The interdisciplinary project www.cov2soul.rs brought together experts dealing with public health, mental health and psychiatric disorders, to apply on a nationally representative sample of the adult population (18-65) of Serbia the state-of-the-art instruments for estimating the frequency of psychiatric disorders and for detecting mental suffering (distress) during a pandemic, along with many other aspects that contribute to mental health/illness.

The decision-makers can benefit from the CoV2Soul.rs project results, who aim at assessing the situation and improving the health of the population, all clinicians who face the consequences of various stressors in their daily work, as well as the scientific community, because the inclusion of current data in the upcoming international meta-analyzes will help overcome the often mentioned lack of relevant data in the field of mental health from our region.

The ability to compare nationally representative results from our country with international mental health indicators and various aspects of the pandemic should help perceive and understand the pandemic. This would allow better control to be established over similar circumstances in the future.

There have been no epidemiological studies of psychiatric disorders in Serbia before, and they are necessary for planning the organization of services and creating programs for the protection of mental health (Government of the Republic of Serbia, 2019). According to current data from CoV2Soul.rs, we have the same rates of psychiatric disorders as, for example Norway. In Norway (data from Johhansen et al., 2005 and Ruud, 2021), 7% of the total health budget is allocated for mental health care. About 1,000 psychiatrists take care of the mental health of adults there, along with 500 doctors on specialization and about 1,500 clinical psychologists. In addition, 120 psychiatrists and 450 clinical psychologists specializing in children and youth provide assistance to young people. It is not known in our country how much is allocated from the health budget for mental health, and as far as specialist doctors and clinical psychologists are concerned, in our country that number is significantly lower - according to some indicators, 10 times lower (Maric et al, 2019).

The survey holder is the Faculty of Medicine of the University of Belgrade (teaching bases Institute of Mental Health Institute and Institute of Social Medicine), in cooperation with the Departments of Psychology of the Faculty of Philosophy, University of Belgrade and Novi Sad. More on researchers https://cov2soul.rs/istrazivaci/

The survey was conducted with the support of the Science Fund of the Republic of Serbia, project number #7528289, COVID-19-CoV2Soul.RS. The survey was registered at Clinicaltrials.gov number NCT 04896983.

STRESS DURING THE COVID-19 PANDEMIC IN SERBIA

During the Cov2Soul.rs survey, we examined the frequency of stressors associated with exposure to Sars-CoV2 virus (infection of respondents with or without hospital treatment, self-isolation, lack of personal protective equipment in the workplace, illness or loss of a loved one or family member due to COVID- 19). Also, data was collected on the frequency of various life-threatening events since the beginning of the pandemic, which are not directly related to exposure to the virus, such as death of a loved one due to other diseases, financial and work problems, personal or partner problems.

You can read more about the frequency of certain stressors during the pandemic HERE.

OTHER LIFE THREATENING EVENTS DURING THE PANDEMIC

Since the beginning of the pandemic, most respondents have reported threatening events from the category of stress due to the suffering of loved ones (non-covid injuries, illness or death - about 27% of respondents)), stress related to work/finances (about 22% of respondents). Personal problems (serious personal illness, serious injury or attack, serious problems with a close friend, neighbor or relative, problems with the police or appearing in court, or loss or theft of high value items) were reported by 12.8% of respondents, and partner problems were reported by every twentieth respondent (5.5%).

You can read more about the frequency of certain stressors during the pandemic HERE.

WHICH DISORDERS ARE DETERMINED TO BE CONNECTED WITH THE PANDEMIC STRESSORS?

Anxiety disorders have been the only disorders that have been determined to be connected with specifically pandemic stressors. They occurred more frequently in cases where respondents did not have enough COVID-19 protective equipment in the workplace where it was needed. For other disorders, the current survey did not establish the connection with stressors associated with exposure to the Sars-CoV2 virus, but did with other types of difficulties that occurred after the onset of the pandemic (problems at work, private problems). More information on the analysis is available at: https://psyarxiv.com/j3ac8/

WHAT IS COVID STRESS SYNDROME AND HOW IS IT MEASURED?

Pandemic distress includes not only worries and fears about the infection, but also a wider range of reactions such as over-checking that a person is not infected, reassuring that a person is healthy, traumatic reactions, worries about socio-economic consequences, including fears that foreigners are potential carriers of the infection. Hence, a new instrument was created in the world - the Covid Stress Scale (CSS) - with the aim of measuring this syndrome of related reactions.

During the two years of the pandemic, the distress caused by the pandemic was measured three times on the Serbian population using the CSS scale. The first measurement was performed in three large cities in Serbia on a sample of the general population. The second was online research on a sample of users of different social networks. The third measurement was performed within the CoV2Soul.rs project on a representative sample of the general population.

The average values of distress moved from mild to minimal during the two years

WHO IS AT RISK OF STRONGER COVID-STRESS SYNDROME?

● women
● persons with primary education
● persons who have had a psychiatric diagnosis in the past
● pensioners
● persons who were in self-isolation due to contact with infected persons

Although it is difficult to make comparisons between different countries as they differ both in methodology and the time period when the tests were performed, pandemic distress can be registered worldwide.

More information on CSS analyzes that have been published so far is available at: https://www.sciencedirect.com/science/article/pii/S0033350622000166

IS THERE A DIFFERENCE IN DEPRESSIVE SYMPTOMATOLOGY BEFORE AND DURING THE PANDEMIC?

Depressive disorders are the most common internalizing type of disorder in the population and are potentially life-threatening. According to EHIS (European Health Survey), of all psychiatric disorders, only depression - expressed through PHQ-8 (the most widely used instrument for the detection and self-assessment of depressive symptoms), has been included in measures of general health status. Data on depressive symptoms in Serbia on representative national samples exists for 2013 (National Health Survey is part of the EHIS survey). PHQ-8 values >= 10 are taken as the limit above which the risk of the disorder increases. In 2013, 3.1% of the population had PHQ-8>=10 (National Representative Survey, Batut, n=10622)

In the summer of 2021, 5.9% of the population had PHQ-8>=10 (CoV2Soul.rs, n=1203), while in January 2022, 3.8% of the population had PHQ-8>=10. (Cov2soul.rs follow up, n = 319). Thus, in the second year of the pandemic (2021), an increase in depressive symptoms was registered in Serbia in the categories of moderate disorders (approximately twice as many people were in these categories compared to the period before the pandemic). This means that during the pandemic, there were 80,000 more people than before with moderate depressive disorders, while at least 30,000 more were in the category of those with moderate-severe distress. No difference was observed in the category of those with severe depressive disorders, which most likely indicates that in these cases it is a type of depressive disorder that is weakly influenced by exogenous circumstances (external factors).

Preliminary data on the frequency of distress in our population is published on the page: https://scindeks.ceon.rs/Article.aspx?artid=2737-971X2104337M&lang=sr

More information on future analyzes and results is available at: https://psyarxiv.com/j3ac8/.

HOW FREQUENT WERE PSYCHIATRIC DISORDERS IN THE SECOND YEAR OF THE COVID-19 PANDEMIC?

CoV2Soul.rs survey is the first epidemiological study of the prevalence of 12 most frequent psychiatric disorders and suicidality in Serbia on a representative national sample aged 18-651.

CoV2Soul survey showed that one in six respondents (700,000 adult citizens) meet the criteria for some of 12 most frequent psychiatric disorders. Psychiatric monomorbidity was found in 11.1%, a comorbidity in 4.1% respondents. Also, we established that close to 7% disorders have been reoccurring, while there were approximately 8% of newly-registered disorders.

More information on analyses is available at: https://psyarxiv.com/j3ac8/

IS THE FREQUENCY OF PSYCHIATRIC DISORDERS DURING THE PANDEMIC IN SERBIA DIFFERENT FROM OTHER COUNTRIES?

During the pandemic, there were few surveys done on representative samples of the population of individual countries and which used diagnostic interviews in personal contact with respondents. Meta-analyses published before the pandemic showed that the prevalence of psychiatric disorders ranged between 9.8% and 19.1% (Kessler et al., 2009), with an average of 17.4% (Steel et al., 2014) in the adult population.

HOW COMMON WAS SUICIDALITY?

In Serbia, suicidality was detected in 2.8% of respondents (about 120,000 citizens): mild suicidality was the most common (1.7%), moderate suicidality was less common (0.7%), and high suicidal risk was registered in 0.4% of respondents (corresponding to about 18,000 adults).

According to the data of the Statistical Office of the Republic of Serbia (2021), 895 suicides were recorded in 2020. The suicide rate was relatively stable in the period 2018-2020.

You can find out more about prevalence of psychiatric disorders and suicidality during the pandemic HERE.

PERVASIVENESS OF CONSPIRACY THEORIES ABOUT THE PANDEMIC IN SERBIA

The CoV2Soul.rs project collected data on the acceptance of conspiracy theories about the existence, origin and harmfulness of the SARS-Cov-2 virus in the second year of the pandemic (summer 2021), on a representative national sample of the Serbian population. Acceptance of conspiracy theories is important because this tendency is related to opposing vaccination, as well as other forms of inappropriate health-related behaviour (e.g. risky sexual behaviour).

WHAT IS THE FREQUENCY OF ACCEPTING PANDEMIC-RELATED CONSPIRACY THEORIES IN SERBIA?

According to our data, the percentage of acceptance of conspiracy theories related to the pandemic is similar to the percentage announced for the UK (Freeman et al., 2020), Croatia (Tonković et al., 2021), as well as the Western Balkans (Bieber et al., 2020). Namely, slightly more than a half of the population of these countries to some extent agree with the pandemic-related conspiracy theories (about 10% completely agree), while slightly less than a half of the population completely reject these conspiracy theories.

See more about spreading of conspiracy theories during the pandemic HERE.

IS THERE CONNECTION BETWEEN ACCEPTING PANDEMIC-RELATED CONSPIRACY THEORIES AND VACCINATION STATUS?

The answer is yes!

At the time of the CoV2Soul.rs survey (summer 2021), 49% of the population had been vaccinated (with at least one dose of the vaccine). In our research, the strongest connection with the fact that a person was vaccinated was the age of the respondent, followed by a low level of propensity to accept conspiracy theories. As the SARS-Cov-2 virus was particularly life-threatening for the elderly, it is not surprising that the number of vaccinated people among the elderly subpopulation was higher. The degree of education of a person also had somewhat less importance. Being prone to conspiracy theories is obviously one of the most important factors in not accepting adequate forms of health behaviour such as vaccination during pandemic.

PERCEPTION OF LONELINESS DURING COVID-19 PANDEMIC IN SERBIA

People experience loneliness when there is a discrepancy between the actual level of accomplishing social ties and the quality and number of social ties that a person would like to have.

Data on the perception of loneliness were compiled within the Cov2Soul.rs project. Respondents answered about how often they feel that they lack company, how isolated they feel, and how often they feel rejected by their own society.

Almost half of the respondents in the sample stated that they never feel lonely (45%), 50% report that they sometimes feel lonely, while 5% state that they are often or almost always lonely.

Residents of small towns have the least sense of loneliness, in medium-sized towns this feeling is somewhat more pronounced, while this feeling is most present in large cities. You can see more about loneliness in general population HERE.

HOW DID THE COVID-19 PANDEMIC IMPACT VARIOUS ASPECTS OF LIFE?

Crisis situations, such as declaring a pandemic and adapting to changes in the rhythm of life, can have not only negative consequences, but are also a potential chance for building human resilience. Hence, Cov2Soul project participants answered questions in order to explore the strength and capacity to continue to function during and after the pandemic-related circumstances.

See more about how the personal impression of the pandemic changed HERE.