The Role of Event-Related Rumination and Perceived Social Support on Psychological Distress during the COVID-19 Pandemic: Results from Greater Daegu Region in South Korea

Abstract

Objective

Research on psychological distress from the coronavirus disease 2019 (COVID-19) crisis has increased significantly, but the factors that can exacerbate or mitigate such distress have remained underexplored. To address the research gap, this study examined whether two types of rumination and perceived social support predict psychological distress during the pandemic.

Methods

Participants were recruited from communities of the greater Daegu area (n=316) where the first massive outbreak in South Korea occurred and most residents underwent substantial disruption of daily life. They completed self-report questionnaires that included measures of psychological distress, event-related rumination, and social support.

Results

The hierarchical regression analysis showed that maladaptive intrusive rumination and perceived social support predicted increases and decreases in psychological distress, respectively, even when subjective severity of COVID-19-related experiences was controlled. Putatively adaptive type of rumination (i.e., deliberate rumination) was not a significant predictor concurrently.

Conclusion

This is among the early endeavors to comprehensively understand risk and protective factors associated with an effective coping strategy against the COVID-19 crisis. Our results indicate that intrusive rumination aggravates but social support mitigates psychological distress during the pandemic, indicating that we can better adapt by differently attending to recent experiences and maintaining perceived social support.

INTRODUCTION

The coronavirus disease 2019 (COVID-19) first appeared in late 2019 and rapidly spread over several countries and continents, leading to an unprecedented global crisis in the 21st century. On March 11, 2020, the World Health Organization (WHO) officially declared it as a global pandemic [1,2]. Unfortunately, COVID-19 has remained an emerging and evolving situation. As of November 8, 2020, more than 49.7 million confirmed COVID-19 cases and 1.2 million deaths had been reported globally since the start of the pandemic [3]. And experts have warned of an even steeper increase in the infection rates during the winter in the Northern Hemisphere [4].

COVID-19 has drastically disrupted every aspect of human life. It has threatened not only the physical health but also the psychological well-being of people [5,6]. During the early phase of COVID-19 crisis, the lack of an effective pharmacological treatment and vaccines has led many countries to enforce social distancing to keep people safe and prevent the spread of virus. The COVID-19 outbreak itself and such measures taken to bring it under control have been highly stressful for many people [7,8].

This problem immediately drew considerable research attention, which resulted in numerous published articles on the COVID-19 crisis [5]. Overall, previous research has suggested that the widespread outbreak of infectious diseases, such as COVID-19, is associated with a wide range of mental health problems, including anxiety, depression, stress, and post-traumatic stress disorder (PTSD) [1,9-15]. For example, Xiong et al. [6] reported higher rates of various mental health problems in the general population and associated risk factors (e.g., gender, unemployment, frequent exposure to news/social media related to COVID-19). And Kujawa et al. [13] found that stressful events due to the COVID-19 were moderately correlated with symptoms of depression and anxiety both cross-sectionally and longitudinally among American adults. Furthermore, in a randomized controlled trial, Li et al. [15] attempted to test whether providing cognitive behavioral therapy in addition to routine medical treatment may help reduce depression, anxiety symptoms for COVID-19 patients in China.

However, most of the COVID-19-related mental health articles have relied on participants from China, the United States, and India, and data form the South Korean population is still limited. Moreover, not everyone experiencing a sudden stressor like COVID-19 presents negative outcomes. Although existing studies on the mental health consequences of the COVID-19 crisis have contributed to our increased understanding in a timely manner, now there is an increasing call for studies that will inform us on how to adapt to this prolonged stress. To better understand the individual differences in coping with the pandemic, researchers should shift their focus toward factors that can exacerbate or mitigate psychological distress during the COVID-19 crisis.

One such factor is rumination, defined as repetitively and passively focusing on negative thoughts; a substantial body of literature indicated that it is a transdiagnostic risk factor that exacerbates and prolongs the impact of stressors, resulting in various psychological problems, such as depression and anxiety [16,17]. In addition, rumination has been associated with the development and persistence of PTSD symptoms as a response to accidents [18] or natural disasters [17,19]. More recently, researchers have investigated whether the adverse effects of rumination apply to mental health problems experienced during the COVID-19 pandemic. For example, Hoffart et al. [20] found that rumination and worry in general were positively associated with greater loneliness among Norwegian participants who were observing social distancing. Similarly, Ye et al. [21] found that rumination partially mediated the relationship between stressors of COVID-19 and stress consequences among Chinese university students.

Here it is worth noting that rumination is not a unitary construct but rather a multifaceted one that is composed of functionally differential sub-factors [22]. Especially, Cann et al. [23] proposed the importance of distinguishing the two types of “eventrelated” rumination, which is most relevant to this study. They regarded ruminations as cognitive processes that are involved in the aftermath of traumatic or stressful life events, which have different implications for determining the psychological impact of events. Intrusive rumination is characterized by the involuntary invasion of repetitive thoughts about the event into awareness. By contrast, deliberate rumination entails a more problem-focused cognitive process to make meaning of the event. Although intrusive and deliberate ruminations are both a “normal by-product” (p. 139) [23] that can manifest in a person’s struggles in times of major life crises, the former is likely to lead to continued distress and failed coping while the latter is related to post-traumatic growth over time [23,24]. Therefore, the distinction between the two types of ruminative thoughts and their implication for subsequent outcomes must be considered when examining how rumination affects one’s psychological response to the COVID-19 crisis, a sudden, major life stressor that can provoke considerable cognitive processing.

Social support is another important protective factor that may be associated with psychological distress during the COVID-19 pandemic. Perceived social support is defined as perceived availability and adequacy of the general availability of support and/or global satisfaction with the support provided [25]. There are varying views on the concept of perceived social support; however, they generally indicate that the concept refers to individuals’ perception of the availability of social support than objective elements (e.g., network size) or what is actually received [26]. Moreover, many studies have indicated that the perception of social bonds and supportive relationships with others are vital for not only people’s mental health but also protecting them in the face of adversity [27,28]. The lack of social support was also found to increase the probability of psychological distress, including depression [26,29]. Recent studies have begun to document the meaningful role that perceived social support plays in coping with the COVID-19 pandemic [30,31]. For example, Labrague and De los Santos [32] observed that resilient nurses who perceived higher social support were more likely to report lower COVID-19-related anxiety. Also, Li et al. [33] reported that social support has a negative relation with psychological symptoms during the COVID-19 pandemic among Chinese university students. The role of social support as a coping resource is highlighted during the COVID-19 pandemic when social distancing has been implemented as a preventive strategy to reduce direct interpersonal contacts; this measure may deteriorate people’s sense of social support.

The major aim of this study was to examine whether the two types of event-related rumination and perceived social support influence psychological distress during the COVID-19 crisis. Participants in this study were adults living in greater Daegu area, where the first massive outbreak in South Korea occurred and most residents went through severe restrictions in daily life due to COVID-19. We hypothesized that intrusive rumination and perceived social support would predict increases and decreases in psychological distress, respectively. At this point, there was not enough backgrounds for specifying the concurrent relation between deliberate rumination and distress [23]. Nonetheless, we included deliberate rumination for an exploratory purpose and expected a differential pattern of relationship of deliberate rumination with other variables in comparison to intrusive rumination.

METHODS

Participants

Data were collected from community-dwelling residents of Daegu and Gyeongsangbuk-do Province in South Korea using an online questionnaire in early August 2020. We recruited a representative sample of residents in terms of age and gender to enhance generalizability of this study. The number of participants totaled 316 adults aged 20 years or older; all were included in subsequent analyses. Half (50.6%) were female and participants’ age ranged from 20 to 73 years (M=43.28, SD=12.61). All procedures and materials were approved by the Institutional Review Board of Kyungpook National University (KNU-2020-0054). An online informed consent was obtained from all participants. Sample characteristics are presented in Table 1.

Table 1.

Sample characteristics (N=316)

	Mean	SD	N (%)
Age	43.28	12.61
Gender
Male			156 (49.4)
Female			160 (50.6)
Residence
Daegu			220 (69.6)
Gyeonsangbuk-do			96 (30.4)
Subjective severity
Disruption in daily life	3.84	0.78
Perceived traumatic experience	2.94	0.10
COVID-19-related experience
Diagnosis confirmed			1 (0.3)
Diagnosis of family or close friends			31 (9.8)
Screening test			42 (13.3)
Self-quarantine			23 (7.3)
Education
University			239 (75.7)
High school			74 (23.4)
Middle school			3 (0.9)
Marital status
Unmarried			117 (37.0)
Married or cohabiting			175 (55.4)
Divorced			20 (6.3)
Bereaved			4 (1.3)

Measures

Subjective severity

Two questions, which were originally suggested by García et al. [19], were revised to assess the subjective severity of COVID-19-related experiences: “To what degree do you feel your life was disrupted as a result of COVID-19?” and “To what degree do you rate COVID-19 as a traumatic experience to your life?” These two questions were scored using a 5-point Likert scale, ranging from 1 (“not at all”) to 5 (“extremely”). They were moderately correlated (r=0.39, p<0.001).

Korean-Brief Symptom Inventory (K-BSI)

The BSI-18 is a self-report questionnaire use for conveniently assessing psychological distress with limited number of items [34]. The K-BSI was administered in this study [35]. It consists of 18 items rated on a 5-point Likert scale (from 1=not at all to 5=very much). The K-BSI contains three subscales (i.e., depression, anxiety, and somatization), each composing of six items. We used the total score of the three subscales [global severity index (GSI)] as an index for the general level of psychological distress. A higher score indicated greater psychological distress. The internal consistency in the present study was excellent (Cronbach’s α=0.95).

Korean version of the Event-related Rumination Inventory (K-ERRI)

The ERRI was developed to separately assess the two types of rumination related to a stressful life event: intrusive and deliberate rumination [23]. The K-ERRI was used in this study [36]. Participants were asked to respond to 10 items that measure intrusive rumination (e.g., “I thought about the event when I did not mean to”) and another 10 items for deliberate rumination (e.g., “I thought about whether I could find meaning from my experience”). The items were rated on a 4-point Likert scale (from 0=not at all to 3=often). A higher score indicated higher levels of intrusive and deliberate rumination. To specifically capture event-related ruminations in response to the pandemic, we slightly changed the wording of the phrase “during the weeks immediately after the event” to “during COVID-19.” In this way, participants would answer each item in relation to their recent COVID-19-related experiences. Internal consistencies of both subscales were excellent (Cronbach’s α: intrusive rumination=0.96, deliberate rumination=0.92).

Social support

The Perceived Social Support Scale was used to assess the extent to which an individual perceives social support [37]. The scale consists of 25 items rated on a 5-point Likert scale (from 1=not at all to 5=very much) and covers four dimensions: emotional, material, informational, and evaluative social support. In this study, we used the total score to determine the general level of perceived social support. Internal consistency was within an excellent range (Cronbach’s α=0.97).

Statistical analyses

After descriptive statistics, we conducted correlational analyses to examine the relationship of the main variables, namely, psychological distress, event-related rumination, and social support. Next, a hierarchical regression analysis was performed to examine the predictors of psychological stress. To demonstrate the incremental variance explained by intrusive rumination, deliberate rumination, and perceived social support in Step 2, two variables of subjective severity were entered as independent variables to be controlled in Step 1. Statistical analyses were carried out using SPSS ver. 24.0 (IBM Corp, Armonk, NY, USA).

RESULTS

Descriptive statistics

On average, participants reported having experienced considerable disruption in daily life (M=3.84, SD=0.78) owing to COVID-19 and rated COVID-19 as a traumatic experience of moderate severity (M=2.94, SD=0.10). One participant (0.3%) was diagnosed with COVID-19 and 31 (9.8%) had family members or close friends who were diagnosed with the disease. About 20% of the participants underwent a screening test or self-quarantine, suggesting a widespread infection within the community at that time.

Correlational analyses of the main variables

As can be seen in Table 2, both types of event-related rumination demonstrated significant positive correlation with psychological distress. The magnitude of correlation was larger in intrusive rumination (r=0.65, p<0.001) than in deliberate rumination (r=0.34, p<0.001). In partial correlation analyses in which the other type of event-related rumination was controlled, the positive correlation between intrusive rumination and psychological distress remained significant (partial r=0.59, p<0.001). On the other hand, the significant relationship between deliberate rumination with psychological distress disappeared (partial r=-0.04, n.s.), indicating that the positive correlation might be due to the shared variance between two types of ruminations.

Table 2.

Descriptive and correlation analyses (N=316)

	K-BSI	K-ERRI		Social support
		IR	DR
K-BSI	-	0.65***	0.34***	-0.26***
K-ERRI		-
Intrusive rumination (IR)			0.56***	-0.20***
Deliberate rumination (DR)			-	0.07
Mean	42.86	20.69	23.05	90.56
SD	15.22	7.62	6.40	16.12

^***p<0.001.

K-BSI: Korean-Brief Symptom Inventory, K-ERRI: Korean-Event Related Rumination Inventory

As predicted, social support was negatively correlated with psychological distress (r=-0.26, p<0.001). However, it showed a varying pattern of correlation with the two types of event-related rumination. It was significantly negatively associated with intrusive rumination (r=-0.20, p<0.001) but uncorrelated with deliberate rumination (r=0.07, n.s.).

Hierarchical regression analysis predicting psychological distress

To consider the individual differences at a specific level of COVID-19-related stress, we controlled for two variables of subjective severity (i.e., disruption in daily life and perceived traumatic stress) in Step 1 in a series of hierarchical regression analysis (Table 3). The results of Step 2 indicated that intrusive rumination and social support had significant incremental variance in predicting psychological distress during the COVID-19 crisis (ΔR²=0.24, p<0.001); the amount of variance explained by the regression model was substantially large (R²=0.51, p<0.001). Intrusive rumination or the maladaptive type of event-related rumination could predict increases in psychological distress (t=8.72, p<0.001), whereas social support would predict decreases in psychological distress (t=-4.12, p<0.001). Meanwhile, deliberate rumination was found to be insignificant in predicting psychological distress when other variables were jointly considered.

Table 3.

Hierarchical regression predicting psychological distress (N=316)

Step	IV	B	SE	β	t	R2	ΔR2
1	SS 1	1.02	1.03	0.05	0.99	0.27***
	SS 2	7.58	0.80	0.40	9.44***
2	SS 1	0.02	0.86	0.00	0.03	0.51***	0.24***
	SS 2	4.67	0.72	0.31	6.47***
	Intrusive rumination	0.96	0.11	0.48	8.72***
	Deliberate rumination	-0.01	0.12	0.00	-0.09
	Social support	-0.16	0.04	-0.17	-4.12***

^***p<0.001.

SS: subjective severity (1=disruption in daily life, 2=perceived traumatic experience)

For an exploratory purpose, we repeated the hierarchical regression modeling using the same independent variables that predict depression, anxiety, or somatization, instead of the GSI, to see if this relation is robust across specific symptom contents. The results were identical; intrusive rumination was a positive and the strongest predictor, whereas perceived social support was a negative predictor of each psychological symptom in Step 2. These findings indicate the generalizability of the results of the present study irrespective of symptom domain.

DISCUSSION

The present study explored whether certain factors could explain the individual differences in coping with COVID-19 among residents of Daegu and Gyeongsangbuk-do, who underwent the first massive COVID-19 outbreak in South Korea. Specifically, we investigated how people perceived their COVID-19-related experiences (intrusive versus deliberate rumination) and whether their perceived social support could predict unique variances in psychological distress. Overall, the results supported our hypotheses. Intrusive rumination, or the maladaptive type of ruminative thinking, was positively associated with psychological distress, whereas social support was negatively associated with the latter.

An increasing amount of evidence has shown that the adverse impact of COVID-19 is not confined to physical health but extends to mental health issues [6]. As discussed earlier, there has been an urgent demand for research that target the factors of a successful coping strategy against COVID-19-related stress across various methodologies and populations. In other words, a collection of multidisciplinary and high-quality empirical data is the immediate priority [38]. To the best of our knowledge, our study is among the early endeavors to investigate the factors that can aggravate and ameliorate psychological distress caused by COVID-19. We think that this line of studies can pave the way to start the development of evidence-based mental health guidelines for the public by identifying both the risk and protective factors of an effective coping in times of the so-called “new normal.”

First, the way people think about their COVID-19-related experiences seemed to matter. Consistent with the previous literature, our study provides converging evidence that rumination may yield an increased level of psychological distress as a response to the COVID-19 crisis. However, different from previous investigations, such as Ye et al. [21], we used the ERRI, which was specifically designed to measure the role of rumination in the aftermath of traumatic or stressful events [23]. In the ERRI, rumination was divided into two distinct types that possess varying implications for subsequent adaptation. We found that intrusive rumination, and not deliberate rumination, plays a central role in exacerbating psychological distress, although both types of rumination were positively associated with psychological distress in pair-wise correlations. Considering that there was a large correlation between intrusive and deliberate ruminations (r=0.56, p<0.001), their differential relationship with psychological distress in hierarchical regression is interesting.

A disruption in life and increased stress after the COVID-19 outbreak may naturally lead people to engage in repetitive thinking about what has been going wrong. In this case, the “how,” rather than the “how much,” they think about these stressors is more important. Our results suggest that people with heightened intrusive rumination are susceptible to more psychological distress. From a therapeutic perspective, it may be difficult to divert ruminators from a repetitive thinking pattern particularly when under stress [39]. A more realistic goal would be to guide them to deal with their internal thoughts in a more reflective and constructive way, exemplified by deliberate rumination.

In line with previous studies [21,30,31,40,41], perceived social support was negatively associated with psychological distress and predicted an incrementally significant variance, even when subjective severity and different types of rumination were jointly considered. This finding suggests that perceived social support could mitigate the negative consequences of psychological distress during the COVID-19 crisis. Given that many scholars have consistently stressed the importance of social support for resilience and post-traumatic recovery [26-28], it would be necessary to highlight that the current results on perceived social support are worth noting beyond a mere replication. The characteristic of COVID-19 as a novel, biomedical disaster that is prevented through social distancing, which is a complete opposite of social support, creates a paradoxical condition for mental health [28]. This problem leaves researchers much to ponder for mental health care of post-COVID-19 era. Because of the highly contagious nature of COVID-19, coupled with a shortage of effective and safe vaccines, ensuring personal hygiene (e.g., hand washing and wearing of a mask) and reducing direct interpersonal contact are the only viable options for reducing the rate of infection. However, such necessary measure for prevention may result in unintended side effects in mental health, such as increased loneliness and isolation, which, in turn, are associated with poorer mental and physical health [42].

Therefore, the next step in addressing the crisis should be to create ways to strengthen social support as psychological resources to effectively cope with this prolonged, global pandemic. Which component of social support (e.g., emotional, material, informational, evaluative social support) is more conducive to maintaining mental health in times of COVID-19? Is social support delivered online or by a virtual technology as effective as that delivered offline and through direct interpersonal contact? What is the active component or mechanism of buffering effect of social support in the face of pandemic? These questions can be a few starting points for future research that will inform mental health care guidelines during the COVID-19 crisis.

Lastly, we would like to emphasize that our results were obtained from a representative sample of adults living in Daegu and adjacent Gyeongsangbuk-do area, where residents underwent severe restrictions in daily life during the first major outbreak in South Korea from early to mid of 2020. Although a complete lockdown has not been executed as a governmental policy, as people who were tested positive for COVID-19 drastically increased specifically within these areas, mobility from and out of these regions was greatly diminished, and economic and social activities were profoundly hampered during that period. Unlike previous studies that used convenience sampling, our sample was stratified by age and gender to increase the ecological validity of the current findings. Additionally, considering that approximately half of the COVID-19-related mental health articles have relied on participants from China, the United States, and India [5,6], our results supplement the existing gap by providing data from the South Korean population, where COVID-19 outbreak has been relatively under control and the majority of the population have shown high adherence to follow preventive regulations imposed on their daily routines, such as social distancing [43].

Limitations

Certain limitations should be noted. First, because this is a cross-sectional study, it was not possible to directly examine the causality between variables. Therefore, directionality between rumination, social support, and psychological distress should be investigated in future studies employing longitudinal design. In particular, the impact of deliberate rumination, which did not concurrently predict psychological distress in our results, may vary across time and exert time-lagged protective effect [44]. Deliberate rumination is conceptualized as a putatively adaptive thinking style to make meaning of a problematic situation, elicited later in time by intrusive rumination [45,46]. That is, intrusive rumination tends to prevail especially in an earlier adaptation phase with its detrimental consequences; however, at the same time, it may facilitate increased deliberate rumination in the latter adaptation phase, at least, in some individuals. Thus, the relationship between these two eventrelated ruminations may be rather dynamic, unfolding with the passage of time, which cannot be properly captured cross-sectionally. The following questions may warrant testing in a separate study in the future: Will deliberate rumination prospectively predict differences in adaptation toward COVID-19? What could be the moderators of this relationship over time?

Second, although we tried to enhance ecological validity by recruiting community-dwelling residents in a severely affected region, the role of rumination and perceived social support should be examined in other samples as well for generalizability, especially those who are undergoing tremendous stress during the COVID-19 crisis. For instance, health professionals in the front lines are in dire need of mental health support [32]. Moreover, as Amerio et al. [5] argued, the current results should be replicated in vulnerable groups (e.g., individuals with preexisting mental and/or health issues, older adults, children and adolescents, unemployed persons, and people under self-quarantine or lockdown) and other general population.

Third, reliance on self-report data is also a limitation. Although self-report measures are convenient tools for data collection, especially when participants are adults without literacy difficulty and when research topics deal with internal experiences that cannot be externally observed, which was the case in our study, they are susceptible to issues of certain reporting bias or social desirability. Therefore, subsequent studies would benefit from diversifying methods of data collection.

Conclusions

In summary, the current study extends existing literature regarding rumination and social support by providing evidence that intrusive rumination exacerbates but social support may mitigate psychological distress in reaction to stress caused by the novel pandemic. Although no one can be absolutely free from COVID-19-related stress for the time being, our results suggest that we can still be buffered from psychological distress by differently attending to recent experiences and maintaining or improving perceived social support. In short, the impact of COVID-19 on mental health may not be equal to everyone, despite its ubiquitous presence worldwide. We hope that continued research with a refined focus on plausible risk and/or protective factors will contribute to a better understanding of how we can stay not only physically but also psychologically healthy throughout the prolonged pandemic, which will eventually serve as a sound basis for developing an evidencebased mental health guideline for COVID-19.