The research team of the Cov2Soul.RS project, reports the preliminary results on depressiveness in Serbia, on the occasion of the world mental health day

Dear Editors,

The national survey on psychiatric disorders at the time of the COVID-19 pandemic in Serbia (acronym - Cov2Soul.RS; funded by the Science Fund of the Republic of Serbia - www.cov2soul.rs), which is carried out by researchers from the University of Belgrade and the University of Novi Sad, has, so far, gathered more than 80.0% of the material necessary for the final analyses. To achieve a representative sample, a total of 52 trained research assistants (doctors, psychologists, senior medical students) were recruited to perform more than 1,000 in-depth clinical interviews, all over Serbia. In addition to the clinical interviews, other data was also collected – on the intensity of the COVID stress syndrome in the population of Serbia, general health, the use of sedatives, loneliness, beliefs related to the origin and spread of the pandemic, positive and negative aspects of the current situation, the quality of living, and personality structure (see Research protocol (reference 1)).

The final results will, for the first time, show the frequency of psychiatric disorders in the general population of Serbia classified according to the ICD-10, and we expect them in the first half of 2022. For World Mental Health Day, October 10, 2021, we are presenting part of the preliminary results – at this moment only related to how depressed we are in the second year of the pandemic, by comparing this data to 2013 and 2019, using the same method to assess depresiveness in general population (The National Health Survey of the Republic of Serbia included more than 10,000 participants, aged 15 years and above.) [2],[3]. Importantly, direct comparison is enabled as the same instrument for assessment of depression was used, that is the Patiend HEalth Questionnaire - PHQ9 [4]. This questionnaire is used all over the world to measure depressiveness, as an indicator of general health, and its purpose is to assess the intensity of symptoms, such as: low mood, decline of energy and initiative, negative thoughts about oneself, tension, insomnia, changes in appetite and oscillation in the will to live, with a note that this instrument is not sufficient for establishing the diagnosis of depressive disorder, rather it is used for initial screening. The questions are focused on the complaints experienced in the two weeks prior to survey, and the result indicates the intensity of depressiveness (mild, moderate, severe). PHQ result below 10 indicates that the person is not depressed at a clinically relevant level [1],[2],[3], while result above 10 (“threshold”) is a signal that the person is in need of some form of support – counseling, a change in lifestyle, or perhaps psychotherapy or pharmacotherapy, while in some cases, only careful monitoring is necessary to avoid the worsening of the complaints.

Our results obtained on the sample of 970 respondents, average age 42 years, interviewed throughout Serbia during summer 2021, show that the percentage of individuals with the score above threshold is 5.7% (ratio men : women – 1.8 : 1), when compared to the data from 2013 and 2019 [2],[3] the number of people with depressiveness score above the "threshold" almost doubled (earlier, it was 3,0% in the adult population of Serbia, aged between 18 and 65 years). Additionally, when analyzing which type of depressiveness is more common in 2021 – whether it is related to cases of mild/moderate complaints or severe symptoms, it was shown that, in the era of the COVID-19 pandemic, only the incidence of mild/moderate depressiveness is on the rise, and not of severe depressiveness – very intensive symptoms are stable in their occurrence in the population (0.4%), i.e., they cannot be linked to the current situation, which is to be expected. However, our results speak in favor of a rise of so called “reactive” depression, i.e., in favor of the fact that there is, indeed, reaction to many aspects of the pandemic (medical risks, but also different psychosocial changes caused by the pandemic). Although it was to be expected that depressiveness and age would correlate, which was the case in 2013 [2], in 2021, this correlation was not registered. This could mean that the number of depressed younger persons during the pandemic is rising, which can also be observed in studies from other countries [5],[6]. In the Cov2Soul.RS survey we have also obtained information on how the respondents assess their position on the social ladder (in relation to education, status, income, on a scale from 1 to 10) [7]. Persons in the top third of the ladder, who evaluate themselves as more educated and of higher socio-economic status, reported more depressive complaints. Whether this may be an indicator of a particular effect of the pandemic remains to be further analyzed in future studies.

What do the percentages related to Serbia specifically mean? Transformed into absolute numbers, this means that, during the summer of 2021, for about 240,000 persons, aged between 18 and 65, there was a need for the provision of the some sort of assistance in mental health care institutions and departments. In some cases, the complaints would have subsided without external assistance, however, this is not always the case – the risk of the symptoms intensifying or complications occurring should not be overlooked (self-treatment with alcohol, illegal drugs or sedatives, neglect of physical health, family, social, and professional problems, suicide risk), as treatment is the more difficult the more it is delayed.

Five years prior to the pandemic, the frequency of depressiveness, measured with the PHQ instrument, in EU countries, was around 6.6%, which is considered to be the European average (it varies from 3.0% in Greece to above 9.0% in Germany) [8]. Although, in Serbia, depressiveness during the pandemic has practically doubled (increase was also reported in studies from Austria, Great Britain and Canada) [5],[6],[9], it is important to note that, among the population of Serbia, even with the rise during the pandemic, depressiveness has remained lower than the European pre-pandemic average [8]. Comparison with other countries, where measurement was performed in the same way on nationally representative samples, shows that the percentage of depressive persons “above the threshold” in Great Britain was around 13.0% [6], which is double the number found in Serbia at this point, while in Austria and Australia, percentages above 18.0% have been reported, which is three times higher than in Serbia [5],[9]. This can partially, but not completely, be attributed to the fact that the data from the above-mentioned studies were gathered a year before the data from our study, i.e., not long after exposure to shocking information, isolation, and intensification of every type of uncertainty [10]. There are other explanations, as well. One would be that, as a people, we are more resilient, i.e., that we have psychologically developed a tolerance to uncertainty during the decades of instability. Then, there is also the explanation that the sense of belonging to a community, which protects people from depressiveness, has been preserved, after all. However, there is also a possibility that there is disparity in so called “health literacy”, i.e., the extent to which we are able or unable to describe our psychological state (“words for feelings”), or to which we do or do not feel comfortable to do so, due to the fear of stigma, which may also be the reason why these psychological complaints are registered at a lesser rate in Serbia.

What do we undoubtedly know at this time? Firstly, mental health should be considered one of the priorities of public health – a priority, but also a challenge of health policy. Secondly, at this moment, it is quite clear that data collected in online surveys should be assessed critically and that conclusions must not be made lightly on the basis of such data [10]. Media in Serbia reported that “a month after the state of emergency was declared, 28.9% respondents reported mild to severe depression, 36.9% reported anxiety, while 38.1% stated having severe stress symptoms”. These are very high numbers. It is very important that both the media and the public are very careful when drawing conclusions on the health of the population in Serbia.

It seems that, in Serbia, a particular subpopulation responds to online surveys on mental health [11]. An illustration on the extent to which data from online testing can differ from quality sampling (representative samples) can be found, amongst other sources, in the pilot study of the CoV2Soul.RS project, where, at the beginning of 2021, we used the same instrument – the ultra short instrument for the detection of anxiety/depressiveness (PHQ-4) [12] to a convenience sample of over 3,000 online respondents, and then to the described representative sample of the population of Serbia, tested in the field. The difference in the data was tenfold – the data collected online showed people in Serbia to be ten times more anxious and depressed than is actually the case.

Our recommendation would be to base conclusions related to the mental health and psychiatric illnesses of the general population on representative, rather than on convenience or biased samples, as well as to avoid sensationalism. Representative samples entail very demanding implementation procedures and a lot of resources, which is why the execution of the CoV2Soul.RS study in the field, at the time of increased epidemiological risk (field studies during the pandemic are rare anywhere in the world) was a challenge. Nevertheless, to the best of our knowledge, this is the only way for our country to obtain data that would provide insight into the real consequences of the pandemic and help meet the needs of the population. We hope that the preliminary results reported in this paper may be useful in facilitating the planning and execution of appropriate measures for protecting the population health jeopardized by the pandemic.

Note: This study is supported by the Science Fund of the Republic of Serbia, Contract No. #7528289 – CoV2Soul.RS – Special COVID-19 Research Program.