Global and risk-group stratified well-being and mental health during the COVID-19 pandemic in adults: Results from the international COH-FIT Study Marco Solmi a,b,c,d,e,f,1, Trevor Thompson g,1, Andrés Estradé d,i,1, Agorastos Agorastos j, Joaquim Radua d,k,l, Samuele Cortese h, Elena Dragioti m,n, Davy Vancampfort o, Lau Caspar Thygesen p, Harald Aschauer q, Monika Schlögelhofer q, Elena Aschauer q, Andres Schneeberger r, Christian G. Huber s, Gregor Hasler t, Philippe Conus u, Kim Q. Do Cuénod u, Roland von Känel v, Gonzalo Arrondo l,w, Paolo Fusar-Poli d,x,y, Philip Gorwood z,aa, Pierre-Michel Llorca ab, Marie-Odile Krebs aa,ac, Elisabetta Scanferla z, Taishiro Kishimoto ad, Golam Rabbani ae, Karolina Skonieczna-Żydecka af, Paolo Brambilla ag,ah, Angela Favaro ai, Akihiro Takamiya ad, Leonardo Zoccante aj, Marco Colizzi ak, Julie Bourgin al, Karol Kamiński am, Maryam Moghadasin an, Soraya Seedat ao, Evan Matthews ap, John Wells ap, Emilia Vassilopoulou aq, Ary Gadelha ar, Kuan-Pin Su as,at, Jun Soo Kwon au, Minah Kim av, Tae Young Lee aw, Oleg Papsuev a,b,c, Denisa Manková ay, Andrea Boscutti az, Cristiano Gerunda ai, Diego Saccon ba, Elena Righi bb, Francesco Monaco bc,bd, Giovanni Croatto be, Guido Cereda ag, Jacopo Demurtas bf, Natascia Brondino y, Nicola Veronese bg, Paolo Enrico ag, Pierluigi Politi y, Valentina Ciappolino bh, Andrea Pfennig bi, Andreas Bechdolf bj, Andreas Meyer-Lindenberg bk, Kai G. Kahl bl, Katharina Domschke bm, Michael Bauer bi, Nikolaos Koutsouleris bn, Sibylle Winter f, Stefan Borgwardt bo, Istvan Bitter bp, Judit Balazs bq,br, Pál Czobor bp, Zsolt Unoka bp, Dimitris Mavridis bs, Konstantinos Tsamakis bt, Vasilios P. Bozikas j, Chavit Tunvirachaisakul bu, Michael Maes bu, Teerayuth Rungnirundorn bu, Thitiporn Supasitthumrong bu, Ariful Haque ae, Andre R. Brunoni bv,bw, Carlos Gustavo Costardi ar, Felipe Barreto Schuch bx,by,bz, Guilherme Polanczyk bv, Jhoanne Merlyn Luiz ca, Lais Fonseca ar, Luana V. Aparicio bv, Samira S. Valvassori ca, Merete Nordentoft cb, Per Vendsborg cc, Sofie Have Hoffmann p, Jihed Sehli cd, Norman Sartorius ce, Sabina Heuss cf, Daniel Guinart cg,ch,ci, Jane Hamilton cj, John Kane ck, Jose Rubio ck, Michael Sand cm, Ai Koyanagi cn, Aleix Solanes k, Alvaro Andreu-Bernabeu co, Antonia San José Cáceres co, Celso Arango co, Covadonga M. Díaz-Caneja co, Diego Hidalgo-Mazzei cp, Eduard Vieta cp, Javier Gonzalez-Peñas co, Lydia Fortea k, Mara Parellada co, Miquel A. Fullana k, Norma Verdolini cp,cq, Eva Andrlíková ay, Karolina Janků ay, Mark J. Millan cr, Mihaela Honciuc ab, Anna Moniuszko-Malinowska cs, Igor Łoniewski af,ct, Jerzy Samochowiec cu, Łukasz Kiszkiel cv, Maria Marlicz af, Paweł Sowa am, Wojciech Marlicz cw,cx, Georgina Spies ao, Brendon Stubbs cy, Joseph Firth cz, Sarah Sullivan da, Asli Enez Darcin db, Hatice Aksu dc, Nesrin Dilbaz dd, Onur Noyan dd, Momoko Kitazawa ad, Shunya Kurokawa ad, Yuki Tazawa ad, Alejandro Anselmi de, Cecilia Cracco de, * Corresponding author at: Department of Child and Adolescent Psychiatry, Psychosomatic Medicine and Psychotherapy, Charité University Medical Center, Campus Virchow, Augustenburger Platz 1, D-13353, Berlin, Germany. E-mail address: christoph.correll@charite.de (C.U. Correll). Contents lists available at ScienceDirect Psychiatry Research journal homepage: www.elsevier.com/locate/psychres https://doi.org/10.1016/j.psychres.2024.115972 Received 15 October 2023; Received in revised form 15 May 2024; Accepted 18 May 2024 Psychiatry Research 342 (2024) 115972 Available online 23 May 2024 0165-1781/© 2024 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ ). mailto:christoph.correll@charite.de www.sciencedirect.com/science/journal/01651781 https://www.elsevier.com/locate/psychres https://doi.org/10.1016/j.psychres.2024.115972 https://doi.org/10.1016/j.psychres.2024.115972 https://doi.org/10.1016/j.psychres.2024.115972 http://crossmark.crossref.org/dialog/?doi=10.1016/j.psychres.2024.115972&domain=pdf http://creativecommons.org/licenses/by/4.0/ AnaInés Machado de, Natalia Estrade de, Diego De Leo df, Jackie Curtis dg, Michael Berk dh, Andre F. Carvalho dh, Philip Ward di, Scott Teasdale di, Simon Rosenbaum di, Wolfgang Marx dh, Adrian Vasile Horodnic dj, Liviu Oprea dj, Ovidiu Alexinschi dk, Petru Ifteni dl, Serban Turliuc dj, Tudor Ciuhodaru dm, Alexandra Bolos dj, Valentin Matei dn, Dorien H. Nieman do, Iris Sommer dp, Jim van Os dq, Therese van Amelsvoort dr, Ching-Fang Sun at,ds, Ta-wei Guu at,bt,dt, Can Jiao du, Jieting Zhang du, Jialin Fan du, Liye Zou du, Xin Yu dv, Xinli Chi du, Philippe de Timary dw,dx, Ruud van Winkel dy, Bernardo Ng dz, Edilberto Peña de León dz, Ramon Arellano dz, Raquel Roman dz, Thelma Sanchez dz, Larisa Movina ax, Pedro Morgado ea,eb, Sofia Brissos ec, Oleg Aizberg ed, Anna Mosina ee, Damir Krinitski ef, James Mugisha eg, Dena Sadeghi-Bahmani eh,ei, Farshad Sheybani ej, Masoud Sadeghi ek, Samira Hadi el, Serge Brand ei,em,en,eo,ep,eq, Antonia Errazuriz er, Nicolas Crossley er, Dragana Ignjatovic Ristic es, Carlos López-Jaramillo et, Dimitris Efthymiou eu, Praveenlal Kuttichira ev, Roy Abraham Kallivayalil ew, Afzal Javed ex, Muhammad Iqbal Afridi ey,ez, Bawo James fa, Omonefe Joy Seb-Akahomen fb, Jess Fiedorowicz a,b,c, Jeff Daskalakis r, Lakshmi N. Yatham fc, Lin Yang fd,fe, Tarek Okasha ff, Aïcha Dahdouh fg, Jari Tiihonen l,fh, Jae Il Shin fi, Jinhee Lee fj, Ahmed Mhalla fk, Lotfi Gaha fk, Takoua Brahim fk, Kuanysh Altynbekov fl, Nikolay Negay fl, Saltanat Nurmagambetova fl, Yasser Abu Jamei fm, Mark Weiser fn, Christoph U. Correll f,cg,ck,cl,* a University of Ottawa, Department of Psychiatry, Ontario, Canada b The Ottawa Hospital, Department of Mental Health, Ontario, Canada c Ottawa Hospital Research Institute (OHRI) Neurosciences Program, Ottawa Ontario d Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK e Centre for Innovation in Mental Health-Developmental Lab, School of Psychology, University of Southampton, and NHS Trust, Southampton, United Kingdom f Charité Universitätsmedizin Berlin, Department of Child and Adolescent Psychiatry, Berlin, Germany g Centre for Chronic Illness and Ageing, University of Greenwich, London, UK h University of Southampton, Centre for Innovation in Mental Health, Southampton, UK i Universidad Católica, Department of Psychology, Montevideo, Uruguay j Aristotle University of Thessaloniki, II. Dept. of Psychiatry, Division of Neurosciences, Medical School, Faculty of Health Sciences, Greece k Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Imaging of Mood- and Anxiety-Related Disorders (IMARD), University of Barcelona, CIBERSAM, Instituto de Salud Carlos III, Barcelona, Spain l Karolinska Institutet, Centre for Psychiatric Research and Education, Department of Clinical Neuroscience, Stockholm, Sweden m Linköping University, Pain and Rehabilitation Centre and Department of Health, Medicine and Caring Sciences, Linköping, Sweden n University of Ioannina, Research Laboratory Psychology of Patients, Families & Health Professionals, Department of Nursing, School of Health Sciences, Ioannina, Greece o Katholieke Universiteit Leuven (KU Leuven), Department of Rehabilitation Sciences, Leuven, Belgium p National Institute of Public Health, University of Southern Denmark, Denmark q BioPsyC - Biopsychosocial Corporation, Non-profit association for Research Funding Ltd., Vienna, Austria r University of California San Diego, California, USA s University of Basel, Universitäre Psychiatrische Kliniken Basel (UPK), Basel, Switzerland t University of Fribourg, Fribourg Network of Mental Health (RFSM), Fribourg, Switzerland u University of Lausanne, Department of Psychiatry, Lausanne, Switzerland v University of Zurich, University Hospital Zurich, Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, Switzerland w University of Navarra, Mind-Brain Group, Institute for Culture and Society (ICS), Pamplona, Spain x OASIS service, South London and Maudsley NHS Foundation Trust, London, UK y University of Pavia, Department of Brain and Behavioral Sciences, Pavia, Italy z Université Paris Cité, CMME, GHU Paris Psychiatrie et Neurosciences, Paris, France aa Institute de Psychiatrie et Neuroscience de Paris, INSERM U1266, F-75014, Paris, France ab Université Clermont Auvergne, CHU Clermont-Ferrand, Service de Psychiatrie B, Clermont-Ferrand, France ac Université de Paris, PEPIT, GHU Paris Psychiatrie et Neuroscience, Paris, France ad Keio University School of Medicine, Department of Neuropsychiatry, Tokyo, Japan ae The National Foundation of Mental Health of Bangladesh, Bangladesh af Pomeranian Medical University in Szczecin, Department of Biochemical Sciences, Szczecin, Poland ag University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy ah Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Neurosciences and Mental Health, Milan, Italy ai University of Padua, Neurosciences Department, Padua, Italy aj UOC Infanzia, Adolescenza, Famiglia e Consultori - Districts 1 & 2 AULSS 9 Scaligera, Verona, Italy ak University of Udine, Department of Medicine (DAME), Unit of Psychiatry, Italy al Service de Psychiatrie de l’enfant et de l’adolescent, GHNE, 91440 Bures Sur Yvette, France am Medical University of Białystok, Department of Population Medicine and Lifestyle Diseases Prevention, Bialystok, Poland an Kharazmi University, Department of Clinical Psychology, Faculty of Psychology and Education, Tehran, Iran ao South African Medical Research Council Unit on the Genomics of Brain Disorders, Stellenbosch University, Department of Psychiatry, Faculty of Medicine and Health Sciences, South Africa ap South East Technological University, School of Health Science, Waterford, Ireland aq University of Nicosia, Department of Life and Health Sciences, Nicosia, Cyprus ar Universidade Federal de São Paulo, Department of Psychiatry, São Paulo, Brazil as An-Nan Hospital, China Medical University, Department of Psychiatry, Tainan, Taiwan at China Medical University Hospital, Mind-Body Interface Research Center, Taichung, Taiwan au Seoul National University College of Medicine, Department of Psychiatry, Seoul, Republic of Korea av Seoul National University Hospital, Department of Neuropsychiatry, Seoul, Republic of Korea aw Pusan National University Yangsan Hospital, Department of Psychiatry, Yangsan, Republic of Korea ax Moscow Research Institute of Psychiatry, Moscow, Russia M. Solmi et al. Psychiatry Research 342 (2024) 115972 2 ay National Institute of Mental Health, Klecany, Czech Republic az UTHealth Houston, Department of Psychiatry, 1941 East Rd, Houston, TX 77054, USA ba AULSS4 Veneto Orientale, Addictions Department, Italy bb University of Modena and Reggio Emilia, Department of Biomedical, Metabolic and Neural Sciences, Modena, Italy bc ASL Salerno, Department of Mental Health, Salerno, Italy bd European Biomedical Research Institute of Salerno (EBRIS), Salerno, Italy be University of Padova, Padova, Italy bf University of Modena and Reggio Emilia, Clinical and Experimental Medicine PhD Program, Modena, Italy bg University of Palermo, Department of Internal Medicine, Geriatrics Section, Palermo, Italy bh Unit of Psychiatry, Azienda Ospedaliero-Universitaria Ss. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy bi Technische Universität Dresden, University Hospital Carl Gustav Carus, Department of Psychiatry and Psychotherapy, Dresden, Germany bj Charité Universitätsmedizin Berlin, Department of Psychiatry and Psychotherapy, Berlin, Germany bk Heidelberg University, Central Institute of Mental Health, Medical Faculty Mannheim, Germany bl Hannover Medical School, Department of Psychiatry, Social Psychiatry and Psychotherapy, Germany bm University of Freiburg, Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, Freiburg, Germany bn Ludwig-Maximilians-University of Munich, Munich, Germany bo Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany bp Semmelweis University, Department of Psychiatry and Psychotherapy, Budapest, Hungary bq Eotvos Lorand University, Institute of Psychology, Budapest, Hungary br Bjørknes University College, Oslo, Norway bs University of Ioannina, Department of Primary Education, Ioannina, Greece bt King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK bu Chulalongkorn University, Department of Psychiatry, Thailand bv Faculdade de Medicina da Universidade de São Paulo, Departments of Internal Medicine and Psychiatry, São Paulo, Brazil bw Instituto de Psiquiatria do Hospital das Clínicas da FMUSP, R. Dr. Ovídio Pires de Campos, 785 - Cerqueira César, São Paulo - SP, 05403-903, Brazil bx Universidade Federal de Santa Maria, Department of Sports Methods and Techniques, Santa Maria, RS, Brazil by Faculty of Health Sciences, Universidad Autónoma de Chile, Providencia, Chile bz Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil ca Universidade do Extremo Sul Catarinense, Translational Psychiatry Laboratory, Graduate Program in Health Sciences, Criciúma, SC, Brazil cb University of Copenhagen, Copenhagen, Denmark cc Psykiatrifonden, Copenhagen, Denmark cd Le Jolimont Psychiatry and Psychotherapy, Fribourg, Switzerland ce Association for the Improvement of Mental Health Programmes (AMH), Switzerland cf FHNW University of Applied Sciences and Arts Northwestern Switzerland, Switzerland cg Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, USA ch Institut de Salut Mental, Parc de Salut Mar, Barcelona, Spain ci Hospital del Mar Research Institute, CIBERSAM, Barcelona, Spain cj University of Texas Health Science Center Houston, McGovern Medical School, Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, USA ck The Zucker Hillside Hospital, Northwell Health, New York, USA cl The Feinstein Institute for Medical Research, Center for Psychiatric Neuroscience, Manhasset, NY, USA cm S2 Consulting LLC cn Parc Sanitari Sant Joan de Deu, Barcelona, Spain co Hospital General Universitario Gregorio Marañón, Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health (IPS MARAÑÓN), IiSGM, CIBERSAM, Universidad Complutense, Madrid, Spain cp University of Barcelona, Hospital Clínic, IDIBAPS, CIBERSAM, Barcelona, Spain cq Local Health Unit 1, Department of Mental Health, Mental Health Center of Perugia, Italy cr Glasgow University, Institute of Neuroscience and Psychology, College of Medicine, Vet and Life Science, Glasgow, UK cs Medical University of Białystok, Department of Infectious Diseases and Neuroinfections, Poland ct Sanprobi Sp. z o.o. Sp. k, Poland cu Pomeranian Medical University in Szczecin, Department of Psychiatry, Szczecin, Poland cv University of Białystok, Institute of Sociology, Society and Cognition Unit, Białystok, Poland cw Pomeranian Medical University in Szczecin, Department of Gastroenterology, Szczecin, Poland cx The Centre for Digestive Diseases Endoklinika, Szczecin, Poland cy King’s College London, London, UK cz University of Manchester, Division of Psychology and Mental Health, Manchester, UK da Bristol Medical School, University of Bristol, Bristol, United Kingdom db Istanbul Topkapı University, Istanbul, Turkey dc Adnan Menderes University Department of Child and Adolescent Psychiatry, Aydın, Turkey dd Uskudar University, Department of Psychiatry and Psychology, Istanbul, Turkey de Department of Psychology, Universidad Católica del Uruguay, Avenida 8 de Octubre 2738, Montevideo, Montevideo 11600, Uruguay df Griffith University, South East Queensland, Australia dg Mindgardens Neuroscience Network, Sydney, Australia dh Deakin University School of Medicine, Victoria, Australia di UNSW Sydney, School of Psychiatry, Sydney, Australia dj University of Medicine and Pharmacy Grigore T. Popa, Faculty of Medicine, Iasi, Romania dk Institute of Psychiatry "Socola", Iasi, Romania dl Transilvania University of Brasov, Faculty of Medicine, Brasov, Romania dm Emergency Hospital "Nicolae Oblu", Iasi, Romania dn Psychiatry Department, University of Medicine and Pharmacy "Carol Davila" Bucharest, "Prof. Dr. Alexandru Obregia" Psychiatric Hospital, Bucharest, Romania do Amsterdam University Medical Centers (location AMC), Department of Psychiatry, Amsterdam, the Netherlands dp University Medical Center Groningen, Groningen, the Netherlands dq Utrecht University Medical Centre, Department of Psychiatry, Utrecht, the Netherlands dr Maastricht University, Department of Psychiatry and Neuropsychology, Maastricht, the Netherlands ds Department of Psychiatry and Behavioral Medicine, Carilion Clinic Virginia Tech Carilion School of Medicine, Roanoke, VA, USA dt China Medical University Beigang Hospital, Division of Psychiatry, Department of Internal Medicine, Taiwan du Shenzhen University, School of Psychology, Shenzhen, China dv Peking University Institute of Mental Health, Department of Public Mental Health, Pekin, China dw UCLouvain, Institute of Neuroscience and Cliniques Universitaires Saint-Luc, Department of Adult Psychiatry, Brussels, Belgium dx Cliniques Universitaires Saint-Luc, Department of Adult Psychiatry, Brussels, Belgium dy Katholieke Universiteit Leuven (KU Leuven), Department of Neurosciences, Leuven, Belgium M. Solmi et al. Psychiatry Research 342 (2024) 115972 3 dz Asociación Psiquiátrica Mexicana, Mexico ea University of Minho, Life and Health Sciences Research Institute (ICVS), School of Medicine, Braga, Portugal eb ICVS/3B’s - PT Government Associate Laboratory, Braga/Guimarães, Portugal ec Lisbon’s Psychiatric Hospital Centre, Department of Psychiatry, Portugal ed Belarusian Medical Academy of Postgraduate Education, Belarus ee Clienia AG, Wetzikon Psychiatric Centre, Switzerland ef Integrated Psychiatry Winterthur (IPW), Switzerland eg Kyambogo University, Department of Sociology and Social Administration, Kampala, Uganda eh Stanford University, Department of Psychology, California, USA ei Universitäre Psychiatrische Kliniken Basel (UPK), Center of Affective, Stress and Sleep Disorders (ZASS), Basel, Switzerland ej Department of Psychiatry and Clinical Psychology, Mashhad University of Medical Sciences, Mashhad, Iran ek Kermanshah University of Medical Sciences, Medical Biology Research Center, Kermanshah, Iran el Kharazmi University, Tehran, Iran em University of Basel, Department of Sport, Exercise, and Health, Division of Sport Science and Psychosocial Health, Basel, Switzerland en Kermanshah University of Medical Sciences, Substance Abuse Prevention Research Center, Kermanshah, Iran eo Kermanshah University of Medical Sciences, Sleep Disorders Research Center, Kermanshah, Iran ep Tehran University of Medical Sciences, School of Medicine, Tehran, Iran eq Center for Disaster Psychiatry and Disaster Psychology, Psychiatric Clinics of the University of Basel, Basel, Switzerland er Pontificia Universidad Católica de Chile, Department of Psychiatry, School of Medicine, Santiago, Chile es University of Kragujevac, Department of Psychiatry, Faculty of Medical Sciences, Kragujevac, Serbia et University of Antioquia, Department of Psychiatry, Medellín, Colombia eu Nous Therapy Center, Thessaloniki, Greece ev Jubilee Mission Medical College & Research Institute, Thrissur, India ew Pushpagiri Institute of Medical Sciences, Department of Psychiatry, Thiruvalla, Kerala, India ex Chairman, Pakistan Psychiatric Research Centre-Fountain House, Lahore, Pakistan ey Distinguished National Professor, Jinnah Sindh Medical University, Karachi, Pakistan ez Adjunct Professor of Psychiatry, Baylor College of Medicine, Texas, USA fa Tees Esk & Wear Valleys NHS Foundation Trust, UK fb Irrua Specialist Teaching Hospital, Department of Psychiatry, Edo State, Nigeria fc University of British Columbia, Vancouver, Canada fd Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Canada fe Departments of Oncology and Community Health Sciences, University of Calgary, Calgary, Canada ff Okasha Institute of Psychiatry, Faculty of Medicine, Ain Shams University, Cairo, Egypt fg Oran 1 University, Department of Psychiatry-Addictology, Oran, Algeria fh University of Eastern Finland, Department of Forensic Psychiatry, Niuvanniemi Hospital, Kuopio, Finland fi Yonsei University College of Medicine, Department of Pediatrics, Seoul, South Korea fj Yonsei University, Wonju College of Medicine, Department of Psychiatry, Wonju, South Korea fk University of Monastir, Faculty of Medicine of Monastir, Research Unit "Vulnerability to Mental Disorders" LR05ES10, Monastir, Tunisia fl Republican Scientific and Practical Center of Mental Health, Almaty, Kazakhstan fm Gaza Community Mental Health Programme, Gaza, Palestine fn Sheba Medical Center, Israel A R T I C L E I N F O Keywords: Covid-19 Pandemic Survey WHO-5 P-factor Well-being Mental health Psychiatry Psychopathology A B S T R A C T International studies measuring wellbeing/multidimensional mental health before/ during the COVID-19 pandemic, including representative samples for >2 years, identifying risk groups and coping strategies are lacking. COH-FIT is an online, international, anonymous survey measuring changes in well-being (WHO-5) and a composite psychopathology P-score, and their associations with COVID-19 deaths/restrictions, 12 a-priori defined risk individual/cumulative factors, and coping strategies during COVID-19 pandemic (26/04/2020-26/ 06/2022) in 30 languages (representative, weighted non-representative, adults). T-test, χ2, penalized cubic splines, linear regression, correlation analyses were conducted. Analyzing 121,066/142,364 initiated surveys, WHO-5/P-score worsened intra-pandemic by 11.1±21.1/13.2±17.9 points (effect size d=0.50/0.60) (compa- rable results in representative/weighted non-probability samples). Persons with WHO-5 scores indicative of depression screening (<50, 13% to 32%) and major depression (<29, 3% to 12%) significantly increased. WHO-5 worsened from those with mental disorders, female sex, COVID-19-related loss, low-income country location, physical disorders, healthcare worker occupations, large city location, COVID-19 infection, unemployment, first- generation immigration, to age=18-29 with a cumulative effect. Similar findings emerged for P-score. Changes were significantly but minimally related to COVID-19 deaths, returning to near-pre-pandemic values after >2 years. The most subjectively effective coping strategies were exercise and walking, internet use, social contacts. Identified risk groups, coping strategies and outcome trajectories can inform global public health strategies. 1. Introduction Until June-7-2023 >767,750,000 persons have been infected with COVID-19, and >6,941,000 died (World Health Organization, 2020). The pandemic also worsened mental health of the general population (Clift et al., 2022), as measured in cohort studies and surveys in indi- vidual countries. Several non-COVID-19-related cohort studies had a pre-pandemic mental health assessment (Ahrens et al., 2021), but most did not, retrospectively assessing pre-pandemic mental health (Huang et al., 2022). Also, to avoid in-person visits, both cohort studies and surveys assessed mental health with questionnaires (Lu et al., 2022). Many surveys have reported alarming rates of anxiety, depression, and post-traumatic symptoms during COVID-19 (Dragioti et al., 2022). However, most studies were affected by methodological limitations limiting the impact, representativeness, and generalizability of findings (e.g., assessing one intra-pandemic time-point only). Also, studies were set in at most two countries, used questionnaires in one language only 1 Joint first authors. M. Solmi et al. Psychiatry Research 342 (2024) 115972 4 (neglecting linguistic/ethnic minorities), focused on one or few mental health domains, in non-representative samples, or in specific population subgroups, collecting few candidate risk/mitigating factors for mental health, without concurrently assessing physical health outcomes (Dra- gioti et al., 2022). Such limitations impede a comprehensive under- standing of the health impact COVID-19. For instance, previous reports from individual countries showed that general population mental health is closely related with COVID-19 infection (Abel et al., 2021) and re- strictions (Fancourt et al., 2021), but such associations at the global level remain unclear. Moreover, no study has assessed whether risk factors for poor mental health identified in individual countries, like younger and older age (Patel et al., 2022), female sex (Patel et al., 2022), or pre-existing physical and mental disorders (Dragioti et al., 2022), replicate globally. The Collaborative Outcomes study on Health and Functioning during Infection Times (COH-FIT, www.coh-fit.com) (Solmi et al., 2022a, b) is an international survey study, conducted in 30 languages in repre- sentative/weighted non-representative samples. COH-FIT has been measuring well-being and the psychopathology factor (P-score), a composite mental health measure (Solmi et al., 2022a), in the general population across all continents since April-26-2020, including a retro- spectively recalled pre-pandemic assessment, comprehensive multidi- mensional factors relevant for well-being and mental health. Here, we report globally in adults, findings of the two co-primary COH-FIT out- comes, well-being and the P-score, hypothesizing reduced well-being and increased psychopathology globally, with increased impairment in vulnerable subgroups and related to death rates and stringency mea- sures over time, and with cumulative effects across multiple risk factors. We also assessed subjectively most effective coping strategies for dealing with the impact of the pandemic. 2. Methods COH-FIT was approved by institutional ethics committees in study investigators’ countries (published protocol (Solmi et al., 2022a, b)). COH-FIT translations and the P-score have been validated (Solmi et al., 2022a). For detailed methods and data dictionary with items’ text and response values, see supplementary material. Below, we report methods and results following A Consensus-Based Checklist for Reporting of Survey Studies (CROSS) (Sharma et al., 2021) (eChecklist). 2.1. Outcomes The two co-primary outcomes were intra- vs. pre-pandemic changes in the WHO-5 well-being score (Topp et al., 2015), and the “P-score”, a 5-dimensional measure composed of anxiety, depression, post-traumatic symptoms, psychotic symptoms, and psychophysiologic parameters (stress, sleep problems, and concentration problems). Participants rated symptoms “during the last two weeks”, and “during the last two weeks of their regular life” before the pandemic (visual analogue scale, 0-100 range WHO-5=0-100, P-score=0-100, higher scores better and worse status, respectively). Additionally, we calculated the proportion of subjects with WHO-5 <50 (indication for testing for depression), and <29 (indicative of major depression) (Topp et al., 2015), pre- and intra-pandemic. We examined possible recall bias for WHO-5 and P-score performing polynomial regression analyses using linear or quadratic relationships. Additionally, respondents rated how important (“very”, “some- what”, “not”) the following coping strategies were for dealing effectively with the pandemic: exercise or walking, internet use, direct social con- tact, hobby, information about the COVID-19 pandemic, media, social media, work, studying/learning, pet, physical intimacy, prescribed medications, religion/meditation/spirituality, gaming, substance use, or other strategies. 2.2. At-risk groups Based on previous literature (Dragioti et al., 2022; Salazar de Pablo et al., 2020) we a priori identified 12 risk factors for poor well-being/mental health, namely having had COVID-19 infection, age ≤30, female sex, being unemployed, healthcare worker employment, having a mental disorder, having a physical disorder, first-generation immigrant status, large city location, low-income country location, obesity, and having lost someone due to COVID-19. 2.3. COVID-19 deaths and restrictions Time- and region-specific COVID-19 daily deaths, and stringency index were extracted from Johns Hopkins University repository (htt ps://coronavirus.jhu.edu/data), and University of Oxford stringency metric (0-100) (https://covidtracker.bsg.ox.ac.uk/) (eMethods). 2.4. Data analysis The missing item data were imputed using multivariate chained equations, using predictive mean matching (van Buuren and Groothuis-Oudshoorn, 2011) to impute missing continuous values, and logistic regression for categorical variables (eMethods). Two iterations of outlier screening were undertaken, using a relatively high threshold of |z|=5.0, and winsoring them to the next highest non-outlying value. Details on survey weighting are available in eMethods. WHO-5 and P-score values and proportion of WHO-5 <50 and <29 pre- vs during pandemic were compared with paired t-test and χ2 test. Changes in the co-primary outcomes were compared in subjects with vs. without each risk factor for poor well-being/high P-score during the pandemic, using independent t-tests. Both weighted t-tests, using calibration weights, and unweighted t-tests with the original unweighted data were con- ducted. All tests of primary outcomes were evaluated for significance using an alpha threshold of α=.01. We also explored a cumulative effect of multiple risk factors on outcomes by testing a linear regression model between number of concomitant risk factors and co-primary outcomes. As the trajectory of intra-pandemic changes in WHO-5 and P-score could not be realistically predicted a priori, we conducted exploratory modelling of the course of outcomes using penalised cubic splines, plotting them together with COVID-19 deaths and restrictions. To quantify the association of out- comes with COVID-19 deaths, stringency, stringency/death ratio, and time, we conducted correlation and smoothed regression analyses. All analyses were performed in R, except for regression analyses for cu- mulative risk factors and correlation analyses, which were conducted with STATA. 3. Results 3.1. Survey sample Overall, from 142,364 initiated surveys, 121,066 adults (age=42.0 ±15.9 (range=18-100); male=35.4%, female=64%, non-binary=0.4%, transgender/intersex=0.2%) provided analyzable data between 26-Apr- 2020/19-Jun-2022. (participant flow in eFig. 1). Baseline characteristics (see Table 1, and eTable 2 comparing included/excluded samples), indicated over-representation of females, younger adults, and those with higher education vs. national population statistics (eFig. 2). A longer interval between survey completion and pandemic start was related to both pre-pandemic well-being scores (linear β=-0.03, quadratic β=-0.03, p<.001) and P scores (linear β=-0.01, quadratic β=-0.07, p<.001), yet with a negligible effect size (see eFigs. 3 and 4/), reflecting absence of substantial recall bias/drift. M. Solmi et al. Psychiatry Research 342 (2024) 115972 5 http://www.coh-fit.com https://coronavirus.jhu.edu/data https://coronavirus.jhu.edu/data https://covidtracker.bsg.ox.ac.uk/ Table 1 Basic participant characteristics for overall, representative and non-probability samples. Overall Representative Non-probability N Percent N Percent N Percent Representative sample non-probability 86017 71.0 0 0 86017 100 representative 35049 29.0 35049 100 0 0 Age 18-34 46159 38.1 10216 29.1 35943 41.8 35-49 33947 28.0 9829 28.0 24118 28.0 50-64 28769 23.8 10058 28.7 18711 21.8 65+ 12191 10.1 4946 14.1 7245 8.4 Gender Male 42891 35.4 17242 49.2 25649 29.8 Female 77487 64.0 17696 50.5 59791 69.5 Non-binary 462 0.4 67 0.2 395 0.5 Transgender or intersex 226 0.2 44 0.1 182 0.2 Ethnicity White 83498 69.0 28641 81.7 54857 63.8 African/African-descent 3375 2.8 632 1.8 2743 3.2 Hispanic 3366 2.8 884 2.5 2482 2.9 Asian 23795 19.7 2765 7.9 21030 24.4 Mixed 5121 4.2 1561 4.5 3560 4.1 Other 1403 1.2 449 1.3 954 1.1 Prefer not to answer 508 0.4 117 0.3 391 0.5 First-generation immigrant No 73346 92.6 26480 92.2 46866 92.8 Yes 5897 7.4 2253 7.8 3644 7.2 Education None 671 0.6 196 0.6 475 0.6 Primary school 3401 2.8 2018 5.8 1383 1.6 High school 38726 32.0 18706 53.4 20020 23.3 College/university degree 68335 56.4 12986 37.1 55349 64.3 PhD 9933 8.2 1143 3.3 8790 10.2 Socio-economic status 0-24 7104 5.9 2298 6.6 4806 5.6 25-49 23091 19.1 7253 20.7 15838 18.4 50-74 71109 58.7 21148 60.3 49961 58.1 75-100 19762 16.3 4350 12.4 15412 17.9 Employment No 46890 38.7 13909 39.7 32981 38.3 Yes 74176 61.3 21140 60.3 53036 61.7 Healthcare worker No 56004 76.1 18864 89.4 37140 70.7 Yes 17606 23.9 2239 10.6 15367 29.3 Mental health diagnosis No 101325 83.7 30523 87.1 70802 82.3 Yes 19741 16.3 4526 12.9 15215 17.7 Physical disease diagnosis No 66840 55.2 20404 58.2 46436 54.0 Yes 54226 44.8 14645 41.8 39581 46.0 COVID-19 infection No 27989 82.8 10874 77.6 17115 86.6 Yes 5805 17.2 3147 22.4 2658 13.4 Urbanicity Village/rural 21415 17.7 8459 24.1 12956 15.1 Small city/town (10,000-100.000 population) 30037 24.8 10199 29.1 19838 23.1 Medium city/town (100,000-500.000 population) 27312 22.6 7186 20.5 20126 23.4 Large city/town (over 500.000 population) 42302 34.9 9205 26.3 33097 38.5 Restrictions (Oxford Stringency Index) 0-24 4578 3.8 3446 9.8 1132 1.3 25-49 24754 20.4 10270 29.3 14484 16.8 50-74 61978 51.2 17914 51.1 44064 51.2 75-100 29756 24.6 3419 9.8 26337 30.6 Country income High income 83214 68.7 29492 84.1 53722 62.5 Middle income 32517 26.9 5557 15.9 26960 31.3 Low income 5335 4.4 0 0 5335 6.2 Obesity No (BMI < 30) 98291 85.0 26998 79.1 71293 87.4 Yes (BMI 30+) 17371 15.0 7113 20.9 10258 12.6 COVID-19-related loss No 114424 94.8 32684 93.3 81740 95.4 Yes 6329 5.2 2347 6.7 3982 4.6 M. Solmi et al. Psychiatry Research 342 (2024) 115972 6 3.2. Well-being The WHO-5 score decreased by 11.1±21.1 points from pre- (71.5 ±19.3) to intra-pandemic (60.4±24.5) (paired t=183.68, p<.001, moderate effect size of d=.50). The proportion of individuals scoring <50 increased from 13% pre-pandemic to 32% intra-pandemic (McNe- mar’s χ2=17637.38, p<.001), with the proportion scoring <29 increasing from 3% pre-pandemic to 12% intra-pandemic (McNemar’s χ2=9103.50, p<.001). A world map of WHO-5 changes shows that worsening varied across countries, but with a general pattern of global deterioration (Figs. 1A, 2A, and B, eTable 3). Compared with those without each risk factor, larger decreases in WHO-5 score emerged for those, in descending order, with a mental disorder, females, COVID-related loss, living in low-income countries, with a physical disorder, healthcare workers, living in a large city, with prior COVID-19 infection, unemployment, and age 18-29 years old, but not for first-generation immigrants. Obesity was associated with smaller decline of WHO-5 (Fig. 3A, eTable 4). Multiple concomitant risk factors cumulatively increased WHO-5 worsening (1.95 WHO-5 score wors- ening for each risk factor, standard error/SE=0.070, p<0.01). 3.3. P-score The P-scores increased by 13.2±17.9 points from pre-pandemic 27.5 ±19.9 to intra-pandemic 40.7±23.6 (paired t=256.23, p<.001, mod- erate effect size d=.60). Additionally, 63% experienced a P-score in- crease by ≥20%, 57% by ≥30%, 52% by ≥40%, and 47% by ≥50%. A world map of P-score changes shows that P-score worsening varied across countries, but with a general pattern of global increase (Fig. 1B, eTable 3). Compared with those without each risk factor, larger increases in P- score emerged for those, in descending order, with a mental disorder, living in low-income countries, females, age 18-29 years old, a physical disorder, COVID-related loss, healthcare workers, unemployment, living in a large city, first-generation immigrants, with history of COVID-19 infection, but without any difference for obesity (Fig. 3A, eTable 4). Multiple concomitant risk factors increased P-score worsening (2.03 P- score worsening for each risk factor, SE=0.06, p<0.01) 3.4. Coping strategies The coping strategies most frequently rated as “very important” were Fig. 1. Global change in WHO-5 well-being score (1A) and the composite psychopathology P-score (1B) in the general population during COVID-19 pandemic in COH-FIT. Legend Fig. 1.: COH-FIT, Collaborative Outcomes study on Health and Functioning during Infection Times, WHO, World Health Organization; larger negative and positive values indicate worsening of WHO-5, and P-score, respectively. M. Solmi et al. Psychiatry Research 342 (2024) 115972 7 exercise or walking=56.0%, internet use=55.3%, direct social con- tacts=52.7%, followed by hobby=48.8%, COVID-19 pandemic information=44%, media use=43.9%, social media use/remote inter- actions=39.4%, work=37.5%, studying/learning=31.6%, spending time with a pet=31.4%, physical intimacy=27.4%, prescribed medi- cations=26.7%, religion/meditation/spirituality=20.9%, gaming=18 .0%, other strategies=12.9%, and substance use=7.8% (Fig. 3B, eTable 5). 3.5. Change trajectories in well-being, P-score, COVID-19 deaths and restrictions in the overall sample, and across risk factors The smoothed trajectories of changes in well-being suggested a worsening of WHO-5 until May-June 2021, when well-being returned to early intra-pandemic levels (Fig. 4A and eFig. 17). P-score peak worsening overall preceded WHO-5 oscillations by 1-2 months (Fig. 4B). The course of well-being and P-score, together with the course with COVID-19 deaths and restrictions during the pandemic across risk fac- tors, are visualized in eFigs. 5–16. Exploratory correlation analyses showed that in the whole sample and across risk factors, both co-primary outcomes were significantly associated with COVID-19 deaths, restrictions stringency, and with stringency/death ratio, yet with very small effect sizes (eTable 6). WHO-5 and P-score worsening returned towards near-pre-pandemic values over time (F=116.20, p<0.001, F=83.38, p<0.001). 4. Discussion This transcontinental study shows that during the COVID-19 pandemic well-being and mental health worsened in the general popu- lation, with a medium effect size, heterogeneously across one or mul- tiple risk factors, countries, and time. COVID-19-related deaths, restriction stringency, and their ratio were significantly yet only mini- mally associated with worsening of well-being and psychopathology. Most effective coping strategies were identified. Well-being and com- posite psychopathology returned to near-pre-pandemic values after >2 years of the pandemic. Results of COH-FIT confirm, though transcontinentally, findings from a systematic review that pooled 177 European studies, reporting a significant negative impact of COVID-19 on mental health, followed by a trending towards pre-pandemic levels over time (Ahmed et al., 2023). Also, COH-FIT results should be interpreted in comparison with findings of a well-conducted recent meta-analysis of cohort studies, which concluded that no/minimal mental health changes occurred during COVID-19 (Sun et al., 2023). Despite the methodological rigor of that Fig. 2. Proportion of subjects with a WHO-5 well-being score < 50 (2A) and <29 (2B) in the general population during COVID-19 pandemic in COH-FIT. M. Solmi et al. Psychiatry Research 342 (2024) 115972 8 meta-analysis, the included cohort studies had several limitations. First, 97% of response came from high/upper-middle-income countries. In COH-FIT, 31% of responses came from low/middle-income countries, which had the largest worsening. Second, only 23% of the studies recruited representative samples. In COH-FIT, 29% were representative samples, and results did not differ between representative and weighted non-probability samples. Third, only 31% of included cohorts followed up with ≥75% participants, with selective retaining of persons that were doing well enough no to drop from the study. COH-FIT kept collecting responses longitudinally at the population level, and the retrospective assessment of pre-pandemic well-being and mental health did not show an upward or downward (idealization or contamination) drift. Fourth, the outcomes included general mental health, depressive, and anxiety symptoms, taken individually, and only one study included WHO-5. COH-FIT also measured a psychopathology P-score, integrating five different domains into one validated score (Solmi et al., 2022a), and used WHO-5 in the whole population. Fifth, regarding subgroup ana- lyses, those were largely underpowered, with only 2-3 studies in several subgroup analyses, very wide confidence intervals, and, low power. COH-FIT was adequately powered to detect changes in outcomes and cross largely represented risk groups. Sixth, follow-up was limited to 2020 in 96.3% of the 134 cohorts, with only five studies measuring outcomes in 2021, limiting generalizability of findings beyond the very early stages of the pandemic. COH-FIT collected data for >2 years. Fig. 3. Forest plot of changes in well-being and P-score (3A) across risk factors in adults during versus before COVID-19 pandemic, and coping strategies (3B). Legend Fig. 3A.: Risk factors are ordered by WHO-5 score difference between groups with and without risk factor; **, p value <0.05 M. Solmi et al. Psychiatry Research 342 (2024) 115972 9 Despite the differences above, COH-FIT converges with the systematic review in concluding that on average, after >2 years of the pandemic, adverse effects on well-being and mental health seem to have largely disappeared in the general population. However, worsening of both well-being and mental health were consistently larger in people with mental disorders, females, COVID-19- related loss, living in low-income countries, and those with physical disorders. That mental illness emerged as a top vulnerability factor in- dicates an urgent need for primary and secondary mental illness pre- vention. Access to mental healthcare for those with preexisting mental disorders has been disrupted, despite legislative efforts facilitating telemedicine (Kinoshita et al., 2022), with subsequent risk of poor clinical outcomes (Sánchez-Guarnido et al., 2021). Several factors can explain the poor well-being and mental health in females, including Fig. 4. Trajectory of change in WHO-5 well-being score (A) and composite psychopathology P-score (B), stringency and daily death rate. M. Solmi et al. Psychiatry Research 342 (2024) 115972 10 pre-pandemic higher prevalence of mental disorder (GBD 2019 Mental Disorders Collaborators, 2022), poor access to care, and disproportion- ately excessive burden of family functioning disruption affecting women more than men, including home schooling (Racine et al., 2021). COVID-19-related loss is a traumatic event, whose reliving has been continuously triggered since COVID-19 outbreak. Regarding low-income countries, poorer pre- and intra-pandemic individual and healthcare system resources, lower government financial support for the population, excessive implementation of restrictions potentially affecting human rights might have worsened well-being, and mental health (Aksunger et al., 2023). For those with physical conditions, access to care deteriorated for non-COVID-19 diseases (Topriceanu et al., 2021), generating poor objective health status and anxiety regarding uncertain care. Age 18-29, being a healthcare worker and living in large cities worsened both co-primary outcomes, yet with different magnitude. In young adults, whose academic, professional, and social routine was seriously disrupted (Patel et al., 2022), a larger effect on mental health rather than well-being emerged, suggesting that the P-score may be more change-sensitive to monitor mental health in this age group. Conversely, healthcare workers and large cities were risk factors asso- ciated with larger worsening in well-being. Healthcare workers have been exposed to unprecedented traumatic events, including death of patients and coworkers, risk for their life, fear of infecting others, long working hours, lack of personal protective equipment, and increased media attention, challenging well-being (Dragioti et al., 2022). Ongoing negative effects on mental health (Dragioti et al., 2022), might have been mitigated by the protective factor of lived altruism. Regarding larger cities, reasons for WHO-5 worsening include higher population density facilitating virus spread and more enforced lock- downs/restrictions, urbanicity’s association with poorer mental health (Luo et al., 2021), worse housing conditions with less access to green areas, and higher cost of living, increasing job/financial insecurities. Better access to mental healthcare in urban centers might have mitigated the ongoing negative impact on mental health. Other risk factors, namely COVID-19 infection, unemployment, first- generation immigrant status, and obesity, may have non-specific or specific effects. Having had COVID-19 infection can worsen acute (Rogers et al., 2020) and long-term mental health, cognition, and physical health (Di Gennaro et al., 2023), yet not necessarily universally. Larger negative effects have been associated with severe COVID-19 infection, likely worsening well-being and mental health (Huang et al., 2022). Job strain that can lead to unemployment is a known risk factor for depression (Köhler et al., 2018). First-generation immigrants have faced most severe isolation (Gama et al., 2022). Regarding obesity, BMI-threshold for obesity varies based on ethnicity and is lower in low-income than middle-/high-income countries. While within each country, obesity is likely associated with larger worsening of well-being and mental health, at the global level the effect of obesity is probably counterbalanced by higher income in countries with larger BMI, likely driving the association to non-significance (P-score), or even in the opposite direction (WHO-5). Importantly, having multiple risk factors increased the pandemic’s impact on well-being and mental health, suggesting that public health prevention, promotion and interventions should prioritize individuals with specific and, especially, multiple risk factors and reduce risk factors globally. Finally, COVID-19-related deaths, restriction stringency, and their ratio were only minimally associated with well-being and P-score, sug- gesting that the pandemic and a more complex network of factors needs to be considered to understand how modifiable and non-modifiable factors might interact. Regarding coping strategies, exercise or walking, internet use and direct social contact were most important. Exercise or walking are a positive intervention for physical and mental health (Firth et al., 2020). With appropriate limitations to restrict virus spread, exercise or walking should be allowed. Exercise in open spaces might be a compromise not to spread virus in close spaces, and to also expose persons to sun light and green areas which might boost the effect of exercise alone. Gov- ernments should facilitate internet access, including for those unlikely to afford it. Moreover, allowing direct social contact whenever possible/- safe seems relevant to cope with the pandemic. Strengths of COH-FIT include the longitudinal data collection at the population level for >2 years, describing the trends of outcomes over time accounting for COVID-19 deaths and restrictions. Most studies published to date covered a limited time since COVID-19 outbreak. A recent large meta-analysis showed that the majority of studies measuring mental health during COVID-19 were limited to time points up to around 100 days since first recorded COVID-19 case (Salanti et al., 2022). Also, COH-FIT covered the population level with representative samples and population demographic weighting from all continents, used validated psychometric instruments, and assessed a comprehensive set of risk factors. Also, according to a recent living meta-analysis of cohort studies measuring mental health changes during versus before the COVID-19 pandemic (Sun et al., 2023), only one used WHO-5 as an outcome. Limitations include the cross-sectional design at the individual level paired with retrospective recall to allow for calculation of pre- to intra- pandemic status, which however we assessed using regression and evi- dence synthesis approaches. Furthermore, we did not detect a drift in the retrospective recall of the pre-pandemic WHO-5 or P-factor during the study period and the pre-pandemic WHO-5 values were similar in COH- FIT compared to published pooled matched country scores of the general population. Moreover, we mixed non-representative with representative samples. However, we weighted the non-representative sample, and having representative data from numerous countries is one of the unique strengths of COH-FIT. Moreover, importantly, results in WHO-5 and the P-score did not significantly differ between representative and non- representative COH-FIT samples. Accounting for severity of COVID-19 infections was not possible due to the anonymous nature of data and absence of link to clinical records. In addition, multivariable and network analyses were not conducted, as they go beyond the aims of this global descriptive report, and will require a specifically dedicated approach. Importantly, while this work provides a unique global over- view of COVID-19 pandemic impact on the population mental health and well-being, only few to no responses came from several regions including middle East is not well-represented, nor is much of South American and the Caribbean. Also, we did not account for vaccinations in our analyses, and future works will focus on this. Moreover, digital barriers precluded a larger participation from larger strata of the pop- ulation, and more data are needed from subjects older than 65 years old. Finally, some risk factors might vary within each country, such as the impact of obesity, or socio-economic status. Indeed, detailed within- country analyses leveraging COH-FIT data will better investigate the impact of those two risk factors. More broadly, only local reports from individual countries can inform local policies, and such COH-FIT reports are being prepared to complement global findings described in this work. In conclusion, the COVID-19 pandemic adversely affected well-being and mental health of the general population globally, with differences across countries with different income, across different strata of the population with a-priori defined risk factors, increasingly in presence of more concomitant risk factors, yet with very small associations with COVID-19-related deaths and restrictions, and with overall a return to near-pre-pandemic values after >2 years into the pandemic. Neverthe- less, during infection times groups at risk should be protected and risk factors should be targeted, and access to exercise or walking (ideally in open spaces), internet use, direct social contact and other effective coping strategies should be facilitated to promote and protect wellbeing and mental health during infection times. Results inform public health prevention and intervention policies, at the global level, which should target those at particular risk. M. Solmi et al. Psychiatry Research 342 (2024) 115972 11 Statement of ethics The online survey launches on the COH-FIT website (www.coh-fit.co m) occurred immediately after the first ethics committee/Institutional Review Board (IRB) approval (Aristotle University of Thessaloniki, Greece, 04/27/2020). Afterwards, prior to active local/national inves- tigator outreach and advertisement activities regarding COH-FIT dissemination, approval or waiver (due to the anonymous, observa- tional nature of the study) was obtained from at least one national IRB. Funding statement All the institutions and funding agencies are listed in eTable 7. COH- FIT PIs and collaborators have applied/are actively applying for several national and international grants to cover expenses related to the co- ordination of the study, website, nationally representative samples, advertisement of the study, and future dissemination of study findings. CRediT authorship contribution statement Marco Solmi: Writing – review & editing, Writing – original draft, Validation, Supervision, Project administration, Methodology, Funding acquisition, Data curation, Conceptualization. Trevor Thompson: Formal analysis. Andrés Estradé: Conceptualization. Agorastos Ago- rastos: Conceptualization. Joaquim Radua: Writing – review& editing. Samuele Cortese: Writing – review & editing. Elena Dragioti: Writing – review& editing. Davy Vancampfort: Writing – review& editing. Lau Caspar Thygesen: Writing – review & editing. Harald Aschauer: Writing – review & editing, Conceptualization. Monika Schlögelhofer: Writing – review & editing. Elena Aschauer: Writing – review & edit- ing. Andres Schneeberger: Writing – review & editing. Christian G. Huber: Writing – review & editing. Gregor Hasler: Writing – review & editing. Philippe Conus: Writing – review & editing. Kim Q. Do Cuénod: Writing – review & editing. Roland von Känel: Writing – review & editing. Gonzalo Arrondo: Writing – review & editing. Paolo Fusar-Poli: Writing – review & editing. Philip Gorwood: Writing – review & editing. Pierre-Michel Llorca: Writing – review & editing. Marie-Odile Krebs: Writing – review & editing. Elisabetta Scanferla: Writing – review & editing. Taishiro Kishimoto: Writing – review & editing. 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Alejandro Anselmi: Writing – review & editing. Cecilia Cracco: Writing – review & editing. Ana Inés Machado: Writing – review & editing. Natalia Estrade: Writing – re- view & editing. Diego De Leo: Writing – review & editing. Jackie Curtis: Writing – review & editing. Michael Berk: Writing – review & editing. Andre F. Carvalho: Writing – review & editing. Philip Ward: Writing – review & editing. Scott Teasdale: Writing – review & editing. Simon Rosenbaum: Writing – review & editing. Wolfgang Marx: Writing – review & editing. Adrian Vasile Horodnic: Writing – review & editing. Liviu Oprea: Writing – review& editing. Ovidiu Alexinschi: Writing – review & editing. Petru Ifteni: Writing – review & editing. Serban Turliuc: Writing – review& editing. Tudor Ciuhodaru: Writing – review & editing. Alexandra Bolos: Writing – review & editing. Valentin Matei: Writing – review & editing. Dorien H. Nieman: Writing – review & editing. Iris Sommer: Writing – review & editing. Jim van Os: Writing – review & editing. Therese van Amelsvoort: Writing – review & editing. Ching-Fang Sun: Writing – review & edit- ing. Ta-wei Guu: Writing – review & editing. Can Jiao: Writing – re- view & editing. Jieting Zhang: Writing – review & editing. Jialin Fan: Writing – review & editing. Liye Zou: Writing – review & editing. Xin M. Solmi et al. Psychiatry Research 342 (2024) 115972 12 http://www.coh-fit.com http://www.coh-fit.com Yu: Writing – review & editing. Xinli Chi: Writing – review & editing. Philippe de Timary: Writing – review & editing. Ruud van Winkel: Writing – review & editing. Bernardo Ng: Writing – review & editing. Edilberto Peña de León: Writing – review& editing. Ramon Arellano: Writing – review& editing. Raquel Roman: Writing – review& editing. Thelma Sanchez: Writing – review& editing. Larisa Movina: Writing – review & editing. Pedro Morgado: Writing – review & editing. Sofia Brissos: Writing – review & editing. Oleg Aizberg: Writing – review & editing. Anna Mosina: Writing – review & editing. Damir Krinitski: Writing – review& editing. James Mugisha: Writing – review& editing. Dena Sadeghi-Bahmani: Writing – review & editing. Farshad Shey- bani: Writing – review & editing. Masoud Sadeghi: Writing – review & editing. Samira Hadi: Writing – review& editing. Serge Brand: Writing – review & editing. Antonia Errazuriz: Writing – review & editing. Nicolas Crossley: Writing – review & editing. Dragana Ignjatovic Ristic: Writing – review & editing. Carlos López-Jaramillo: Writing – review & editing. Dimitris Efthymiou: Writing – review & editing. Praveenlal Kuttichira: Writing – review & editing. Roy Abraham Kallivayalil: Writing – review & editing. Afzal Javed: Writing – review & editing. Muhammad Iqbal Afridi: Writing – review & editing. Bawo James: Writing – review & editing. Omonefe Joy Seb-Akahomen: Writing – review & editing. Jess Fiedorowicz: Writing – review & editing. Jeff Daskalakis: Writing – review & editing. Lakshmi N. Yatham: Writing – review & editing. Lin Yang: Writing – review & editing. Tarek Okasha: Writing – review & editing. Aïcha Dahdouh: Writing – review & editing. Jari Tiihonen: Writing – review & editing. Jae Il Shin: Writing – review & editing. Jinhee Lee: Writing – review & editing. Ahmed Mhalla: Writing – review & editing. Lotfi Gaha: Writing – review & editing. Takoua Brahim: Writing – review & edit- ing. Kuanysh Altynbekov: Writing – review& editing. Nikolay Negay: Writing – review & editing. Saltanat Nurmagambetova: Writing – re- view & editing. Yasser Abu Jamei: Writing – review & editing. Mark Weiser: Writing – review & editing. Christoph U. Correll: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Resources, Project administration, Funding acquisition, Data curation, Conceptualization. Declaration of competing interest Conflict of interest statements of all authors are detailed in eTable 8. Data availability Data are not publicly available, currently. Data are currently being used for additional global publications. Local data are available to local COH-FIT collaborators. We estimate making data available upon request and with a specific project proposal in 2025. Acknowledgements All authors thank all respondents who took the survey so far, funding agencies and all professional and scientific national and international associations supporting or endorsing the COH-FIT project. We would also like to acknowledge the contributions made by Friedrich Leisch and Björn Gerdle to the success of this project. Supplementary materials Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.psychres.2024.115972. References Abel, K.M., Carr, M.J., Ashcroft, D.M., Chalder, T., Chew-Graham, C.A., Hope, H., Kapur, N., McManus, S., Steeg, S., Webb, R.T., Pierce, M., 2021. 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http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0026 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0026 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0026 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0027 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0027 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0027 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0028 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0028 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0028 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0028 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0029 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0029 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0030 http://refhub.elsevier.com/S0165-1781(24)00257-9/sbref0030 Global and risk-group stratified well-being and mental health during the COVID-19 pandemic in adults: Results from the inte ... 1 Introduction 2 Methods 2.1 Outcomes 2.2 At-risk groups 2.3 COVID-19 deaths and restrictions 2.4 Data analysis 3 Results 3.1 Survey sample 3.2 Well-being 3.3 P-score 3.4 Coping strategies 3.5 Change trajectories in well-being, P-score, COVID-19 deaths and restrictions in the overall sample, and across risk factors 4 Discussion Statement of ethics Funding statement CRediT authorship contribution statement Declaration of competing interest Data availability Acknowledgements Supplementary materials References