Disrupted rhythms of life, work and entertainment and their associations with psychological impacts under the stress of the COVID-19 pandemic: A survey in 5854 Chinese people with different sociodemographic backgrounds
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This PLOS ONE research article, published May 17, 2021 by Min Yang, Ping He, Xiaoming Xu, Dan Li and colleagues from Army Medical University, Chongqing Medical University and other Chinese institutions, studies how the COVID-19 pandemic disrupted rhythms of life, work and entertainment and how those disruptions related to psychological impacts. The authors conducted a cross-sectional online survey from the 10th to 17th March 2020 in China, covering 5854 people of different sociodemographic backgrounds. The questionnaire combined general information with the Chinese version of the Brief Social Rhythm Scale and Zung's self-rating scales for depression and anxiety.
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PLOS ONE
RESEARCH ARTICLE
Disrupted rhythms of life, work and
entertainment and their associations with
psychological impacts under the stress of the
COVID-19 pandemic: A survey in 5854 Chinese
people with different sociodemographic
backgrounds
Min Yang1☯, Ping He2☯, Xiaoming Xu3☯, Dan Li4☯, Jing Wang1, Yanjun Wang1, Bin Wang1,
a1111111111
Wo Wang5, Mei Zhao4, Hui Lin6, Mingming Deng7‡*, Tianwei Deng8‡*, Li Kuang3‡*,
a1111111111
Dongfeng Chen ID1‡*
a1111111111
a1111111111 1 Army Medical Center of PLA, Daping Hospital, Army Medical University, Chongqing, P.R. China,
a1111111111 2 Department of Gastroenterology, Yongchuan Hospital of Chongqing Medical University, Chongqing, P.R.
China, 3 Department of Psychiatry, the First Affiliated Hospital of Chongqing Medical University, Chongqing,
P.R. China, 4 CAS Key Laboratory of Mental Health, Institute of Psychology, Beijing, P.R. China, 5 Mental
Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, P.R. China,
6 Department of Statistics, Army Medical University, Chongqing, P.R. China, 7 Department of
Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou, P.R. China,
OPEN ACCESS 8 Department of Gastroenterology, Three Gorges Hospital of Chongqing University, Chongqing, P.R. China
Citation: Yang M, He P, Xu X, Li D, Wang J, Wang
☯ These authors contributed equally to this work.
Y, et al. (2021) Disrupted rhythms of life, work and ‡ These authors also contributed equally to this work.
entertainment and their associations with * chendf1981@126.com (DC); kuangli0308@163.com (LK); dengtw1986@163.com (TD); 793070544@qq.
psychological impacts under the stress of the com (MD)
COVID-19 pandemic: A survey in 5854 Chinese
people with different sociodemographic
backgrounds. PLoS ONE 16(5): e0250770. https://
doi.org/10.1371/journal.pone.0250770 Abstract
Editor: Ben Bullock, Swinburne University of
Technology Faculty of Health Arts and Design,
AUSTRALIA
Background & aim
Received: September 15, 2020
The coronavirus disease 2019 (COVID-19) pandemic has affected the life and work of peo-
Accepted: April 13, 2021 ple worldwide. The present study aimed to evaluate the rhythm disruptions of life, work, and
Published: May 17, 2021 entertainment, and their associations with the psychological impacts during the initial phase
Peer Review History: PLOS recognizes the of the COVID-19 pandemic.
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author Method
responses alongside final, published articles. The
editorial history of this article is available here: A cross-sectional study was conducted from the 10th to 17th March 2020 in China. A struc-
https://doi.org/10.1371/journal.pone.0250770 tured e-questionnaire containing general information, the Chinese version of Brief Social
Copyright: © 2021 Yang et al. This is an open Rhythm Scale, and Zung’s self-rating scales of depression and anxiety (SDS and SAS) was
access article distributed under the terms of the posted and collected online through a public media (i.e. EQxiu online questionnaire plat-
Creative Commons Attribution License, which
form). Scores in sleeping, getting up, and socializing (SGS) rhythm and eating, physical
permits unrestricted use, distribution, and
reproduction in any medium, provided the original practice, and entertainment (EPE) rhythm were compared among and between participants
author and source are credited. with different sociodemographic backgrounds including gender, age, education, current
PLOS ONE | https://doi.org/10.1371/journal.pone.0250770 May 17, 2021 1 / 15
PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
Data Availability Statement: All relevant data are occupation, annual income, health status, and chronic disease status. Correlations of SDS
within the manuscript and its Supporting and SAS with SGS-scale and EPE-scale were also analyzed.
Information files.
Funding: This study was supported by the grant Results
from Chongqing basic research and foreword
exploration project, China (Grant No. Overall, 5854 participants were included. There were significant differences in the scores of
CSTC2018jcyjAX0620); and Chongqing Medical SGS-scale and EPE-scale among people with different sociodemographic backgrounds.
University, a special project of the emergency The scores were significantly higher in the groups with female gender, low education level,
clinical research on the new coronavirus disease
(general project): (1)Psychological intervention for
lower or higher than average income, poor health status, ages of 26–30 years or older than
first-line medical personnel in the new coronavirus 61 years, nurses and subjects with divorce or widow status. There were also significant dif-
pneumonia pandemic, and (2) psychological ferences in SAS and SDS scores among people with different sociodemographic back-
intervention model of negative emotion and
grounds (all P< 0.05). The overall prevalence of depression and anxiety was 24.3% and
behavior among hospital workers during the
COVID-19 pandemic. 12.6%, respectively, with nurses having the highest rates of depression (32.94%) and anxi-
ety (18.98%) among the different occupational groups. SGS-scale was moderately corre-
Competing interests: The authors have declared
that no competing interests exist. lated with SDS and SAS, and disruption of SGS rhythm was an independent risk factor for
depression and anxiety.
Conclusion
Social rhythm disruption was independently associated with depression and anxiety. Inter-
ventions should be applied to people vulnerable to the rhythm disruption during the COVID-
19 pandemic.
Introduction
Coronavirus disease 2019 (COVID-19) is an acute respiratory infectious disease caused by a
novel coronavirus, called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1–
3]. Due to the strong infectivity of the coronavirus and the lack of effective treatments and vac-
cines, COVID-19 has spread rapidly and become a pandemic worldwide with serious conse-
quences. The social restriction policies implemented to control the infection in almost all
countries have resulted in unemployment, financial hardship, and a reduction in quality of life
in many countries [4], which have seriously affected the life and work of people. Simulta-
neously, the COVID-19 pandemic has significant implications for a global increase in mental
health problems, and the psychological burden during the COVID-19 pandemic has been
reported [5, 6].
Social rhythm is defined as the regularity of timing of the behaviors in social activities and
also described clinically as “daily routines” [7]. COVID-19-related social changes, particularly
lockdown protocols, have indeed impacted the timing of daily behaviors in stabilizing circa-
dian function, and social rhythm disruption may be correlated with negative psychological
impacts [7]. Previous studies have reported that social rhythm disruption is connected with
mental diseases, especially depression and bipolar disorder in the non-pandemic days, which
has been explained by many theories [8–11]. Recently, several studies have reported social and
circadian rhythm disruptions in students, office workers, the elderly, and patients with narco-
lepsy or autism [12–14]. However, so far it is not clear the characteristics of the disrupted
rhythms of life, work and entertainment behaviors with different sociodemographic back-
grounds and their associations with psychological impacts under the stress of the COVID-19
pandemic. Therefore, the aim of the present study was to evaluate the rhythm disruptions in
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PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
life, work, and entertainment and their associations with the psychological impacts in the gen-
eral Chinese population with different sociodemographic backgrounds during the initial phase
of the COVID-19 pandemic.
Materials and methods
Participants and procedure
Chinese people with different sociodemographic backgrounds voluntarily participated in this
online survey. An e-questionnaire was designed to investigate the rhythm activities and psy-
chological impacts in Chinese people with different backgrounds including gender, age, educa-
tional background, annual income, health status, current occupation, and chronic disease
status during the COVID-19 pandemic through EQxiu online questionnaire platform. The
survey was conducted from 10–17 March 2020 in 22 provinces and five autonomous regions,
four municipalities, and two special administrative regions (i.e., Hong Kong and Macao) of
China. The study protocol was carried out following relevant guidelines and regulations and
approved by the Ethics Committee of the Army Medical Center (Approval No. 2019–144).
During the survey, the participants were asked to read and check the informed consent and
then complete the questionnaire; those under 18 years old were asked to consent by their
guardians before completing the questionnaire. All completed questionnaires were checked
for validity and completeness.
Measures
Social rhythm. The Brief Social Rhythm Scale (BSRS) was developed to quickly assess
social rhythmicity in large-scale multi-national samples and multiple languages [15]. The Chi-
nese version of BSRS also included entertainment and physical practice, and was shown to
have good reliability and validity in China [16]. The scale consisting of 17 items was used to
investigate an individual’s rhythm in six aspects, i.e., sleeping (going to bed), getting up, social-
izing (SGS), eating, physical practice, and entertainment (EPE) on weekdays and weekends.
The first eight items addressing SGS rhythm constituted SGS-scale, and the last nine items
addressing EPE rhythm constituted EPE-scale. Each item was assigned with a score of 1, 2, 3,
4, 5, or 6, corresponding to categories of very regularly, quite regularly, somewhat regularly,
somewhat irregularly, quite irregularly, or very irregularly, respectively. The lower the score,
the more regular the rhythm.
Zung’s depression and anxiety scale. Zung’s self-rating depression scale (SDS) and
Zung’s self-rating anxiety scale (SAS) were used to evaluate the psychological characteristics of
each participant [17, 18]. There were 20 items in SAS and SDS, and each item was rated on a
scale of 1–4 reflecting never, often, sometimes, and always. The raw score was the sum of 20
questions multiplied by 1.25 and rounded to get the standard score as described in previous
studies [19]. The cut-off value was 50 for both SAS and SDS. The higher the score, the more
obvious the anxiety or depression was, with the scores of 50–59, 60–69, and 70 points or more
indicating mild, moderate, and severe anxiety or depressive symptom, respectively. The Chi-
nese version of SDS and SAS, which was used in the present study, was reported to present
good reliability, validity and excellent internal consistency, with the Cronbach coefficient of
0.784 for SDS in Chinese people [20], and of 0.931 for SAS in the general population [21].
Statistical analysis
Data were analyzed using SPSS version 23.0 (SPSS, Chicago, IL, USA). The data of normal dis-
tribution was expressed by mean±standard deviation. One-way analysis of variance with a
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PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
post-hoc analysis, was used to make comparisons among groups. T-test or a nonparametric
test (i.e., Mann-Whitney U test or Kruskal-Wallis test), where appropriate, was used to make
comparisons between the group with the highest score and each of the other groups for each
item. Pearson correlation or Spearman correlation, where appropriate, was used to determine
the correlation between the BSRS scales and the Zung’s scales. In addition, a multivariate linear
regression analysis was used to determine the independent factors for the correlation of anxi-
ety or depression with social rhythm. Cohen’s d, an indication of effect size, was generated and
reported to further indicate the strength of the difference. A P value of < 0.05 was considered
statistically significant (corrected for multiple comparisons where appropriate).
Results
Sociodemographic characteristics of the participants
A total of 5872 people checked the e-questionnaire. Eighteen questionnaires with invalid data
were excluded due to frivolous or incomplete answers, or the same option for different ques-
tions or orderly answers. The data of 5854 participants with valid questionnaires were further
analyzed. The general information on the sociodemographic characteristics of the participants
is listed in Table 1.
Disruptions of social rhythm in the participants
Generally, there were significant differences in SGS-scale and EPE-scale among participants
with different sociodemographic backgrounds including gender, age, educational background,
annual income, health status, current occupation, and chronic disease status (P<0.05,
Table 2). Moreover, the SGS-scale and EPE-scale scores were compared between the group
Table 1. General sociodemographic characteristics of 5854 analyzed participants.
Feature N (%) Feature N (%)
Gender Female 3439(58.75%) Health status Poor 53(0.91%)
Male 2415(41.25%) Normal 787(13.44%)
Age -18 68(1.16%) Good 3686(62.97%)
18–25 1960(33.48%) Very good 1328(22.69%)
26–30 862(14.72%) Current occupation Businessman 481(8.22%)
31–40 1339(22.87%) Officer 245(4.19%)
41–50 852(14.55%) Teacher 231(3.95%)
51–60 682(11.65%) Police 277(4.73%)
61- 91(1.55%) Farmer 217(3.71%)
Marital status Unmarried 2435(41.60%) Employee 270(4.61%)
Married 3232(55.21%) Doctor 1171(20.00%)
Divorced /widowed 187(3.19%) Nurse 1017(17.37%)
Chronic disease No chronic disease 4373(74.70%) Medical technician 139(2.37%)
CDCPD 671(11.46%) Retired re-employee 229(3.91%)
Chronic diseases only 810(13.84%) Non-medical student 1172(20.02%)
Annual income Less than 50000 CY 2482(42.40%) Medical student 405(6.92%)
50000–100000 CY 1849(31.59%) Education Junior high school or lower 97(1.66%)
100000–200000 CY 1188(20.29%) Senior high school 535(9.14%)
200000–300000 CY 225(3.84%) Junior college or undergraduate 4465(76.27%)
More than 300000 CY 110(1.88%) Master or above 757(12.93%)
CY, Chinese yuan; CDCPD, chronic diseases comorbid with psychosomatic diseases.
https://doi.org/10.1371/journal.pone.0250770.t001
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PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
Table 2. Scores of social rhythms in participants with different sociodemographic backgrounds during the COVID-19 pandemic (N = 5854).
Feature SGS-scale EPE-scale
Mean±SD Z/X2 P Cohen’s d Mean±SD Z/X2 P value Cohen’s d
Gender Female 21.64±9.03 -10.183 <0.001 0.269 7.71±6.02 -7.627 <0.001 -
Male 19.24±8.80 - 8.71±5.93 0.167
Age -18 17.63±8.69 146.237 <0.001 - 7.82±5.58 112.103 <0.001 0.102
18–25 18.98±8.95 0.153 7.75±5.35 0.091
26–30 23.04±9.77 0.585 7.22±6.22 -
31–40 21.54±8.95 0.443 7.76±6.18 0.087
41–50 20.79±8.56 0.366 9.10±6.68 0.291
51–60 20.74±7.91 0.374 9.64±5.82 0.402
61- 21.27±8.78 0.417 9.87±6.14 0.429
Marital status Unmarried 19.53±9.19 81.065 <0.001 - 7.81±5.52 2.499 0.294 -
Married 21.42±8.77 0.210 8.32±6.26 0.086
Divorced /widowed 22.04±9.21 0.273 8.76±7.25 0.147
Education Junior high school or lower 18.92±10.07 8.880 0.031 - 7.81±7.18 11.172 0.011 0.009
Senior high school 21.18±8.97 0.237 7.75±5.97 -
Junior college or undergraduate 20.64±9.06 0.180 8.05±5.89 0.051
Master or above 20.59±8.61 0.178 8.85±6.46 0.177
Annual income Less than 50000 CY 19.21±8.90 126.387 <0.001 - 7.88±5.64 48.455 <0.001 0.034
50000–100000 CY 22.18±9.26 0.327 7.68±6.06 -
100000–200000 CY 21.28±8.49 0.238 8.93±6.28 0.203
200000–300000 CY 20.66±8.41 0.167 9.31±6.03 0.270
More than 300000 CY 20.78±9.03 0.175 9.86±8.12 0.304
Health status Poor 28.02±10.00 500.564 <0.001 1.178 9.53±8.85 26.969 <0.001 0.274
Normal 25.21±9.48 0.906 7.94±7.19 0.065
Good 20.93±8.36 0.468 8.35±5.90 0.146
Very good 16.90±8.85 - 7.53±5.30 -
Current occupation Businessman 20.21±8.50 322.663 <0.001 0.302 8.39±5.92 177.273 <0.001 0.322
Officer 19.89±8.18 0.269 9.32±5.94 0.476
Teacher 21.06±8.41 0.404 9.74±6.77 0.510
Police 18.69±8.79 0.121 9.05±5.46 0.448
Farmer 19.81±9.55 0.239 7.47±6.17 0.165
Employee 20.49±7.99 0.345 8.44±5.81 0.333
Doctor 20.99±8.27 0.399 8.52±6.39 0.330
Nurse 24.47±9.91 0.740 6.46±6.08 -
Medical technician 21.31±8.65 0.428 7.63±6.56 0.185
Retired re-employee 21.63±8.78 0.462 9.62±5.28 0.555
Non-medical student 17.65±8.46 - 7.90±5.20 0.255
Medical student 20.64±8.80 0.346 8.66±6.08 0.362
Chronic disease No chronic disease 19.71±8.82 202.421 <0.001 - 7.94±5.67 6.269 0.044 -
CDCPD 24.01±9.18 0.478 8.67±7.40 0.111
Chronic diseases only 22.98±8.82 0.371 8.68±6.37 0.123
SD, standard deviation; CY, Chinese yuan; SGS-scale: the rhythm of sleep, getting-up, and socializing; EPE-scale: the rhythm of eating, physical practice, and
entertainment activities; CDCPD, Chronic diseases comorbid with psychosomatic diseases.
https://doi.org/10.1371/journal.pone.0250770.t002
with the highest score and each of other groups (Table 3). Specifically, the female gender and
poor health status were most closely associated with disrupted rhythms of life, work, and enter-
tainment. The age group of 26–30 years, nurses and subjects with divorce or widow status, the
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PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
Table 3. Comparison of SGS-scale and EPE-scale scores between the group with the highest score and each of the other groups in terms of sociodemographic
backgrounds.
Features SGS-scale EPE-scale
Highest-score Other groups P-value Cohen’s d Highest-score Other groups P-value Cohen’s d
group group
Marital status Divorced Unmarried 0.001 0.273 Divorced /widowed Unmarried 0.227 0.147
/widowed Married 0.748 0.069 Married 0.802 0.065
Chronic disease CDCPD No chronic disease <0.001 0.478 Chronic diseases No chronic disease 0.006 0.123
Chronic diseases only 0.086 0.114 only CDCPD 1.000 0.001
Education Senior high school Junior high school or lower 0.222 0.237 Master or above Junior high school or lower 0.695 0.152
Junior college or 0.720 0.060 Senior high school 0.010 0.177
undergraduate
Master or above 0.811 0.067 Junior college or 0.009 0.129
undergraduate
Health status Poor Normal 0.275 0.288 Poor Normal 0.749 0.197
Good <0.001 0.769 Good 0.918 0.157
Very good <0.001 1.178 Very good 0.499 0.274
Annual income 50000–100000 CY Less than 50000 CY <0.001 0.327 More than 300000 Less than 50000 CY 0.119 0.283
100000–200000 CY 0.056 0.101 CY 50000–100000 CY 0.063 0.304
200000–300000 CY 0.113 0.172 100000–200000 CY 0.938 0.128
More than 300000 CY 0.714 0.153 200000–300000 CY 0.999 0.077
Age 26–30 -18 <0.001 0.585 61- -18 0.473 0.349
18–25 <0.001 0.433 18–25 0.034 0.368
31–40 0.006 0.160 26–30 0.003 0.429
41–50 <0.001 0.245 31–40 0.042 0.343
51–60 <0.001 0.259 41–50 0.998 0.120
61- 0.799 0.191 51–60 1.000 0.038
Current Nurse Businessman <0.001 0.461 Teacher Businessman 0.482 0.212
occupation Officer <0.001 0.504 Officer 1.000 0.066
Teacher <0.001 0.371 Police 1.000 0.112
Police <0.001 0.617 Farmer 0.015 0.350
Farmer <0.001 0.479 Employee 0.781 0.206
Employee <0.001 0.442 Doctor 0.551 0.185
Doctor <0.001 0.381 Nurse <0.001 0.510
Medical technician 0.007 0.340 Medical technician 0.199 0.317
Retired re-employee 0.001 0.303 Retired re-employee 1.000 0.020
Non-medical student <0.001 0.740 Non-medical student 0.008 0.305
Medical student <0.001 0.409 Medical student 0.953 0.168
CY, Chinese yuan; SGS-scale: the rhythm of sleep, getting-up, and socializing; EPE-scale: the rhythm of eating, physical practice, and entertainment activities; CDCPD,
Chronic diseases comorbid with psychosomatic diseases.
https://doi.org/10.1371/journal.pone.0250770.t003
education level of senior high school, annual pre-tax income of 50,000–100,000 Chinese Yuan
(CY), or chronic disease comorbid with psychosomatic diseases mostly suffered from dis-
rupted rhythms of life and work. The age group of older than 61, and subjects with education
levels of master’s degree or above, annual pre-tax income over 300,000 CY, or chronic disease
without psychosomatic diseases mostly suffered from disrupted rhythms of entertainment.
Especially, nurses showed significantly more severe disruption of SGS rhythm, whereas the
elderly reported significant irregularity in EPE rhythm (Table 2).
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PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
Psychological impacts in the participants
There were significant differences in SAS and SDS scores among participants with different
genders, ages, marital status, education levels, annual pre-tax incomes, health status, current
occupation, and chronic diseases with or without psychosomatic diseases in each of the vari-
ables (all P<0.05) (Table 4). Specifically, nurses and participants with female gender, divorce
or widow status, education levels of junior high school or below, poor health status, and
chronic diseases comorbid with psychosomatic diseases mostly suffered from depression and
anxiety. Whereas the age group of 26–30 years, and participants with annual pre-tax income of
50,000–100,000 CY mostly suffered from depression, the age group of 31–40 years and partici-
pants with annual pre-tax income over 300,000 CY mostly suffered from anxiety. Additionally,
SDS scores were significantly higher in medical students than in non-medical students. There
were significant differences in the prevalence of depression and anxiety among participants
with different sociodemographic backgrounds (all P<0.05, S1 and S2 Tables). The overall
prevalence of depression and anxiety was 24.33% and 12.64%, respectively, as defined by SDS
or SAS scores over 50. Among the different occupational groups, nurses had the highest rates
of depression (32.94%) and anxiety (18.98%). Participants with chronic diseases combined
with psychosomatic diseases had the highest rates of depression (45.90%) and anxiety
(31.45%).
Correlations between the social rhythm and psychological impacts
Among the 5854 participants, mean scores on SGS-scale and EPE-scale were 20.65±9.01 and
8.12±6.00, respectively, and mean SAS score and mean SDS score were 30.51±7.49 and 41.95
±11.75, respectively. Spearman correlation analysis found that SGS scale was moderately cor-
related with depression and anxiety, with the correlation coefficients of 0.550 and 0.544,
respectively, (both P<0.001, S3 Table). In the multivariate linear regression analysis where the
scores of SPS-scale or EPE-scale were taken as dependent variables, the score of SDS and SAS
were taken as independent variables, and the age, gender, education, and occupation status
were taken as confounding factors, the correlations between the scores of SPS-scale and EPE-
scale and the scores of SDS and SAS remained unchanged (all P<0.05, Table 5, S1 and S2
Figs). The disruption of sleep, getting-up, and socializing rhythm was positively associated
with depression and anxiety (β = 0.355, P<0.001; β = 0.186, P<0.001). The disruption of eat-
ing, physical practice, and entertainment rhythm showed opposite association to psychological
impact: negatively related to depression and positively related to anxiety (β = -0.049, P = 0.036;
β = 0.082, P<0.001) (Table 5).
Discussion
The COVID-19 pandemic has brought great challenges and altered daily routines. It also
undoubtedly contributes to emotional stress, fear, sadness, loneliness, anxiety and depression,
and thus is associated with a global increase in psychological impacts [5]. One of the many
mechanisms by which COVID-19-related changes in social rhythm impact mental health
involves circadian disruption [7]. A previous study showed that the early identification and
intervention of rhythm disruption are of important clinical significance [21]. Rhythm disrup-
tion is part of the pathogenic cascade and is associated with mood disorders, such as anxiety,
depression, low happiness, strong loneliness, and bipolar disorder during the non-outbreak
period of infectious disease [7, 15, 22]. Limited studies have found that sleep disruption is
related to depression in the general population during the COVID-19 pandemic [11]. The
present study found that the disruption of social rhythm was quite different among people
with various sociodemographic backgrounds. The female gender, low-degree education level,
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PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
Table 4. Scores of depression and anxiety in participants with different sociodemographic backgrounds during the COVID-19 pandemic (N = 5854).
Feature SDS SAS
Mean±SD Z/X2 P Cohen’s d Mean±SD Z/X2 P Cohen’s d
Gender Female 43.34±11.66 -11.870 <0.001 0.290 38.80±9.39 8.441 <0.001 0.173
Male 39.97±11.59 - 37.19±9.23 -
Age -18 39.34±10.93 63.393 <0.001 - 35.09±8.35 266.138 <0.001 -
18–25 40.13±11.63 0.070 35.82±8.27 0.088
26–30 43.87±12.20 0.391 39.66±9.97 0.497
31–40 43.59±11.68 0.376 39.84±9.76 0.523
41–50 42.48±11.89 0.275 39.40±9.94 0.470
51–60 41.27±10.76 0.178 38.12±8.61 0.357
61- 41.03±10.97 0.154 38.91±9.32 0.432
Marital status Unmarried 40.65±11.79 63.778 <0.001 - 36.26±8.56 222.618 <0.001 -
Married 42.78±11.60 0.182 39.39±9.61 0.344
Divorced /widowed 44.57±12.05 0.329 40.87±10.63 0.478
Education Junior high school or lower 45.22±13.29 12.821 <0.05 0.281 39.85±10.43 10.900 <0.001 0.196
Senior high school 42.83±11.37 0.097 38.57±9.38 0.070
Junior college or undergraduate 41.71±11.67 - 37.92±9.24 -
Master or above 42.31±12.17 0.050 38.86±9.85 0.098
Annual income Less than 50000 CY 40.73±11.74 79.210 <0.001 0.107 36.49±8.86 204.895 <0.001 -
50000–100000 CY 43.54±11.65 0.365 39.72±9.45 0.353
100000–200000 CY 42.46±11.79 0.264 39.17±9.67 0.289
200000–300000 CY 39.56±10.12 - 36.93±8.02 0.052
More than 300000 CY 42.19±12.56 0.231 40.05±11.42 0.348
Health status Poor 62.90±11.77 778.373 <0.001 2.342 55.94±12.3 827.454 <0.001 2.112
Normal 49.73±12.34 1.149 44.56±10.55 1.120
Good 42.00±10.57 0.526 37.95±8.48 0.466
Very good 36.36±10.88 - 34.14±7.86 -
Current occupation Businessman 40.42±10.59 249.001 <0.001 0.187 37.29±8.37 374.507 <0.001 0.355
Officer 40.25±9.25 0.182 37.86±7.63 0.449
Teacher 41.58±11.24 0.287 38.58±9.38 0.485
Police 38.89±11.34 0.042 36.71±8.89 0.271
Farmer 43.02±11.59 0.411 37.97±9.14 0.419
Employee 42.08±10.68 0.341 38.25±8.34 0.478
Doctor 43.85±12.39 0.468 40.12±10.32 0.628
Nurse 45.17±12.35 0.583 40.41±10.14 0.668
Medical technician 44.74±11.84 0.558 40.14±9.77 0.653
Retired re-employee 42.24±10.47 0.359 38.98±8.61 0.561
Non-medical student 38.43±10.73 - 34.50±7.32 -
Medical student 41.93±12.18 0.305 37.93±9.59 0.402
Chronic disease No chronic disease 40.27±11.12 363.830 <0.001 - 36.48±8.40 36.616 <0.05 -
CDCPD 48.86±12.70 0.720 44.88±10.97 0.860
Chronic diseases only 45.27±11.42 0.444 41.47±9.45 0.558
SD, standard deviation; CY, Chinese yuan; SDS, Zung’s self-rating depression scale; SAS, Zung’s self-rating anxiety scale; CDCPD, Chronic diseases comorbid with
psychosomatic diseases.
https://doi.org/10.1371/journal.pone.0250770.t004
lower or higher than average income, poor health status, age group of 26–30 years and older
than 61 years, nurses and subjects with divorce mostly suffered from disruption of social
rhythm. In addition, the present study observed that the participants with female gender, age
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PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
Table 5. Correlations between the social rhythm disruption and psychological impacts as determined by multivariate linear regressive analysis.
Standardized coefficient (β) t P EXP(B) 95% CI
Lower Upper
SGS-scale Model 1 SDS 0.381 20.080 <0.001 0.264 0.321
SAS 0.203 10.689 <0.001 0.160 0.231
Model 2 SDS 0.373 19.463 <0.001 0.258 0.315
SAS 0.200 10.385 <0.001 0.156 0.229
Model 3 SDS 0.355 18.370 <0.001 0.243 0.302
SAS 0.188 9.791 <0.001 0.145 0.217
Model 4 SDS 0.355 18.373 <0.001 0.244 0.302
SAS 0.186 9.645 <0.001 0.143 0.216
EPE-scale Model 1 SDS -0.082 -3.565 <0.001 -0.065 -0.019
SAS 0.109 4.780 <0.001 0.041 0.099
Model 2 SDS -0.049 -2.129 0.033 -0.048 -0.002
SAS 0.082 3.582 <0.001 0.024 0.082
Model 3 SDS -0.049 -2.101 0.036 -0.048 -0.002
SAS 0.081 3.513 <0.001 0.023 0.081
Model 4 SDS -0.049 -2.101 0.036 -0.048 -0.002
SAS 0.082 3.518 <0.001 0.023 0.081
SGS-scale: the rhythm of sleep, getting-up, and socializing; EPE-scale: the rhythm of eating, physical practice, and entertainment activities; SDS/ SAS: Zung’s self-rating
depression and anxiety scales.
Model 1: uncorrected; Model 2: corrective factors: gender, age, marital status, and education level; Model 3: corrective factors: based on the corrective factors of Model 2
and health status, annual pre-tax income, and current occupation; and Model 4: corrective factors: based on the corrective factors of Model 3 and psychosomatic
diseases. The results of Model 4 were presented in this table
https://doi.org/10.1371/journal.pone.0250770.t005
group of 26–40 years, divorce or widow status, low education level, lower or higher than aver-
age income, poor health status, and chronic diseases comorbid with psychosomatic diseases,
and nurses mostly suffered from depression and/or anxiety.
There are two major possible explanations for the observed gender differences in rhythm
disruption, depression, and anxiety. First, the steroid receptors are expressed in almost every
site that receives direct suprachiasmatic nucleus (SCN) input [23]. The endogenous circadian
clocks can be reset by estrogen hormone signals in women, affecting the balance of the hypo-
thalamus-pituitary-adrenal (HPA) axis, and making the HPA axis more responsive to stress
than males [23, 24]. The disruption of circadian rhythms within the HPA axis, and the sleep-
arousal system differs between the genders, and is associated with dysfunction and disease
[23]. Understanding gender differences in the circadian timing system can lead to improved
treatment strategies. Second, the psychosocial contexts differ between the genders, and the
impact of traditional gender roles and socio-cultural influences on stress and anxiety are
greater in women than in men [25].
In this study, we found that people with low education levels or low income mostly suffer
from irregular social rhythms, likely due to their weak competitiveness in the job market and
inability to adapt to the new E-commerce models during the COVID-19 pandemic due to the
isolation or even lockdown [26]. Moreover, they did not have sufficient judgment while facing
various, overloaded and timely information on the COVID-19 pandemic, and easily felt
stressed, depressive and anxious [27]. Interestingly, both the people with high incomes and
those with poor health status were mostly suffered from disrupted rhythms. On one hand, the
disrupted rhythm in people with high incomes may be explained as follows: during the
COVID-19 pandemic, the consumption expenditures of high-income groups dropped sharply
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PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
by as much as 17%, while the expenditures of low-income families dropped by only 4% [28].
At the same time, entertainment venues that provide services for high-income groups, such as
cultural activity centers, clubs and gymnasiums, golf playgrounds, luxury party venues, were
mostly closed. All these changes would impact severely on the social rhythms of these groups
of people. On the other hand, the disrupted rhythm in people with poor health status can be
explained that the regular activities, such as walking, jogging, swimming and fitness, which
were significantly restricted since their poor health status with basic diseases, weak immune
function, and low ability to fight pathogens or adapt to a rhythm change [29]. In addition, our
finding that a high frequency of the irregular rhythm in the divorced group might be related to
the disintegration of the family, loose family relations, economic problems, and the problem of
raising children as a single parent. Especially, the isolation during the COVID-19 pandemic
might have aggravated the fear for the unknown future, loneliness, helplessness, or irregular
lifestyle [30].
The present study found that the people aged 26–40 years old and the elderly reported simi-
larly high SGS-scale scores and were vulnerable to circadian disruption. The former is the
main force of the society that promote the consumption, cultural creativity, and economic
development [31]. However, when they must stay at home or fight against the COVID-19 pan-
demic due to the sudden outbreak of the disease, it is difficult for them to maintain a normal
social rhythm. It is worth noting that the elderly reported the highest rate of rhythm disruption
of eating, physical practice, and entertainment behaviors in the present study. Previously, Liu
et al. [32] conducted a study on lifestyle and the health status of Chinese elderly, which
included the elderly who lived in their own houses, with 20.6% of them being widows or wid-
owers. They found that lack of physical practice, advanced age, and alcohol consumption were
risk factors for their self-rate health status whereas a long sleep time was the protective factor
[33]. Indeed, it has been reported that advanced age is characterized by a progressive decreas-
ing amplitude and phase advance of circadian rhythmicity in overall biological functions,
including blood pressure, hormonal circadian secretions, and immune function changes [33].
The elderly could not go out for dancing after dinner, exercise in the morning, or visit old
friends or relatives due to recommended social isolation during the COVID-19 pandemic.
Furthermore, they were inherently at high risk for COVID-19 infection and easily generated
negative emotions [34]. These various factors were prone to form a vicious circle.
It is noteworthy to mention that nurses had the highest score of rhythm disruption in going
to bed, get-up, and socializing among occupations, suggesting that they were more affected by
the pandemic than other occupations such as businessmen, officers, teachers, police, farmers,
doctors, and students. Night shift work has been thought to play a role through a disruption of
the circadian rhythm, decreased synthesis of melatonin and sleep deprivation [35]. We assume
that nurses undertake a working articulation in shifts to keep the continuity of healthcare
throughout a whole day, and the COVID-19 pandemic results in heavy workload, insufficient
rest, quarantine, and social isolation. Consequently, the already dysfunctional social rhythm of
nurses is further exacerbated. McElroy et al. reported that night and long shifts caused fatigue
and adversely affected the family and social life of hospital employees [36]. Rosa et al. indicated
that shift work could cause psychological consequences, including anxiety, stress, and depres-
sion, which is an obstacle for social and family relationships and a risk factor for metabolic dis-
orders, diabetes, cardiovascular disorders, and breast cancer [37].
The present study firstly reported the critical connection between social rhythm disruption
and psychological impacts in a large-scale population under the stress of such a pandemic.
Our study further found that the scores of social rhythms were positively correlated with SDS
and SAS scores under the stress of the COVID-19 pandemic. The following factors are specu-
lated to be involved in the connection. The first factor is the social zeitgeber theory. The notion
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PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
that life events increase the likelihood of mood episodes via decreased zeitgeber scaffolding for
a vulnerable circadian system has been known as the social zeitgeber hypothesis, and the
“social rhythm” refers to the cross-day stability of the timing of behaviors that act as zeitgebers
[7]. Social stimuli under the stress of COVID-19 may affect the circadian behavioral programs
by regulating the phase and period of circadian clocks (i.e. a zeitgeber action, either direct or
by conditioning to photic zeitgebers) which leads to various adverse mental health outcomes
[38, 39]. In turn, depressive episodes that arise because of life events disturbing social zeitge-
bers subsequently affect biological rhythms, and thus derail social and biological rhythms [39,
40]. This present study expanded the scope of application of these rhythm theories from
patients with mood disorders to the population with different sociodemographic backgrounds.
The second factor is the lockdown protocols that have been adopted to minimize COVID-19
pandemic transmission. The protocols may weaken the zeitgeber-setting mechanism, and
impact the stability of the timing of daily behaviors, such as sleeping, getting up, socializing,
eating, physical practice, and entertainment, which, in turn, lead to mental health disorders,
such as anxiety and depression [7]. The third factor is the daily function of HPA activity,
which is also regulated by the biological clock [41]. Anxiety disorders and major depressive
disorder have been associated with increased and blunted HPA axis reactivity to social stress
respectively, which engages the diverse biological pathways that bolster successful stress adap-
tation and promote stress resilience. Adaptation to the challenges of stress is compromised
when these pathways are no longer functioning optimally, resulting in the disrupted rhythms
on psychological impacts [42]. Of course, other mechanisms may also connect social rhythm
dysregulation with psychological impacts, including circadian gene variations [43] and social
jetlag [44].
Based on the findings of the present study, more effective measures that combine circadian
rhythms with the diagnosis and treatment of psychosomatic diseases may improve psychologi-
cal impacts and maximize the effectiveness of treatment. Therefore, the following measures are
recommended for stabilizing daily routines, especially for those specific population who
mostly suffered from disrupted rhythms: 1), self-management strategies for setting up and
increasing regularity of daily activities and lifestyle habits during the COVID-19 pandemic
[45]; 2), spending 1 hour/day outdoors, walking for more than one hour a day and basking in
the sun, which may regulate the body clock by the light-dark cycle [7]; 3), scheduling social
interactions at the same time of the day, and seeking the best candidates who may share
thoughts and feelings in real time [7]; 4), eating meals at the same time every day, and adjust-
ing the eating patterns and food categories. 5), avoiding daylight hour naps and the nocturnal
blue spectrum light pollution from computers, mobile phones, electronic tablets and televi-
sions, which suppresses the sleep-helping hormones [45]. Chronotherapy seems to be a prom-
ising approach to restore the proper circadian pattern in the elderly with an obvious sleep
problem through adequate sleep hygiene, timed light exposure, and the use of a chronobiotic
medication [12]; 6), taking drugs that adjust the biological clock for nurses with sleep disorders
caused by nurses’ shift system when necessary [46]; and 7), encouraging online therapy pro-
gram for normalizing the disrupted social rhythms in COVID-19 environment, with the sup-
port of health care professionals and persuasive systems design and user experience/
interaction features [7].
The present study provides new ideas for the simultaneous intervention from the perspec-
tive of social rhythms and psychology, and would lay an epidemiological foundation for the
interaction of social rhythms with the diagnosis and treatment of psychosomatic diseases and
the maximization of therapeutic efficacy. However, there are a few limitations in the present
study. First, this cross-sectional study cannot reveal causality, and the nature of voluntary par-
ticipation may result in selection bias. Second, in this study, we did not track the 24-hour
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PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
circadian rhythm. Indeed, it is necessary to track the circadian rhythms/sleep-wake cycle by a
multi-lead-sleep monitor considering different psychological impacts, which will be imple-
mented in our further research. Third, the survey response rate was not obtained since this
online-survey was participated voluntarily and the lockdown and social isolation policy did
not encourage a face-to-face survey, and it was difficult to get the survey response rate. Fourth,
we did not consider obtaining the individual informed consent for teenagers themselves under
18 years old, in addition to their parents’ consent, which will also be implemented in our fur-
ther similar research.
In conclusion, there exist rhythm disruptions among Chinese people with different socio-
demographic backgrounds, which are closely associated with psychological impacts under the
stress of the COVID-19 pandemic. Social rhythm disruption is independently associated with
depression and anxiety. Interventions should be applied to the people vulnerable to the rhythm
disruptions during the COVID-19 pandemic.
Supporting information
S1 Fig.
(TIF)
S2 Fig.
(TIF)
S1 Dataset.
(XLSX)
S1 Table. Prevalence of depression with different grades in participants (N = 5854).
(DOCX)
S2 Table. Prevalence of anxiety with different grades in participants (N = 5854).
(DOCX)
S3 Table. Spearman’s correlation between subscale 1, subscale 2, Zung’s self-rating depres-
sion scale (SDS) and Zung’s self-rating anxiety scale (SAS). (N = 5854).
(DOCX)
Acknowledgments
Zhihua Gao, PhD and Jinxia Zhu, PhD, provided valuable assistance with on questionnaire
design. Kai Guo provided the on-line technical support. We are grateful for Medjaden Inc. for
its assistance in the preparation of the manuscript and professional editing and language
polishing.
Author Contributions
Data curation: Ping He, Jing Wang, Yanjun Wang, Hui Lin.
Formal analysis: Hui Lin.
Funding acquisition: Wo Wang, Li Kuang.
Project administration: Bin Wang, Mei Zhao, Mingming Deng, Dongfeng Chen.
Supervision: Tianwei Deng.
Writing – original draft: Min Yang.
Writing – review & editing: Xiaoming Xu, Dan Li.
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PLOS ONE Disrupted rhythms and their associations with psychological impacts under the stress of COVID-19 pandemic
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