Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Psychiatr. Dec 19, 2021; 11(12): 1346-1365
Published online Dec 19, 2021. doi: 10.5498/wjp.v11.i12.1346
Impact of lockdown relaxation and implementation of the face-covering policy on mental health: A United Kingdom COVID-19 study
Shanaya Rathod, Saseendran Pallikadavath, Elizabeth Graves, Mohammad Mahbubur Rahman, Ashlea Brooks, Mustafa G Soomro, Pranay Rathod, Peter Phiri
Shanaya Rathod, Elizabeth Graves, Ashlea Brooks, Peter Phiri, Department of Research and Development, Southern Health NHS Foundation Trust, Southampton SO30 3JB, Hampshire, United Kingdom
Shanaya Rathod, Portsmouth-Brawijaya Centre for Global Health, Population and Policy, University of Portsmouth, Portsmouth PO1 2DT, United Kingdom
Saseendran Pallikadavath, Mohammad Mahbubur Rahman, School of Health and Care Professions, University of Portsmouth, Portsmouth PO1 2DT, Hampshire, United Kingdom
Mustafa G Soomro, Mental Health, Solent NHS Trust, Portsmouth P03 6AD, United Kingdom
Pranay Rathod, PPI, PPI Representative, London SO30 3JB, United Kingdom
Peter Phiri, Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, United Kingdom
Author contributions: Rathod S, Rathod P and Phiri P developed the study protocol and questionnaire; Rathod S, Phiri P, Soomro MG, and Rahman MM contributed to the manuscript development; Rahman MM conducted the analysis; all authors reviewed and approved the final version of the manuscript.
Institutional review board statement: The study received ethics and HRA approval. IRAS project ID: 282858; REC reference: 20/HRA/1934 from London-Westminster Research Ethics Committee on 27 April 2020.
Informed consent statement: All study participants, provided informed consent prior to study enrollment.
Conflict-of-interest statement: Dr Rathod reports others from Janssen, other from Otsuka, other from Lundbeck, outside the submitted work. Dr Phiri reports other from Queen Mary University London, other from Stanford University School of Medicine, other from John Wiley and Blackwell, outside the submitted work. All other authors report no conflict of interest.
Data sharing statement: Data will not be shared.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Shanaya Rathod, MBBS, MD, MRCP, Professor, Department of Research and Development, Southern Health NHS Foundation Trust, Moorgreen Hospital Botley Road, West End, Southampton SO30 3JB, Hampshire, United Kingdom. Shanaya.rathod@southernhealth.nhs.uk
Received: June 17, 2021
Peer-review started: June 17, 2021
First decision: July 14, 2021
Revised: August 4, 2021
Accepted: October 20, 2021
Article in press: October 20, 2021
Published online: December 19, 2021

Pandemic mitigation policies, such as lockdown, are known to impact on mental health of individuals. Compulsory face covering under relaxed lockdown restrictions gives assurance of less transmission of airborne infection and has the potential to improve mental health of individuals affected by restrictions.


To examine the association of the lockdown relaxation and the implementation of the face covering policy on the mental health of the general population and sub-groups in the United Kingdom using interrupted time series model.


Using a web-based cross-sectional survey of 28890 United Kingdom adults carried out during May 1, 2020 to July 31, 2020, changes in mental health status using generalised anxiety disorder (GAD-7), and impact of events scale-revised (IES-R) scales are examined, at the dates of the first lockdown relaxation (July 4, 2020) and the subsequent introduction of face covering (July 24, 2020) in United Kingdom. A sharp regression discontinuity design is used to check discontinuities in mental health outcomes at policy-change dates.


Average GAD-7 scores of participants were 5.6, 5.6 and 4.3 during the lockdown period, the lockdown relaxation phase and the phase of compulsory face covering, respectively, with lower scores indicating lower anxiety levels. Corresponding scores for IES-R were 17.3, 16.8 and 13.4, with lower scores indicating less distress. Easing lockdown measures and subsequent introduction of face covering, on average, reduced GAD-7 by 0.513 (95%CI: 0.913-0.112) and 1.148 (95%CI: 1.800-0.496), respectively. Corresponding reductions in IES-R were 2.620 (95%CI: 4.279-0.961) and 3.449 (95%CI: 5.725-1.172). These imply that both lockdown relaxation and compulsory face-covering have a positive association with mental health scores (GAD-7 and IES-R).


The differential impact of lockdown and relaxation on the mental health of population sub-groups is evident in this study with future implications for policy. Introduction of face covering in public places had a stronger positive association with mental health than lockdown relaxation.

Keywords: COVID-19, Psychological impact, Lockdown, Face-covering, Mental health, Anxiety

Core Tip: Positive association of lockdown relaxation and face-covering policies on the mental health (MH) of various population sub-groups is reported. Professional groups and health workers had lower generalised anxiety disorder (GAD-7) scores than other workers. During the compulsory face-covering phase, all professional groups improved on GAD-7 and impact of events scale-revised (IES-R) scores. Significant improvements in MH scores were found among non-key workers. Gender was associated with different MH outcomes during the lockdown, with females scoring higher on the GAD-7 and IES-R scales than males. However, both groups showed a significant improvement in MH status during the period of face-covering, with slightly higher improvements noted in males.