The relationship between numerous pandemic-related stressors and psychological distress faces in Israel

In a recent study posted to the medRxiv* preprint server, a team of researchers from Israel conducted a longitudinal study to assess the plausible risk and protective factors responsible for coronavirus disease 2019 (COVID-19)-related mental health outcomes in the adult population of Israel. They performed the investigations during a 16-month period through three national lockdowns and the mass COVID-19 vaccination program in Israel.

Study: A 16-Month Longitudinal Investigation of Risk and Protective Factors for Mental Health Outcomes throughout Three National Lockdowns and a Mass Vaccination Campaign: Evidence from a Weighted Israeli Sample During COVID-19. Image Credit: Marjan Apostolovic/Shutterstock


The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has imposed a multitude of restrictions that have led to widespread mental health issues worldwide. Various studies have revealed increased anxiety and depression during the COVID-19 surge. Pandemic fatigue includes feelings of mental or physical exhaustion and mental resources depletion attributed to insomnia or chronic stress.

The present study was conducted to expand the understanding of the impact of the pandemic on the mental health of the general public. The researchers evaluated prospective predictors and examined the association between pandemic-related stressors such as financial issues, fatigue, health-related complaints, and a feeling of lack of protection with different faces of psychological distress such as anxiety, depression, and post-traumatic stress symptoms (PTSS) in the Israeli population.

Study design

The present study participants were adults aged 18 years or older living in Israel. The subjects were invited to participate through instant messaging and social media. The authors launched the first survey (T1) a day later after a national lockdown on March 17th2020, a second survey at the end of the first lockdown [April 2020 to May 2020 (T2)]third survey at the beginning of the second lockdown [September to October 2020 (T3)]and fourth survey at the beginning of third lockdown [December 2020 (T4)]. The final fifth survey (T5) was conducted after six months of the vaccination campaign beginning [June 2021 (T5)]. The authors recruited participants in two rounds, including cohort 1 (n=1262) and cohort 2 (n=1216).

The patient-reported outcome measurement information system (PROMIS) developed by the National Institute of Health (NIH) measured depression and anxiety. PTSS were screened with validated primary care post-traumatic stress disorder (PTSD) screen for diagnostic and statistical manual of mental disorders (DSM-5). COVID-19 related stressors were evaluated with an inventory of pandemic-related stress factors (PRSFs).

The authors performed cross-sectional investigations to evaluate the risk and protective factors by three separate mixed-line regression models with anxiety variable SS, and PT dependent variable factors in each model.

The longitudinal analysis explored synchronization between variations in outcomes related to the stressors and mental health.


The findings of the study demonstrated that more than 50%, 39%, and 28% of enrolled subjects experienced above cut-off anxiety, depression, and PTSS. All these parameters exhibited a significant quadratic trend that peaked during the second lockdown.

During the first lockdown, more than 53%, 45%, and 33% of subjects experienced PRSFs such as anxiety related to the possibility of infecting family, financial worry, and exhaustion, respectively. PRSF, like mental and physical exhaustion and sleep difficulties, increased from 33.6%, 20.8%, and 18.6% during T1 to 38.7%, 41.5%, and 29.1%, respectively, in T5.

The time-sensitive analysis of cross-sectional data with mixed-effects linear regression revealed that age was negatively associated with both depression and anxiety while the female sex was associated with higher anxiety levels. Also, depression was negatively associated with various protective factors, including living with children and spouse and higher income. Intriguingly, PTSS were not associated with any demographic characteristics.

The authors observed that during T1 PRSFs like depression and anxiety were positively associated with financial stressors, health-related stressors, and fatigue but not with protection. Across all time points, financial stressors and fatigue were significantly linked with anxiety and depression, with fatigue eliciting the strongest association with both depression and anxiety.

On the other hand, across all time points, health-related stressors were significantly associated with anxiety. However, post the first lockdown, the positive association between health-related stressors and depression vanished, and it remained insignificant during the second and third lockdown.

Moreover, PTSS were associated with health-related stressors and fatigue and remained significant across all time points. Fatigue showed the strongest association with PTSS across all time points. Only during the second lockdown were financial stressors associated with PTSS.

The longitudinal inter-correlations showed that increased fatigue had the strongest association with distressing depression, anxiety, and PTSS. Worsening of financial stressors was associated with aggravated depression and anxiety but not PTSS, while increased health-related stressors were associated with exacerbation in anxiety but not depression. Lastly, reduced feelings of protection were associated with depression and anxiety worsening but not PTSS.


The present study highlighted the prominent role of fatigue in the exacerbation and conservation of mental disorders such as anxiety and depression to a larger extent compared to other stressors related to financial, health-related, or protection concerns.

The study findings emphasize the impact of multiple risk factors on psychiatric outcomes during the COVID-19 pandemic. They signal health policymakers on the need to consider mental health problems while confronting SARS-CoV-2.

*Important notice

medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.