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COVID-19 Pandemic and Mental Health : Prevalence and Correlates of New-Onset Obsessive-Compulsive Symptoms… Abba-Aji, Adam; Li, Daniel; Hrabok, Marianne; Shalaby, Reham; Gusnowski, April; Vuong, Wesley; Surood, Shireen; Nkire, Nnamdi; Li, Xin-Min; Greenshaw, Andrew J.; Agyapong, Vincent I. O. 2020-09-24

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International  Journal  ofEnvironmental Researchand Public HealthArticleCOVID-19 Pandemic and Mental Health: Prevalenceand Correlates of New-Onset Obsessive-CompulsiveSymptoms in a Canadian ProvinceAdam Abba-Aji 1,2, Daniel Li 1,2, Marianne Hrabok 1,3, Reham Shalaby 1, April Gusnowski 2,Wesley Vuong 2 , Shireen Surood 2, Nnamdi Nkire 1,2, Xin-Min Li 1, Andrew J. Greenshaw 1,4and Vincent I.O. Agyapong 1,2,*1 Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton,AB T6G 2B7, Canada; abbaaji@ualberta.ca (A.A.-A.); Daniel.Li@albertahealthservices.ca (D.L.);marianne.hrabok1@ucalgary.ca (M.H.); rshalaby@ualberta.ca (R.S.);Nnamdi.Nkire@albertahealthservices.ca (N.N.); Xinmin@ualberta.ca (X.-M.L.);andy.greenshaw@ualberta.ca (A.J.G.)2 Addiction and Mental Health, Alberta Health Services, Edmonton, AB T5K 2J5, Canada;April.Gusnowski@albertahealthservices.ca (A.G.); Wesley.Vuong@albertahealthservices.ca (W.V.);shireen.surood@albertahealthservices.ca (S.S.)3 Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada4 APEC Digital Hub for Mental Health, University of British Columbia, Vancouver, BC V6T 1Z4, Canada* Correspondence: agyapong@ualberta.ca; Tel.:+1-780-215-7771; Fax: 1-780-743-3896Received: 1 September 2020; Accepted: 22 September 2020; Published: 24 September 2020 Abstract: Background: This cross-sectional online survey investigates the prevalence of obsessive-compulsive disorder (OCD) symptoms at an early stage of the COVID-19 pandemic in Canada.Methods: OCD symptoms, moderate/high stress, likely generalized anxiety disorder (GAD) andlikely major depressive disorder (MDD) were assessed with the Brief Obsessive-Compulsive Scale(BOCS), Perceived Stress Scale (PSS), Generalized Anxiety Disorder 7-item (GAD-7) scale, and PatientHealth Questionnaire-9 (PHQ-9) scale, respectively. Results: Out of 32,805 individuals subscribedto Text4Hope, 6041 completed an online survey; the response rate was 18.4%. Overall, 60.3% ofrespondents reported onset of OCD symptoms and 53.8% had compulsions to wash hands during theCOVID-19 pandemic. Respondents who showed OCD symptoms only since the start of COVID-19were significantly more likely to have moderate/high stress (z = 6.4, p < 0.001), likely GAD (z = 6.0,p < 0.001), and likely MDD (z = 2.7, p < 0.01). Similarly, respondents who engaged in compulsivehand washing were significantly more likely to have moderate/high stress (z = 4.6, p < 0.001) andlikely GAD (z = 4.6 p < 0.001), but not likely MDD (z = 1.4, p = 0.16). Conclusion: The prevalenceof OCD symptoms increased during the COVID-19 pandemic, at a rate significantly higher thanpre-pandemic rates reported for the sample population. Presenting with OCD symptoms increasedthe likelihood of presenting with elevated stress, likely GAD, and likely MDD.Keywords: COVID-19; obsessive-compulsive disorder; stress; anxiety; generalized anxiety disorder;depression; major depressive disorder; public health; text; technology; pandemic1. IntroductionThe 2019 coronavirus disease (COVID-19) can cause a form of severe acute respiratory syndromethat may rapidly lead to death in vulnerable persons. It has a high droplet transmission rate fromperson to person, with a fatality rate of 2–5% [1,2]. In March of 2020, approximately 136 countriesimposed stringent measures to limit the spread of COVID-19, including staying at home, physicalInt. J. Environ. Res. Public Health 2020, 17, 6986; doi:10.3390/ijerph17196986 www.mdpi.com/journal/ijerphInt. J. Environ. Res. Public Health 2020, 17, 6986 2 of 11distancing of 2 m, and prohibition of social gatherings. This has been accompanied by extensive publichealth campaigns on regular hand washing, hygiene, and personal protective equipment (PPE) such asface masks and gloves.While these measures are important, they may negatively impact the mental health of vulnerableindividuals. Limitations and restrictions imposed on individuals aimed towards the protection of thepublic from communicable diseases can result in mental illness [3]. In this context, public perception ispositively correlated with the psychological impact of an outbreak [4]. An important risk factor formental illness during a pandemic is an individual’s constant worry about self and family members [4].Excessive worry is an accepted etiologic factor in the development of obsessive-compulsive disorder(OCD) symptoms [5].OCD is characterized by obsessions, including fear of contamination by dirt or germs,which generate distress that frequently results in compulsions to temporarily alleviate anxiety. While thelifetime prevalence of OCD symptoms is over 25% [6], the lifetime prevalence of the full disorder ismuch less, estimated at 2–3% for the general population [7]. OCD is highly comorbid with anxietydisorders and depression [8], including major depressive disorder (MDD), social anxiety disorder andgeneralized anxiety disorder (GAD) [9]. Individuals with OCD may experience a significant impairmentin psychosocial and occupational level of functioning, leading to, or exacerbating, poor quality oflife [10]. In the absence of early intervention, OCD can run a chronic course [11]. The diminishedquality of life seen in people diagnosed with OCD is comparable to the level observed with othersevere mental disorders like schizophrenia [12]. The etiology of OCD is associated with the interplayof multiple risk factors, such as gene, environment and life stressors [13].There is a paucity of data describing the prevalence of OCD symptoms during communicabledisease pandemics, despite the fact that these represent a period of time when people are requiredto be hypervigilant about preventing the threat of the contamination of self and others. Our studyaimed to increase our knowledge in this area by investigating associations between OCD symptomsand symptoms of perceived stress, GAD and MDD using a population-based, cross-sectional surveydesign during the COVID-19 pandemic. Stressful life events may precipitate or predispose individualsto development of OCD symptoms. The intense focus on danger of contamination from a virus duringCOVID-19, with the ensuing major disruption of personal health, social routines, health-systems and theeconomy, may increase the risks associated with the genesis of OCD symptoms in the population [14].Data collection for this study occurred during the initial phase of the COVID-19 epidemic inthe province of Alberta, Canada, currently comprising a census population of 4,413,146 persons [15].At the close of the survey collection on 30 March 2020, 690 COVID-19 cases were identified in theprovince, of which 65 were suspected to be community-acquired, 94 were recovered, and 47 had beenhospitalized, with a total of 17 admissions to intensive care units [16]. The objectives of our study areto determine the prevalence and correlates of OCD symptoms amongst a cross-section of Canadiansubscribers to the Text4Hope program during the COVID-19 pandemic, and to examine the associationbetween new onset OCD symptoms and high/moderate perceived stress, likely GAD, and likely MDD.2. Materials and MethodsThis is a cross-sectional study based on data collected online from subscribers to Text4Hope, a dailysupportive text message service launched in partnership with Alberta Health Services, the Provincialhealth authority to support the mental health of Alberta residents. Individuals self-subscribed toText4Hope by texting “COVID19HOPE” to a designated short code number. Subscribers receive a linkto the online survey designed to gather demographic variables such as age, gender, ethnicity, education,employment status, relationship status and housing status. The 10 min (average duration) surveyalso assessed obsessive-compulsive symptoms with two items on the Brief Obsessive-CompulsiveScale (BOCS) [17], perceived stress with the Perceived Stress Scale (PSS) [18], likely GAD with theGeneralized Anxiety Disorder 7-item (GAD-7) scale [19], and likely MDD with the Patient HealthQuestionnaire-9 (PHQ-9) scale [20]. The two modified questions from the BOCS were:Int. J. Environ. Res. Public Health 2020, 17, 6986 3 of 11• I am worried about dirt, germs and viruses. Ex. Fear of getting germs from touching door handlesor shaking hands or sitting in certain chairs or seats or fear of getting COVID-19.• I wash my hands very often or in a special way to be sure I am not dirty or contaminated.Ex. Washing one’s hands many times a day or for long periods after touching, or thinking one hastouched, a contaminated object.The responses to the above questions were modified to these three Likert scales: “Only duringCOVID-19 Pandemic”, “Before and During COVID-19 Pandemic,” or “Never”.The study was approved by the University of Alberta Human Ethics Review Board (Pro00086163),and consent was implied if the participants completed the online survey and submitted responses.With an estimated population of 4,371,316 in Alberta, we calculated the minimum sample size requiredto estimate mental disorder prevalence rates with a confidence level of 99% and a 2% margin oferror as n = 4200. Given the expected response rate of 20% [21], we planned to extract data afterat least 20,785 individuals had subscribed to Text4Hope. Data were collected 23–30 March 2020,with 32,805 subscriptions to Text4Hope, thus exceeding the target sample size. The data were analyzedwith Statistical Package for Social Sciences (SPSS) version 20 [22] using descriptive statistics andChi-Square tests. Two tailed significance (p < 0.05) was used to assess the relationship betweenobsessive-compulsive symptoms and other mental health variables. For mental health variables withstatistically significant relationship with OCD symptoms, we performed post-hoc analysis, comparingthose who had new onset OCD symptoms with those who had never had OCD symptoms and reportedcorresponding z-scores, adjusted residuals and p-values. Given the cross-sectional study design,there was no imputation for missing data and the results were based on completed survey responses.3. ResultsOf the 32,805 individuals invited to complete an online survey, 6041 responded, yielding a responserate of 18.4%. Table 1 provides descriptive summaries of the demographic and clinical characteristicsof the respondents.The data displayed in Table 1 indicate that 60.3% of respondents had obsessions related tocontamination with dirt, germs or viruses, and 53.8% had compulsions to wash hands repeatedly or ina special way, which both started during the COVID-19 pandemic. The one-week prevalence rates formoderate/high stress, likely GAD and likely MDD in Alberta were 84.9%, 46.7% and 41.4%, respectively.Table 2 suggests there were statistically significant correlations between obsessions related to dirt,germs and viruses, and all demographic variables assessed. The groups of respondents who identifiedas male, over 60 years of age, Caucasian, with post-secondary education, retired, widowed, or livingin their own homes contained a higher proportion of respondents who expressed worry related tocontamination with dirt, germs and viruses, compared to other respondents.Table 3 suggests that all demographic variables except gender and relationship status hadstatistically significant relationships with compulsive hand washing. Groups of respondents whoidentified as being over 60 years of age, Caucasian, with post-secondary education, retired or homeowners had higher proportions of respondents who were engaged in compulsive hand washingcompared to other respondents.The data displayed in Table 4 indicate significant correlations between obsessions about dirt,germs and viruses, and between those who engaged in compulsive hand washing and the likelihoodthat respondents had moderate/high stress, likely GAD and likely MDD. Post-hoc analysis usingadjusted residuals indicates that respondents who were worried about dirt, germs and viruses onlysince the start of the COVID-19 pandemic were significantly more likely to have moderate/high stress(z = 6.4, p < 0.001), likely GAD (z = 6.0, p < 0.001) and likely MDD (z = 2.7, p < 0.01) compared torespondents who have never been worried about dirt, germs and viruses. Similarly, respondents whoengage in compulsive hand washing were significantly more likely to have moderate/high stress(z = 4.6, p < 0.001) and likely GAD (z = 4.6 p < 0.001), but not likely MDD (z = 1.4, p = 0.16), comparedto respondents who have never engaged in compulsive hand washing.Int. J. Environ. Res. Public Health 2020, 17, 6986 4 of 11Table 1. Demographic and clinical characteristics of respondents.Variables OverallGenderMale 740 (12.4%)Female 5185 (86.6%)Other Gender 61 (1.0%)Age (Years)≤25 640 (10.9%)26–40 2174 (37%)41–60 2539 (43.3%)>60 517 (8.8%)EthnicityCaucasian 4910 (82.2%)Indigenous 205 (3.4%)Asian 301 (5.0%)Other 554 (9.3%)EducationLess than High School Diploma 218 (3.6%)High School Diploma 583 (9.7%)Post-Secondary Education 5123 (85.6%)Other Education 59 (1.0%)Employment statusEmployed 3726 (72.1%)Unemployed 719 (13.9%)Retired 399 (7.7%)Student 322 (6.2%)Relationship statusMarried/Common-law/Partnered 4284 (71.6%)Separated/Divorced 438 (7.3%)Widowed 93 (1.6%)Single 1105 (18.5%)Other 62 (1.0%)Housing statusOwn Home 3917 (66.6%)Living with Family 548 (9.3%)Renting 1355 (23.0%)Other 63 (1.1%)Worried about dirt, germs, and virusesOnly since COVID-19 pandemic 3111 (60.3%)Before and during COVID-19 pandemic 1293 (25.1%)Never 753 (14.6%)Wash hands very often or in a special wayto be sure he/she is not dirty orcontaminatedOnly since COVID-19 pandemic 2771 (53.8%)Before and during COVID-19 pandemic 1702 (33.0%)Never 678 (13.2%)Respondents had moderate/high stress a 4689 (84.9%)Respondents had likely GAD b 2362 (46.7%)Respondents had likely MDD c 2130 (41.3%)a Moderate or high stress defined as Perceived Stress Scale score ≥14. b Likely GAD defined as Generalized AnxietyDisorder-7 scale score ≥10. c Likely MDD defined as Patient Health Questionnaire -9 scale score ≥10.Int. J. Environ. Res. Public Health 2020, 17, 6986 5 of 11Table 2. Demographic characteristics of respondents with obsessive symptoms (dirt, germs, andviruses).VariablesWorried about Dirt, Germs, and Virusesp-Value * Effect Size (Phi)Only Since COVID-19Pandemic “After”Before and During COVID-19PandemicNeverGenderMale 388 (63.2%) 106 (17.3%) 120 (19.5%)<0.001 0.08Female 2694 (60.1%) 1168 (26%) 623 (13.9%)Other Gender 25 (52.1%) 16 (33.3%) 7 (14.6%)Age (Years)≤25 308 (55.7%) 166 (30%) 79 (14.3%)<0.001 0.0626–40 1146 (60.8%) 494 (26.2%) 246 (13%)41–60 1333 (60.9%) 513 (23.4%) 344 (15.7%)>60 281 (62.0%) 96 (21.2%) 76 (16.8%)EthnicityCaucasian 2630 (61.2%) 1023 (23.8%) 642 (14.9%)<0.001 0.07Indigenous 101 (56.4%) 57 (31.8%) 21 (11.7%)Asian 131 (58.5%) 73 (32.6%) 20 (8.9%)Other 241 (54.8%) 131 (29.8%) 68 (15.5%)EducationLess than High School Diploma 93 (52.8%) 53 (30.1%) 30 (17.0%)0.01 0.06High School Diploma 280 (57.7%) 133 (27.4%) 72 (14.8%)Post-Secondary Education 2714 (61.0%) 1085 (24.4%) 647 (14.6%)Other Education 19 (45.2%) 19 (45.2%) 4 (9.5%)Employment statusEmployed 1994 (62.4%) 739 (23.1%) 460 (14.4%)<0.01 0.07Unemployed 327 (54.0%) 186 (30.7%) 92 (15.2%)Retired 225 (63.2%) 75 (21.1%) 56 (15.7%)Student 172 (59.9%) 73 25.4(%) 42 (14.6%)Relationship statusMarried/Common-law/Partnered 2287 (61.6%) 911 (24.5%) 515 (13.9%)<0.001 0.07Separated/Divorced 243 (62.5%) 87 (22.4%) 59 (15.2%)Widowed 56 (66.7%) 18 (21.4%) 10 (11.9%)Single 507 (55.0%) 257 (27.9%) 158 (17.1%)Other 16 (38.1%) 17 (40.5%) 9 (21.4%)Housing statusOwn Home 2087 (61.4%) 807 (23.7%) 505 (14.9%)<0.001 0.07Living with Family 249 (52.1%) 142 (29.7%) 87 (18.2%)Renting 722 (60.7%) 320 (26.9%) 148 (12.4%)Other 26 (56.5%) 16 (34.8%) 4 (8.7%)* Effect size as measured by Phi: A value of 1 is considered a small effect, 3 a medium effect and 5 a large effect.Int. J. Environ. Res. Public Health 2020, 17, 6986 6 of 11Table 3. Demographic characteristics of respondents with compulsive symptoms (repeated handwashing).VariablesWash Hands Very Often or in a Special Way to Be Sure He/She Is NotDirty or Contaminatedp-Value * Effect Size (Phi)Only since COVID-19Pandemic “After”Before and during COVID-19Pandemic NeverGenderMale 350 (57.3%) 189 (30.9%) 72 (11.8%)0.06 0.04Female 2395 (53.4%) 1495 (33.4%) 592 (13.2%)Other Gender 22 (45.8%) 14 (29.2%) 12 (25.0%)Age (Years)≤25 264 (47.7%) 238 (43.0%) 51 (9.2%)<0.001 0.1126–40 989 (52.5%) 658 (34.9%) 237 (12.6%)41–60 1198 (54.7%) 656 (30.0%) 335 (15.3%)>60 284 (63.3%) 121 (26.9%) 44 (9.8%)EthnicityCaucasian 2363 (55.1%) 1348 (31.4%) 577 (13.5%)<0.001 0.08Indigenous 82 (45.8%) 79 (44.1%) 18 (10.1%)Asian 119 (53.1%) 83 (37.1%) 22 (9.8%)Other 197 (44.7%) 184 (41.7%) 60 (13.6%)EducationLess than High School Diploma 79 (44.6%) 83 (46.9%) 15 (8.5%)<0.001 0.09High School Diploma 251 (51.9%) 196 (40.5%) 37 (7.6%)Post-Secondary Education 2417 (54.4%) 1403 (31.6%) 620 (14.0%)Other Education 19 (45.2%) 17 (40.5%) 6 (14.3%)Employment statusEmployed 1789 (56.1%) 991 (31.1%) 408 (12.8%)<0.001 0.09Unemployed 276 (45.5%) 242 (39.9%) 89 (14.7%)Retired 220 (62.1%) 92 (26.0%) 42 (11.9%)Student 142 (49.5%) 112 (39.0%) 33 (11.5%)Relationship statusMarried/Common-law/Partnered 2030 (54.7%) 1182 (31.9%) 496 (13.4%)0.09 0.05Separated/Divorced 205 (52.6%) 126 (32.3%) 59 (15.1%)Widowed 45 (53.6%) 32 (38.1%) 7 (8.3%)Single 468 (50.8%) 342 (37.1%) 111 (12.1%)Other 21 (51.2%) 16 (39.0%) 4 (9.8%)Housing statusOwn Home 1894 (55.8%) 1022 (30.1%) 477 (14.1%)<0.001 0.10Living with Family 208 (43.5%) 215 (45.0%) 55 (11.5%)Renting 626 (52.6%) 430 (36.1%) 134 (11.3%)Other 19 (41.3%) 20 (43.5%) 7 (15.2%)* Effect size as measured by Phi: A value of 1 is considered a small effect, 3 a medium effect, and 5 a large effect.Table 4. Chi-Square test of association between obsessive-compulsive symptoms and perceived stress,likely GAD and likely MDD.VariablesPerceived Stress Generalized Anxiety Disorder Major Depressive DisorderModerate/HighStressp-Value Effect Size(Phi)GADLikelyp-Value Effect Size(Phi)MDDLikelyp-Value * Effect Size(Phi)Worried about dirt, germs, and virusesOnly since COVID-19pandemic 2656 (85.6%)<0.001 0.111445 (47.3%)<0.001 0.101276 (41.1%)<0.001 0.06Before and duringCOVID-19 pandemic 1133 (88.0%) 656 (51.7%) 581 (45.1%)Never 571 (76.0%) 258 (35.1%) 268 (35.6%)Wash hands very often or in a special way to be sure hands are not dirty or contaminatedOnly since COVID-19pandemic 2359 (85.3%)<0.001 0.081288 (47.3%)<0.001 0.071111 (40.1%)0.01 0.05Before and duringCOVID-19 pandemic 1471 (86.8%) 820 (49.2%) 759 (44.8%)Never 526 (78.0%) 249 (37.4%) 252 (37.2%)* Effect size as measured by Phi: A value of 1 is considered a small effect, 3 a medium effect, and 5 a large effect.4. DiscussionTo our knowledge, this population-based, cross-sectional survey of 6501 respondents duringthe COVID-19 pandemic is the first to report the prevalence of OCD symptoms and their correlationwith stress, anxiety and depression symptoms. The high levels of stress, anxiety and depressionsymptoms underscore the need for focused the mental health prevention, intervention and follow-upof affected vulnerable groups during the COVID-19 pandemic. These results align with the prevalenceInt. J. Environ. Res. Public Health 2020, 17, 6986 7 of 11rates in a survey-based measurement of 1257 health care workers in fever clinics and wards forCOVID-19 patients in China, which also used the PHQ-9 and GAD-7, in which participants reportedhigh rates of distress (71.5%), anxiety (44.6%) and depression (50.4%) [23]. Similarly, in anothersurvey study of the initial stage of the COVID-19 epidemic in China, 1652 respondents rated thepsychological impact as moderate-to-severe, with one-third reporting moderate-to-severe anxiety, and16.5% reporting moderate-to-severe depressive symptoms [24]. Further, an Italian study by Magnavitaand colleagues [25] found similar levels of anxiety and depression during a comparable period in thepandemic. These studies both show similar findings in different geographical jurisdictions. The resultsof this early-stage pandemic study support the proposal that surveying the OCD symptom dimensionsare important for future pandemic planning, where strict public health measures (e.g., requiring regularhandwashing, use of facemask and social distancing) are implemented or enforced. While 25.1–33.1%of the sample reported pre-COVID-19 OCD symptoms, an additional 60.3% were obsessed with fearsof contamination and 53.8% had compulsive hand-washing. Post-hoc analysis revealed that those withnew onset OCD symptoms are statistically more likely to have high stress, likely GAD, and likelyMDD. This is a 10 to 30-fold increase in OCD symptoms relative to the prevalence reported in thepre-pandemic general population [6].These results indicate that both previous and new onset OCD contamination symptoms correlatewith, and may serve as a marker for, a moderate/high stress group that is more vulnerable to GADand MDD during COVID-19. Because global pandemics are associated with increased somatic andcognitive anxiety [22,26,27], the combination of this stress and specific OCD contamination worriesmay result in negative-valence cognitive ruminations that activate vulnerabilities to GAD and MDD.The correlation among OCD, GAD and MDD has been explained by the overlap of common genetics,neurobiology, and shared psychological constructs [28,29].The lifetime prevalence of OCD symptoms is over 25%, but only a small proportion fulfill thefull criteria for OCD, with a lifetime prevalence of 2.1% [6]. In a four year follow-up of a subgroup of181 severe acute respiratory syndrome (SARS) survivors that used the Structured Clinical Interviewfor Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), common diagnoses includedpost-traumatic stress disorder (54.5%), depression (39.0%) and OCD (15.6%)—the latter of which isseven times higher than the lifetime prevalence rate of OCD (2.1%) [30]. Thus, whether the new-onsetOCD symptoms observed in our study are related to true OCD disease risk, are an expression of specificphobia-type risks in the context of COVID-19, or are a combination of both, will be for future researchto determine. It may also be that the obsessive-compulsive symptoms are an adaptive response toprotect the self and others from the virus, as the behaviors sampled are in line with public healthrecommendations. In order to evaluate the adaptive nature of OCD symptoms during the COVID-19pandemic, the persistence or resolution of these symptoms must be determined in the recovery stageof the pandemic when the acute phase has ended.In this study, OCD contamination symptoms were associated with male gender, an age over 60 years,Caucasian ethnicity, post-secondary education, retired employment status, widowed relationshipstatus, and living in your own home. These findings are in contrast with other studies reportingsignificant association of OCD with younger age, marital status [31] and female gender, specificallywith OCD contamination symptoms [32]. The mean age of respondents in our study is 42 years(age range 11–88 years), which is higher than the generally reported mean age of the onset of 17.9 yearsfor OCD [33]. This is important because the onset of OCD prior to 20 years of age is associated witha poor prognosis, whereas an onset over 20 tends to have a shorter course and better outcomes [34].Therefore, given the later age of onset of OCD symptoms in our study, those who develop OCDsymptoms during the COVID-19 pandemic are likely to have a better prognosis.This study suggests that OCD symptoms are associated with the liabilities of increased stress,GAD and MDD. In balance, in a survey of 705 Hong Kong and 1201 Singaporean residents during theSARS epidemic, general anxiety measured using the State-Trait Anxiety Inventory (STAI) was adaptiveand positively associated with the adoption of personal protection measures in Hong Kong [35].Int. J. Environ. Res. Public Health 2020, 17, 6986 8 of 11Determining to what degree GAD and OCD symptoms are adaptive versus a liability during the initialphase of the COVID-19 pandemic will require further work. This study, however, adds the associationof depressive symptoms in a pandemic to obsessive symptoms, which may indicate a further risk ofvulnerability to adverse psychological sequelae.The limitations of the present study include the use of a self-reported questionnaire for cognitiveand behavioral symptoms of OCD, GAD and MDD that would require objective clinical assessment fordefinitive diagnosis. Secondly, our study is not representative of the population in Alberta either by ageor gender [36], and so our findings may not be generalized to the entire population. Thirdly, we cannotclaim to have sufficient statistical power to clearly determine the strength of the correlation betweenthe COVID-19 pandemic and the onset of OCD. In addition, the associated demographic and clinicalfactors as determined by Chi-Square test could have confounding factors, which means the effectsize estimates could be overestimated. To minimize the influence of potential confounding factors,the research team plan to use machine learning methods to develop models on a bigger data set,as described in the study protocol. Furthermore, the increased OCD symptoms may be a reflectionof the real threat posed by COVID-19. As a result, it is possible that once the pandemic is over,a proportion of those with new-onset OCD symptoms would not continue to report these symptoms.Post-pandemic studies are therefore required to determine and understand the temporal relationshipbetween OCD symptoms and the COVID-19 pandemic. We used well-validated and standardizedscales to mitigate the risk of information bias that could possibly be introduced in a self-reportedquestionnaire. However, the lack of randomization may have introduced selection bias and, therefore,effected the strength of the generalizability of our finding. Lastly, this survey is unable to measure thedirect effect of COVID-19 on persons with a confirmed diagnosis of OCD, and this is an interesting areafor future investigation. Our data support the proposal that public health advice during pandemicsshould incorporate mental health wellness campaigns aiming to reduce the psychological impact ofpandemics. There is increasing attention being paid to this need in the media, and our data may serveto provide evidence-based support for such policy implementation.5. ConclusionsThe results of our study reveal a surge in reported obsessive-compulsive symptoms withcorresponding high level of stress, likely GAD and likely MDD during the COVID-19 pandemic.The use of a large population-based sample of Canadians is a significant strength of this study. As ourfindings correspond to some prevalence rates observed in recent studies from different geographicjurisdictions [23,24], as described above, conclusions drawn from our data regarding the prevalence ofOCD symptoms, likely GAD and likely MDD correlates are likely fairly representative of the generalCanadian population. Innovative and cost-effective interventions with the capability to be deployedquickly at the population level, such as supportive text messaging which is free to the end user,does not require expensive data plans, can reach thousands of people simultaneously, is independentof geographic location [21,37–43], and could be particularly useful for those experiencing OCDsymptoms and those who are at a higher risk of experiencing stress, anxiety and depression during theCOVID-19 pandemic.Author Contributions: A.A.-A. participated in writing—original draft preparation, and writing—review andediting. D.L. participated in conceptualization, writing—original draft preparation, and writing—review andediting. M.H. participated in conceptualization, data curation, and writing—review and editing. R.S. participatedin conceptualization, data curation, and writing—review and editing. A.G. participated in data curationand writing—review and editing. W.V. participated in data curation and writing—review and editing.S.S. participated in data curation and writing—review and editing. N.N. participated in writing—reviewand editing. X.-M.L. participated in conceptualization and writing—review and editing. A.J.G. participatedin methodology and writing—review and editing. V.I.O.A. participated in conceptualization, methodology,validation, formal analysis, supervision, funding acquisition, writing—original draft preparation, data curation,and writing—review and editing. All authors have read and agreed to the published version of the manuscript.Funding: This study was supported by grants from the Mental Health Foundation, the Edmonton and CalgaryCommunity Foundations, The Edmonton Civic Employee’s Foundation, the Calgary Health Trust, the UniversityInt. J. Environ. Res. Public Health 2020, 17, 6986 9 of 11Hospital Foundation, the Alberta Children’s Hospital Foundation, the Royal Alexandra Hospital Foundation,and the Alberta Cancer Foundation. The funders had no role in the design and conduct of the study; collection,management, analysis and interpretation of the data; preparation, review or approval of the manuscript;and decision to submit the manuscript for publication.Acknowledgments: Support for the project was received from Alberta Health Services and the Universityof Alberta.Conflicts of Interest: The authors declare no conflict of interest.References1. Li, L.-Q.; Huang, T.; Wang, Y.-Q.; Wang, Z.-P.; Liang, Y.; Huang, T.-B.; Zhang, H.-Y.; Sun, W.-M.; Wang, Y.COVID-19 patients’ clinical characteristics, discharge rate, and fatality rate of meta-analysis. J. Med Virol.2020, 92, 577–583. [CrossRef] [PubMed]2. Onder, G.; Rezza, G.; Brusaferro, S. Case-Fatality Rate and Characteristics of Patients Dying in Relation toCOVID-19 in Italy. JAMA 2020. 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