factor in moods [46], further large studies analysing differences between countries are warranted. The ECLB-COVID19 survey has since been further translated to Dutch, Persian, Italian, Russian, Indian, Malayalam and Greek languages which has allowed for the addition of more participants and countries. The data will be used in our future post-hoc studies to assess the interaction between the mental and emotional strain evoked by COVID-19 and the demographical and cultural characteristics of the participants. Identifying exact behavioural changes in each country will be also performed to provide better-informed decisions during pandemics’ re-opening process. Regarding the methodological issues, possible limitations could be related to the (i) use of the cross-sectional design assessing the “before” home confinement condition retrospectively and to the (ii) disuse of cookie-based or IP-based duplicate protection to exclude duplicates. However, it should be noted that our consortium elected to avoid IP or cookie safety measures as we know that during home confinement more than one family member can use the same computer (e.g., same IP). Moreover, given that home confinement was a sudden measure in most countries, we were not able to develop and spread the survey at “before” home confinement.

Conclusion

Besides stresses inherent in the illness itself, results from the ECLB-COVID19 survey reveal a negative effect of home-confinement on mental and emotional wellbeing with more people developing depressive symptoms “during” compared to “before” the confinement period. This increased psychosocial strain triggered by the enforced home confinement should encourage stakeholders and policy makers to implement a crisis-oriented interdisciplinary intervention to mitigate the negative effects of restrictions and to foster an Active and Healthy Confinement Lifestyle (AHCL).

A copy of the complete ECLB-COVID19 survey’s questionnaires.

(PDF)

Click here for additional data file.

Distribution of responses (%) in each item of the mental wellbeing questionnaire.

(PDF)

Click here for additional data file.

Distribution of responses (%) in each item of the mood and feeling questionnaire.

(PDF)

Click here for additional data file.

13 Jul 2020

PONE-D-20-15158

Emotional consequences of COVID-19 home confinement: The ECLB-COVID19 multicenter study

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is and interesting manuscript and the study topic is very relevant in the current situation. In general, the article is well written and easy to read. The sample number is enough. However, some aspects must be detailed to improve the quality of the article.

GENERAL COMMENTS

The written form of some results could be improved. For example: Statistical symbols letters Could be written in cursive letters or p and r values should be written without “0” before the dot (p = .011). But this depends on the journal. Please check if the results are written correctly according to the journal's criteria

Reading the paper, I understand that the two questionnaires (Short Warwick-Edinburgh Mental Well-being Scale and Short Mood and Feelings Questionnaire) are added to the demographic questions in Table 1. In my opinion, to help other researchers to replicate the study, the complete survey could be attached as a supplementary file. Moreover, this paragraph “The survey included sixty-four questions on health, mental wellbeing, mood, life satisfaction and multidimension lifestyle behaviors (physical activity, diet, social participation, sleep, technology-use, need of psychosocial support).” Suggest that the survey is longer and that only a part of the questionnaire was used in this study.

Regarding the questionnaire, it was translated to “English, German, French, Arabic, Spanish, Portuguese, and Slovenian languages”. This in very interesting as the authors can reach more people and therefore expand the sample. However, the validation process of the different versions has not been explained. On the other hand, the cronbach's alpha values have not been reported. What was the reliability of the questionnaire in this sample?

Results are showed for the total of the sample. However, the survey was sent to different countries and continents which has different isolation conditions when the questionnaire was filled. How might this have affected the results? Would this detail be a possible limitation of the study? Furthermore, cultural differences can be a relevant factor in moods [1].

Another important aspect is the sample distribution which is well balanced in gender but interestingly high educated (Master/doctorate degree 527 (50.3%)). This could generate some bias. Fortunately, the authors have mentioned this in the limitations of the study. Nonetheless, differences by gender has not been reported. In my opinion, it is important to report the existence or not of these differences since the analysis has been carried out men and women together.

MINOR POINTS

Some cites should be revised in the manuscript. For example: “Google’s privacy policy (https://policies.google.com/privacy?hl=en)” or “depression in the respondent.18”.

Authors have use different social networks, although this method has been validated previously [2], how the authors think that this percentage could be affected the sample?

The authors have written the following: “we considered that a score between 7 and13 reflects very low positive mental wellbeing, 14-20 reflects low positive mental wellbeing, 21-27 reflects medium positive mental wellbeing; and 28-35 reflects high positive mental wellbeing.” Why this values or scale? Is there any reference supporting these cut points?

The following discussion paragraph is not supported by the results showed in this study. “The significantly lower total SWEMWBS score and higher total SMFQ score “during” compared to “before” confinement support the negative effects of the current COVID-19 pandemic on mental wellbeing and emotional state in participants from Western Asian, North Africa and Europe.”

Authors interestingly suggest possible solutions to improve health during confinement related to lifestyle and physical activity :“Given that an active lifestyle including physical and social activity is an important modifiable factor for mental health across the lifespan (Rohrer et al. 2005), this intervention should focus on fostering social communication and physical activity (Ammar et al.2020a-c). More references regarding this topic could be added.[3,4]

1. Palinkas, L.A.; Johnson, J.C.; Boster, J.S.; Rakusa-Suszczewski, S.; Klopov, V.P.; Fu, X.Q.; Sachdeva, U. Cross-cultural differences in psychosocial adaptation to isolated and confined environments. Aviation, space, and environmental medicine 2004, 75, 973-980.

2. Browne, K. Snowball sampling: using social networks to research non‐heterosexual women. Int J Soc Res Methodol 2005, 8, 47-60.

3. Xiang, M.; Zhang, Z.; Kuwahara, K. Impact of COVID-19 pandemic on children and adolescents' lifestyle behavior larger than expected. Progress in Cardiovascular Diseases 2020.

4. Brooks, S.K.; Webster, R.K.; Smith, L.E.; Woodland, L.; Wessely, S.; Greenberg, N.; Rubin, G.J. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet 2020.

Reviewer #2: This work is a quality study.

Its main contribution is that it focuses on comparing levels of well-being and distress before and during COVID-19 crisis, which is a novel approach to the study of the phenomenon, since studies have usually focused on how mental health is at the time of assessment during confinement or the health emergency.

It also has another advantage, the participants belong to different continents, with a prominent participation of North Africa. As we know most studies provide data from Asia, Europe, and United States or similar, so this is an advantage as well.

Major issues:

In the description of the SWEMWBS cut-off points, it is indicated that the following points were followed in this study: "In this study, we considered that a

score between 7 and13 reflects very low positive mental wellbeing, 14-20 reflects low positive mental wellbeing, 21-27 reflects medium positive mental wellbeing; and 28-35 reflects high positive mental wellbeing." Unlike the Short Mood and Feelings Questionnaire (SMFQ), where it is stated what the use of the cut-off point is based on, this is not the case. It would be necessary to provide the authors' basis for this classification.

Although the decrease in well-being and distress before and after the crisis is established, later in the discussion and conclusions it is recommended to apply Active

and Healthy Confinement Lifestyle (AHCL), a crisis-oriented interdisciplinary

intervention focused on Weakening of physical and social contacts with the disruption of normal lifestyles. From my point of view this suggestion is not well argued on the basis of the current study. The current study establishes that there is a worsening of mental health and well-being in the world population due to COVID-19, but it does not deepen the knowledge of the factors that explain this worsening, so I see it as very pretentious to recommend a specific intervention in this sense. I would like the authors to review this point and to go deeper into the justification of this issue.

Minor issues:

- On page 16 when describing the effect sizes there is a misprint in “Cohn, 1988.”

"Effect size (Cohen's d) was calculated to determine the magnitude of

the change of the score and was interpreted using the following criteria: 0.2 (small), 0.5 (moderate), and 0.8 (large) (Cohn, 1988). Statistical significance was accepted as α<0.05."

- On page 18, there is a room left in "significantly by 9.4 % during home"

**********

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Reviewer #1: No

Reviewer #2: No

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20 Jul 2020

Reviewer #1:

This is an interesting manuscript and the study topic is very relevant in the current situation. In general, the article is well written and easy to read. The sample number is enough. However, some aspects must be detailed to improve the quality of the article.

The authors would like to thank the reviewer for the insightful and constructive comments on our work. We have carefully considered all of the suggestions and have revised the manuscript accordingly. We believe that our manuscript is much stronger as a result of these modifications.

Please find the authors’ responses to the individual comments below.

GENERAL COMMENTS

The written form of some results could be improved. For example: Statistical symbols letters Could be written in cursive letters or p and r values should be written without “0” before the dot (p = .011). But this depends on the journal. Please check if the results are written correctly according to the journal's criteria

Thank you for your comment. We revised the results section according to your suggestion and with respect to the journal guidelines.

Reading the paper, I understand that the two questionnaires (Short Warwick-Edinburgh Mental Well-being Scale and Short Mood and Feelings Questionnaire) are added to the demographic questions in Table 1. In my opinion, to help other researchers to replicate the study, the complete survey could be attached as a supplementary file.

Thank you for your suggestion. The complete survey (google form copy) has been attached as a supplementary file (S1 Google form survey). This has been also indicated in the revised text.

Moreover, this paragraph “The survey included sixty-four questions on health, mental wellbeing, mood, life satisfaction and multidimension lifestyle behaviors (physical activity, diet, social participation, sleep, technology-use, need of psychosocial support).” Suggest that the survey is longer and that only a part of the questionnaire was used in this study.

Yes, the survey including questionnaires related to multiple lifestyle variables (more details on these questionnaires were included in the revised version section: “Survey questionnaires”) and in the present manuscript only data from SWEMWBS and SMFQ were presented. This has been highlighted in the revised version (at the end of the introduction section).

Regarding the questionnaire, it was translated to “English, German, French, Arabic, Spanish, Portuguese, and Slovenian languages”. This in very interesting as the authors can reach more people and therefore expand the sample. However, the validation process of the different versions has not been explained. On the other hand, the cronbach's alpha values have not been reported. What was the reliability of the questionnaire in this sample?

Thank you for your comment. More details about the validation, translation and reliability of the whole survey were added in the revised version as following.

“The ECLB-COVID19 is a translational electronic survey designed to assess emotional and behavioral change associated with home confinement during the COVID-19 outbreak. Therefore, a collection of validated and/or crisis-oriented brief questionnaires were included (Ammar et al. 2020a-e). These questionnaires assess mental wellbeing (Short Warwick-Edinburgh Mental Wellbeing Scale (SWEMWBS)) [18-20], mood and feeling (Short Mood and Feelings Questionnaire (SMFQ)) [18,19,21], life satisfaction (Short Life Satisfaction Questionnaire for Lockdowns (SLSQL)) [17,19], social participation (Short Social Participation Questionnaire for Lockdowns (SSPQL) [17,19), physical activity (International Physical Activity Questionnaire Short Form (IPAQ-SF)) [6,7,19,22], diet behaviours (Short Diet behaviours Questionnaire for Lockdowns (SDBQL)) [6,7,19], sleep quality (Pittsburgh Sleep Quality Index (PSQI)) [23], and some key questions assessing the technology-use behaviours (Short Technology-use Behaviours Questionnaire for Lockdowns (STBQL)), demographic information, and the need of psychosocial support [19]. Reliability of the shortened and/or newly adopted questionnaires was tested by the project steering group through piloting, prior to survey administration. These brief crisis-oriented questionnaires demonstrated high to excellent test-retest reliability coefficients (r = 0.84-0.96). A multi-language validated version already existed for the majority of these questionnaires and/or questions. However, for questionnaires that did not already exist in multi-language versions, we followed the procedure of translation and back-translation, with an additional review for all language versions from the international scientists of our consortium. In this manuscript, we report only results on mental wellbeing (SWEMWBS), mood, and feeling (SMFQ). A copy of the complete survey can be found in S-1 Google form survey (supplementary file)”

Results are showed for the total of the sample. However, the survey was sent to different countries and continents which has different isolation conditions when the questionnaire was filled. How might this have affected the results? Would this detail be a possible limitation of the study? Furthermore, cultural differences can be a relevant factor in moods [1].

Thank you for your comment. We agree that cultural differences can be an important moderator of the emotional consequences of home confinement. We have highlighted this limitation in the revised manuscript (section “strengths, limitations and perspectives”). We are already working on identifying all possible moderators using the entire dataset in our future manuscripts.

Indeed, the present paper is a part of the whole ECLB-COVID19 project, in which the first step is to understand and to confirm the psychosocial strain of COVID-19 home confinement and the behavioral changes in the general population. The next step will be to identify possible moderators such as demographical, cultural, and/or geographic variables, as well as the restrictions adopted by the included countries. To confirm the presence of psychosocial strain in the general population, data from the first thousand responders were used in this paper. However, our consortium plan to identify the aforementioned moderators using the final collected data (6000-10000 responses). In the second step, a between group (e.g., countries, age group, gender, educational level etc.) analysis will be performed. Using the entire dataset will allow our consortium to perform a between country comparison when home confinement measures end in all countries. For example, comparison between more and low affected countries OR countries with more and lower restrictions will give more insight into the emotional consequence of this pandemics and possible reopening measures for each country.

Regarding the preliminary data presented in this manuscript, we believe that the global community, especially countries which start the re-opening measures (e.g., Germany, Tunisia, Italy, Spain) OR are still imposing total or partial home-confinement (e.g., Iran), are in need of these preliminary results to help understand the emotional consequences of the covid-19 pandemic. Identifying specific psychological changes will allow for better-informed decisions during the re-opening process.

These points have been highlighted in the limitation and perspectives section of the revised manuscript as following:

“However, given that most participants (90.2%) were 55 years old or younger, healthy (90.5%), and educated with a degree beyond high school (90.9%). These demographic characteristics may influence the results, thus the present findings need to be interpreted with caution. Additionally, as cultural differences were previously suggested be a relevant factor in moods [46], further large studies analyzing differences between countries are warranted. The ECLB-COVID19 survey has been also translated to Dutch, Persian, Italian, Russian, Indian, Malayalam and Greek languages which has allowed for the addition of more participants and countries. The data will be used in our future post-hoc studies to assess the interaction between the mental and emotional strain evoked by COVID-19 and the demographical and cultural characteristics of the participants. Identifying exact behavioural changes in each country will be also performed to provide better-informed decisions during pandemics’ re-opening process”

Another important aspect is the sample distribution which is well balanced in gender but interestingly high educated (Master/doctorate degree 527 (50.3%)). This could generate some bias. Fortunately, the authors have mentioned this in the limitations of the study. Nonetheless, differences by gender has not been reported. In my opinion, it is important to report the existence or not of these differences since the analysis has been carried out men and women together.

Thank you for your comments. This point has been highlighted in the limitation section and as we mentioned in the previous responses, analyzing differences by demographical and cultural characteristics with other possible moderators using the entire dataset are our future goals within the ECLB-COVID19 project.

MINOR POINTS

Some cites should be revised in the manuscript. For example: “Google’s privacy policy (https://policies.google.com/privacy?hl=en)” or “depression in the respondent.18”.

Thank you for your comment. We corrected these errors.

Authors have use different social networks, although this method has been validated previously [2], how the authors think that this percentage could be affected the sample?

In such crisis with physical and social distancing, using electronic survey was the only safe way to collect data and understand the psychosocial effect of pandemics. The consortium is aware that through using electronic survey, some no-accurate responses can be collected, and can bias the results. To reduce this bias, our consortium tried to collect as many responses as possible during a short period through approaching participants via official email-invitation and institute website, but also via different social media platforms. Additionally, in the consent participation, participants were requested to be honest in their response. By collecting, 1000 responses during the first week and up to 5000 responses during the first month, this strategy demonstrated high efficiency.

The authors have written the following: “we considered that a score between 7 and13 reflects very low positive mental wellbeing, 14-20 reflects low positive mental wellbeing, 21-27 reflects medium positive mental wellbeing; and 28-35 reflects high positive mental wellbeing.” Why this values or scale? Is there any reference supporting these cut points?

Thank you for your comment. We adjusted the cut-off points in the revised version according to Stranges et al. 2014 and Ng Fat et al. 2017. Indeed, based on scores that were at least one standard deviation below and above the mean, respectively (Stranges et al. 2014), categories for SWEMWBS were considered ‘low’ (7–19.3), ‘medium’ (20.0–27.0) and ‘high’ (28.1–35) mental wellbeing (Ng Fat et al. 2017).

The following sentences were added in the subsection: The Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) “Total scores range from 7 to 35 with higher scores indicating higher positive mental wellbeing. Based on scores that were at least one standard deviation below and above the mean, respectively [26], categories for SWEMWBS were considered ‘low’ (7–19.3), ‘medium’ (20.0–27.0) and ‘high’ (28.1–35) mental wellbeing [20].”

The following discussion paragraph is not supported by the results showed in this study. “The significantly lower total SWEMWBS score and higher total SMFQ score “during” compared to “before” confinement support the negative effects of the current COVID-19 pandemic on mental wellbeing and emotional state in participants from Western Asian, North Africa and Europe.”

Thank you for your comment.

The first one thousand responders to our survey are from Western Asian, North Africa and Europe. The SWEMWBS total score decreased significantly by 9.4% during compared to before home confinement, the SMFQ total score increased significantly by 44.9% “during” compared to “before” home confinement. Lower SWEMWBS was previously linked to low mental wellbeing (Ng Fat et al. 2017), while higher SMFQ was previously suggested to indicate the presence of depression in the respondent (Thabrew et al. 2018). Therefore, we indicated that results support the negative effects of the current COVID-19 pandemic on mental wellbeing and emotional state in the present survey participants.

However, as we did not analyses the data of western Asia, North Africa and Europe separately we reformulated this paragraph, as following, to avoid any misunderstanding: “The significantly lower total SWEMWBS score and higher total SMFQ score “during” compared to “before” confinement, observed in a sample of one thousand participants from Western Asian, North Africa and Europe, support the negative effects of the current COVID-19 pandemic on mental wellbeing and emotional state”.

Authors interestingly suggest possible solutions to improve health during confinement related to lifestyle and physical activity :“Given that an active lifestyle including physical and social activity is an important modifiable factor for mental health across the lifespan (Rohrer et al. 2005), this intervention should focus on fostering social communication and physical activity (Ammar et al.2020a-c). More references regarding this topic could be added3,4]

Thank you for the suggested references. Both references were added in the revised version

1. Palinkas, L.A.; Johnson, J.C.; Boster, J.S.; Rakusa-Suszczewski, S.; Klopov, V.P.; Fu, X.Q.; Sachdeva, U. Cross-cultural differences in psychosocial adaptation to isolated and confined environments. Aviation, space, and environmental medicine 2004, 75, 973-980.

2. Browne, K. Snowball sampling: using social networks to research non‐heterosexual women. Int J Soc Res Methodol 2005, 8, 47-60.

3. Xiang, M.; Zhang, Z.; Kuwahara, K. Impact of COVID-19 pandemic on children and adolescents' lifestyle behavior larger than expected. Progress in Cardiovascular Diseases 2020.

4. Brooks, S.K.; Webster, R.K.; Smith, L.E.; Woodland, L.; Wessely, S.; Greenberg, N.; Rubin, G.J. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. The Lancet 2020.

Reviewer #2: This work is a quality study.

Its main contribution is that it focuses on comparing levels of well-being and distress before and during COVID-19 crisis, which is a novel approach to the study of the phenomenon, since studies have usually focused on how mental health is at the time of assessment during confinement or the health emergency.

It also has another advantage, the participants belong to different continents, with a prominent participation of North Africa. As we know most studies provide data from Asia, Europe, and United States or similar, so this is an advantage as well.

The authors would like to thank the reviewer for the insightful and constructive comments on our work. We have carefully considered all of the suggestions and have revised the manuscript accordingly. We believe that our manuscript is much stronger as a result of making these modifications.

Please find below the authors’ responses to the individual comments

Major issues:

In the description of the SWEMWBS cut-off points, it is indicated that the following points were followed in this study: "In this study, we considered that a

score between 7 and13 reflects very low positive mental wellbeing, 14-20 reflects low positive mental wellbeing, 21-27 reflects medium positive mental wellbeing; and 28-35 reflects high positive mental wellbeing." Unlike the Short Mood and Feelings Questionnaire (SMFQ), where it is stated what the use of the cut-off point is based on, this is not the case. It would be necessary to provide the authors' basis for this classification.

Thank you for your comment. We adjusted the cut-off points in the revised version (subsection: “The Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS)”) according to Stranges et al. 2014 and Ng Fat et al. 2017. Indeed, based on scores that were at least one standard deviation below and above the mean, respectively (Stranges et al. 2014), categories for SWEMWBS were considered ‘low’ (7–19.3); ‘medium’ (20.0–27.0) and ‘high’ (28.1–35) mental wellbeing (Ng Fat et al. 2017).

Although the decrease in well-being and distress before and after the crisis is established, later in the discussion and conclusions it is recommended to apply Active

and Healthy Confinement Lifestyle (AHCL), a crisis-oriented interdisciplinaryintervention focused on Weakening of physical and social contacts with the disruption of normal lifestyles. From my point of view this suggestion is not well argued on the basis of the current study. The current study establishes that there is a worsening of mental health and well-being in the world population due to COVID-19, but it does not deepen the knowledge of the factors that explain this worsening, so I see it as very pretentious to recommend a specific intervention in this sense. I would like the authors to review this point and to go deeper into the justification of this issue.

Thank you for your comment. This point has been reviewed in the revised discussion section and the following paragraph was added.

“An active lifestyle, including physical and social activity, is an important modifiable factor for mental health across the lifespan (Rohrer et al. 2005). Taking into-consideration that psychosocial tolls of the COVID-19 pandemic appears to be significantly associated with unhealthy lifestyle behaviours including physical and social inactivity, poorer sleep quality as well as unhealthy diet (Ammar et al. 2020e, Xiang et al. 2020), it seems important that this intervention should focus on fostering social communication, physical activity, sleep quality and healthy dietary behaviours (Ammar et al. 2020a-c; Brooks et al. 2020). This multidisciplinary intervention can be supported and delivered to the general populations through technology-based solutions such as fitness and nutritional apps, sleep monitoring device, video streaming, exergames, social network, gamification, and/or virtual coach.”

Minor issues:

- On page 16 when describing the effect sizes there is a misprint in “Cohn, 1988.”

"Effect size (Cohen's d) was calculated to determine the magnitude of the change of the score and was interpreted using the following criteria: 0.2 (small), 0.5 (moderate), and 0.8 (large) (Cohn, 1988). Statistical significance was accepted as α<0.05."

Thank you for your comment. Correction done

- On page 18, there is a room left in "significantly by 9.4 % during home"

Thank you for your comment. Correction done

Submitted filename: 20-07-Point by point responses.docx

Click here for additional data file.

23 Sep 2020

Psychological consequences of COVID-19 home confinement: The ECLB-COVID19 multicenter study

PONE-D-20-15158R1

Dear Dr. Ammar,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: In my opinion the authors have make a good job. The paper now is clearer and more replicable. The method section has been improved and the paper it is very interesting. However, I would make small suggestions which could improve the manuscript:

Authors write the following paragraph: “Reliability of the shortened and/or newly adopted questionnaires was tested by the project steering group through piloting, prior to survey administration. These brief crisis-oriented questionnaires demonstrated high to excellent test-retest reliability coefficients (r = 0.84-0.96).”. This paragraph is confused. It seems that the reliability of the questionnaires was analysed in the pilot study and not with the actual data. Why with the pilot study and not with the used data in this manuscript? If this is the case, authors could analyse the reliability of the used questionnaires if possible. Specially, as the sample could have some bias as they have written in the limitation section. Moreover, why they use the “r” instead “α” to show the reliability coefficient?

Regarding the instrument and all the questionnaires used, it seems that the length of the survey was large which could affect the response rate. In addition, authors have not informed about the response rate. In my opinion it would be interesting to add information about the response rate. If this is not possible because the authors have used the snowball sampling technique, maybe they should add some sentence in the limitations section. In any case, I think the sample, or the number of participants can be representative enough. Adding any reference regarding this aspect could make more robust the method section. The following references could help.

Deutskens E, De Ruyter K, Wetzels M, Oosterveld P. Response rate and response quality of internetbased surveys: An experimental study. Mark Lett. 2004; 15(1): 21-36. https://doi.org/10.1023/B:MARK. 0000021968.86465.00).

Mavletova, A.; Couper, M.P. Mobile web survey design: scrolling versus paging, SMS

versus e-mail invitations. Journal of Survey Statistics and Methodology 2014, 2, 498-

518.

Browne, K. (2005). Snowball sampling: using social networks to research non‐heterosexual women. International journal of social research methodology, 8(1), 47-60.

Lastly authors informed that the total number of questions was: “The survey included sixty-four questions on health, mental wellbeing, mood, life satisfaction and multidimension lifestyle behaviors” in the method section, but this does not match with the “Supporting Information S1 Google form survey.pdf” please revise this aspect.

Reviewer #2: The authors have responded all suggestions and comments by reviewers. The manuscript has improved its quality, so I think the manuscript should be published as it is.

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Reviewer #1: No

Reviewer #2: No

22 Oct 2020

PONE-D-20-15158R1

Psychological consequences of COVID-19 home confinement: The ECLB-COVID19 multicenter study

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