|Ahead of print publication
Mental health impact of COVID-19 pandemic in India: A web-based community survey
Mamta Singh1, Nitin Raut2, Shipra Singh3
1 Organizational Behavior and Human Resources, Chandragupt Institute of Management, Patna, Bihar, India
2 Department of Psychiatry, Lady Hardinge Medical College, New Delhi, India
3 Department of Psychiatry, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
|Date of Submission||21-Jun-2021|
|Date of Decision||18-Sep-2021|
|Date of Acceptance||29-Sep-2021|
Department of Psychiatry, Postgraduate Institute of Medical Sciences, Rohtak, Haryana
Source of Support: None, Conflict of Interest: None
Background: The coronavirus pandemic has impacted the globe, altering lives of people in all domains, and added insecurity, thereby taking a toll on their mental health. Addressing the parallel surge of psychological problems and identifying the vulnerable population is of equal concern. This study aims at assessing the symptoms of anxiety and depression in the population during the coronavirus pandemic. Methodology: It was a cross-sectional methodological web-based survey to assess psychological influence of the coronavirus pandemic. A sociodemographic pro forma, validated questionnaire consisting questions about awareness regarding coronavirus, and Goldberg Anxiety and Depression Scale were included in the survey. Results: A total of 1027 participants completed the survey questionnaire. Clinically significant anxiety and depressive symptoms were found in 17.9% and 40.7%, respectively. There was statistically significant difference in prevalence of anxiety symptoms by gender (P = 0.009), age group (P = 0.030), marital status (P = 0.001), and occupation (P = 0.012). Depressive symptoms also significantly differed across age group (P = 0.001), marital status (P = 0.000), education (P = 0.020), occupation (P = 0.009), income group (P = 0.038), and place of living (P = 0.039). A significant difference of knowledge (about COVID-19) was seen between the groups with and without clinically significant depressive symptoms. Distress was noted mostly with information overload and the fear of contracting coronavirus infection. Conclusion: More than one-third of participants had clinically significant psychological symptoms. This suggests the requirement of more structured and long-term studies, and the need for appropriate mental health services to masses.
Keywords: Anxiety, COVID-19, depression, mental health
| Introduction|| |
Coronavirus pandemic is now a well-established public health catastrophe of global concern. Currently, it is affecting 221 countries worldwide, with approximately 203,203,317 cases and 4,304,717 deaths by August 8, 2021.,
Ranking second in the global list of total cases, India has already seen an enormous total of 31,941,850 cases and 428,043 deaths. Moreover, the experts predict that situation might be getting even worse with subsequent waves of the pandemic. In addition to rapid spread of infection and loss of lives, it is also thought to have a lasting impact on resources, economy, and life of people depending upon the rapidity with which it affects us.,
The route of spread of this virus is mainly via infected droplets produced while coughing, sneezing or talking, etc. Although the disease is of mild severity in most, it can be fatal in the elderly and people with comorbid medical problems. Treatment is mainly supportive except in severe cases. Numerous medications are being given fast-track approval but are applicable mostly for moderate-to-severe cases and covering the huge population for vaccination is itself a challenge.
This random rapidly spreading virus has resulted in anxiety and distress, which have been described as innate psychological responses to such changing circumstances. Adverse psychological conditions in people are however anticipated to increase considerably due to the pandemic itself and also due to continuous stream of information and overload of messages obtained via various social networking and media platforms. This may result in rapidly growing distress and panic regarding COVID-19 and further give rise to lasting psychological problems in public, which in fact would be more harmful in long run than the pandemic itself. Previous studies have shown that mental health is adversely affected in this kind of global pandemic.,
Apart from the information overload, various other factors found associated with psychological problems include the stigma of getting infected with the virus, worry about isolation and quarantine, fear that self or loved ones may contract the virus, financial problems due to the lockdown, worry of inadequate of health-care services, and so on.
A study in China conducted during initial part of the pandemic found that more than half of participants suffered moderate-to-severe psychological impact due to the pandemic; about one-third reported significant anxiety symptoms, while 17% reported significant depressive symptoms. Further, most people also agreed of having worries about their family members contracting the virus. Participants from a study from India reported worries about finances during the lockdown, depressive symptoms, and difficulty adjusting to this new situation of COVID-19. Another recent multicentric study showed that around two-fifth (38.2%) of participants had anxiety, while 10.5% had depression. Further three-fourth reported significant stress and 71.7% conveyed poor well-being.
Thus, pandemic itself as well as other associated conditions such as lockdown and fear of the disease has been seen to affect psychological health adversely in many individuals which prompted us to look into the psychological impact of COVID-19 in community with the help of an online survey.
| Methodology|| |
Study design and study population
It was a cross-sectional web-based survey to assess the psychological effect of coronavirus pandemic. Approval of the Institutional Review Board was sought prior to data collection.
- A semi-structured pro forma was used to ascertain sociodemographic profile of participants
- Based on available information on authentic sites about COVID-19, 12 questions were formed related to awareness about coronavirus infection (transmission routes, symptoms, and treatment) and preventive measures (meaning of social distancing, isolation, use of simple mask). Questions were answered as “Yes” or “No.” Every correct response was assigned 1 value and incorrect was assigned 0 value. The total knowledge score was calculated by adding all the correct answers. Participants who scored higher marks were considered more knowledgeable toward COVID-19
- In addition, Goldberg Anxiety and Depression Scale (GADS) was included in the survey to detect symptoms of anxiety and depression. It is an 18-item self-report inventory, developed by Goldberg et al. from 36 items in the Psychiatric Assessment Schedule. Latent trait analyses demonstrated that GADS items defined two correlated dimensions of anxiety and depression, along with a third factor of sleep disturbance. GADS score is based on responses of “yes” or “no” to nine depression and nine anxiety items, asking how respondents have been feeling in the past month. Patients with anxiety scores of 5 or more or those with depression scores of 2 or more are considered to have a 50% chance of clinically important disturbance
- A Hindi version of the survey was also constructed. The questions regarding knowledge/awareness about coronavirus infection and GADS were translated into Hindi, as per the WHO guidelines for translation and adaptation of the instrument, to tap more number of participants. The survey was live for 4 weeks and a reminder was sent after 10 days. Once completed, the same individual could not fill the questionnaire again.
The questionnaire was shared on platforms such as WhatsApp and E-mail groups. A brief message specifying the objective of the questionnaire, voluntary attributes of participation, and provision of anonymity was included at the beginning of the survey, along with the question about participant's willingness to take part in the survey.
Data were coded and entered in statistical Package for IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. (Armonk, NY: IBM Corp.). Qualitative data were expressed in proportions. A Chi-square test was applied for comparing frequency of anxiety and depressive symptoms in various sociodemographic groups. Mean and standard deviation (SD) were used for quantitative data. The relationship between knowledge/awareness and clinically significant anxiety/depressive symptoms was assessed using an independent t-test for equality of means. The statistical significance level was set at P < 0.05.
| Results|| |
A total of 1027 participants completed the survey questionnaire. Male and female respondents were 71.5% and 28.5%, respectively. Married respondents were 68.4%, while single respondents were 31.6%. Percentage of respondents who were postgraduates and above was 50.1%, while the rest 49.9% accounted for graduates or below. About 80.9% resided in urban areas.
Knowledge scores were significantly different across age groups, categories of marital status, education levels, occupation, family income, and residence places. The mean COVID-19 knowledge score was 9.56 (SD: 1.3, range: 0–12), suggesting an overall 79.67% (9.56/12 × 100) correct rate on the knowledge questions.
The overall prevalence of anxiety and depressive symptoms was 17.9% and 40.7%, respectively. There was a statistically significant difference in prevalence of anxiety symptoms by gender (P = 0.009), age group (P = 0.030), marital status (P = 0.001), and occupation (P = 0.012). Based on the results, females (22.9%), 16–29 years age group (22.6%), single (23.7%), and students (25.4%) reported higher anxiety compared to others [Table 1]. Depressive symptoms also significantly differed across age group (P = 0.001), marital status (P = 0.000), education (P = 0.020), occupation (P = 0.009), income group (P = 0.038), and place of living (P = 0.039). Higher depressive symptoms were found in 16–29 years of age group (48.4%) and those who were single (49.2%) [Table 2].
|Table 1: Significant anxiety symptoms across different demographic variables|
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|Table 2: Significant depressive symptoms across different demographic variables|
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To assess whether knowledge/awareness about COVID-19 is related to clinically significant anxiety/depressive symptoms, an independent t-test for comparing the means scores was performed, which showed a significant difference of knowledge (about COVID-19) between the groups with and without clinically significant depressive symptoms [Table 3].
|Table 3: Independent sample t-test for equality of means for the groups with clinically significant anxiety and depressive symptoms|
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Reasons for the distress were explored during current times of the pandemic and participants were asked to rate that distress on a scale of 1–4 (1 = none, 2 = minimal, 3 = excessive, 4 = unbearable) [Figure 1]. More distressing responses of “3” (excessive) and “4” (unbearable) were taken into account and summated. A huge number of people expressed distress secondary to information overload on social media (N = 662), fear of getting infected with coronavirus (N = 660), and fear of not getting adequate treatment (if and when required) (N = 637), as compared to worry about prices and supply of essential goods and being lonely (N = 499 and 413, respectively).
| Discussion|| |
The coronavirus pandemic, a public health emergency of international concern, has brought about unexpected variations in every domain of our life and has added a sense of uncertainty as well. Rapidly changing guidelines, nationwide lockdown, financial and job losses, inability to meet our loved ones, and moreover insecurity for life itself are certain factors that are very likely to have adverse effects on mental well-being. This study was planned to assess the impact of current situation on mental health of people.
The study involved 1027 participants. The mean COVID-19 knowledge score was 9.56, suggesting an overall 79.67% correct rate on the knowledge questions. This indicates that a high number of people had fair understanding related to coronavirus (routes of disease transmission, symptoms, and preventive measures, etc.), which might be due to the fact that surge of cases in India started later than in many other countries and there were constant information updates on various news sources. In addition, the government of India started various awareness campaigns, starting from the grassroot level, which helped in spreading the cognizance about the disease.
On GADS assessment, it was found that clinically significant anxiety and depressive symptoms were present in 17.9% and 40.7%, respectively. Roy et al. found in an online survey that more than 80% of the participants were preoccupied with COVID-19 pandemic and around 72% reported of being worried about themselves and their close ones. Jungman and Witthöft reported that about half of the respondents had moderate-to-severe anxiety associated with severe acute respiratory syndrome coronavirus 2, which is in accordance with earlier studies on pandemics/epidemics.,, Another study from India showed a significant psychological impact on approximately one-third of the participants.
In our study, anxiety symptoms significantly differed with gender, age group, marital status, and occupation. The subgroups of females, age group 16–29 years, those who are single, and students had higher clinically significant anxiety symptoms. Higher depressive symptoms were found in 16–29 years of age group, single, and those having education below Class X.
Other researchers have also found that women suffered from higher virus-related anxiety than men, which is consistent with our study and the higher prevalence of anxiety disorders in women in general.,, They also found higher corona-related anxiety symptoms in middle-aged people (30–59 years), probably because this group is generally the main caretakers or breadwinner in the family. However, we found 16–29 age group more affected by both depressive and anxiety symptoms, which is also noted by another Indian study as well. Results also reveal that those having education of tenth standard or less had more symptoms as compared to those having higher education, which might be due to better awareness of more educated people about the virus that it can be averted with adequate preventive measures and probably had better access and understanding of authentic data. Students in our study were found more affected, which is also in accordance with Wang et al. Wang and Zhao assessed the impact of anxiety of COVID-19 in university students and found it to be higher than the general population; some of the main concerns of those students were about how the examinations would be conducted, when would the new term start, adjusting with online teaching, etc., which is very well applicable at nearly every place/country, and probably is the reason for similar results in our study.
The difference in knowledge score was significant between those with and without clinically significant depressive symptoms. People with significant depressive symptoms had lower knowledge score. This suggests that better awareness reduces distress as mentioned earlier.
On exploring reasons for distress during the pandemic, information overload, fear of getting infected with coronavirus, and fear of not getting adequate treatment were the main concerns. Due to improved access to Internet and smartphones, both the quality/authenticity and amount of information could not be controlled initially. However, later on with implementation of Epidemic Disease Act, India, people became more responsible in forwarding the information. Apart from this, due to huge population and population density of the country, the likelihood of contracting infection is definitely high, and considering the inadequate health services (with respect to the population) and lack of government health insurance, getting treatment and affording the treatment of such an illness (if becomes severe) can take a toll on an individual.
The strength of this study is participation from community and inclusion of people from varied demographic profiles. Second, the questionnaire used here was in two widely prevalent languages (English and Hindi). However, there were certain limitations. The study participants were predominantly males and those residing in urban areas. This could be due to use of online tools, which could not have penetrated rural areas due to lesser access to Internet and smartphones.
| Conclusion|| |
COVID-19 has led to a parallel surge of various mental health issues. This study has highlighted such aspects and identified the vulnerable groups. The findings can be of significance while policy formation for tackling the mental health issues for the future waves of this virus or any similar infectious disease outbreaks. Clinicians can be sensitized and vulnerable people could be screened for mental health issues. Prospective studies, studies done in person, and including those who were under-represented would yield more generalizable results.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]