key: cord-0828752-37rk1jxp
authors: Khan, Md. Abdullah Saeed; Debnath, Sourav; Islam, Md. Shahnoor; Zaman, Susmita; Ambia, Noor-E; Barshan, Anindita Das; Hossain, Mohammad Sorowar; Tabassum, Tamanna; Rahman, Monjur; Hasan, Mohammad Jahid
title: Mental health of young people amidst COVID-19 pandemic in Bangladesh
date: 2021-05-28
journal: Heliyon
DOI: 10.1016/j.heliyon.2021.e07173
sha: 6f1f3d01eb8b578bd607223854722452b2474df0
doc_id: 828752
cord_uid: 37rk1jxp

BACKGROUND: The psychological burden of the coronavirus disease 2019 (COVID-19) outbreak and lockdown strategy among young people not diagnosed with COVID-19 in the general population remains unknown and often have been overlooked. The objective of the study was to assess the prevalence and predictors of anxiety, depression and stress among young people diagnosed with COVID-19 of Bangladesh amidst the pandemic. METHODS: A cross-sectional online survey was conducted from 1 May to 30 May 2020 using an online Google form-based questionnaire posted on Facebook. A snowball sampling approach was used for data collection. A total of 974 self-declared healthy individuals not diagnosed with COVID-19 participated here. Anxiety, depression and stress were measured using Bangla validated Generalized Anxiety Disorder Scale-7 (GAD-7), Patient Health Questionnaire (PHQ-9) scale, and Perceived Stress Scale (PSS), respectively. Statistical software SPSS 20 was used for analysis. RESULT: Average age of the population was 25.86±6.26 (SD) years with nearly half (48.6%) of them being young people (15 to ≤24 years). Most of the participants were male (76.3%). The overall prevalence of anxiety, depression and stress was found to be 64.1%, 73.3% and 69.4%, respectively. Young people had significantly higher proportion of anxiety (67.2% vs 61.1%), and depression (78.2% vs 68.7%) compared to adults (p=0.045 and p<0.001, respectively). However, most of the participants had mild depression (30.3%), minimal anxiety (31.4%), and moderate stress (67.5%) and severity of depression and anxiety being higher in the young participants. The mean GAD-7, PHQ-9 and PSS scores were 7.57±5.61, 9.19±6.15 and 16.02±5.55 (SD), respectively. On multivariable logistic analysis, unemployment (Adjusted Odds Ratio [AOR] 3.642; Confidence Interval [CI]: 1.005-13.200; p<0.05) was the single most important predictor of depression. For stress, unemployment (AOR 1.399; CI: 1.055-1.855), and female sex (AOR 1.638; CI: 1.158-2.317) were significant predictors. CONCLUSION: Anxiety, depression and stress were highly prevalent among young people (≤24 years) not diagnosed with COVID-19 in Bangladesh amidst the pandemic. Unemployment is the most common underlying determinant. Authorities should address the issue on a priority basis.

Coronavirus disease-2019 (COVID-19) originated in Wuhan city, China, in December 2019 (1) and spread quickly to other countries. (2) . The World Health Organization (WHO) declared COVID-19 a public health emergency of international concern (PHEIC) on 30th January 2020 and announced it as a pandemic on 11 th March (2, 3) . By this time, the health sector of almost all countries activated themselves with their highest level of capacity. Governments launched existing and innovative strategies to combat COVID-19. Public health authorities prioritized preventive strategies to limit the spread of the disease (4) . As COVID-19 had already been marked as a highly contagious disease, mostly spread via respiratory droplets, by direct contact with infected persons, or by contact with contaminated objects and surfaces, social distancing became the mainstay of prevention (5) . Social distancing is a very new term for a certain population, and there is no easy way to make people accustomed to it in a short period of time.

Thus, the lockdown system was adopted by many countries of the world (6) , where people were confined within a defined area, and more strictly, people were not allowed to go outside.

Although the process of lockdown is beneficial in terms of infection reduction, it has severely affected the economy from the individual to global levels (7, 8) . People from all levels of status were affected either by the disease or due to its socioeconomic consequences (9) .

COVID-19 has become a concern in developing countries such as Bangladesh, which is densely populated with a struggling health care system. People were afraid because of inadequate protective and management capacity. Additionally, they were experiencing economic loss due to drastic lockdown measures (10) . Moreover, evidence suggests that individuals who are kept in isolation and quarantine experience significant distress in the form of anxiety, anger, confusion and posttraumatic stress symptoms (11) . Anxiety and concerns in society globally affect every J o u r n a l P r e -p r o o f individual in various aspects. Nonetheless, uninfected individuals are expected to have a mild impact compared to infected individuals. However, the 'infodemic' caused by electronic and social media in the form of rumors and misinformation might have made reactions worse among the former group (12) .

Mental health is often an ignored issue in countries such as Bangladesh (13) . Earlier studies carried out among the adult population of Bangladesh suggested a high prevalence of symptoms of anxiety, depression and stress as well as the considerable presence of suicidal ideation among a certain population (14, 15) . The initial progression of events indicated that people, particularly who were young, considered the lockdown steps lightly (16) . This indicates a difference in reactions of uninfected persons to the pandemic than those who were infected. To date, very few studies have exclusively addressed the mental health of persons who were not diagnosed with COVID-19. Considering the relevance of all the above factors, the objective of the study was to assess the prevalence and predictors of anxiety, depression and stress among the adults not diagnosed with COVID-19 in Bangladesh amidst the pandemic.

Study period, design and study subjects: The study was conducted from 1st May to 30th May 2020. As the number of cases was increasing in March, the Government of the People's Republic of Bangladesh adopted country-wide lockdown as a public health measure to mitigate the transmission of the disease (17) . Hence, health center-based or community-based surveys were not practicable to perform, and face-to-face interviews were not feasible as well. Therefore, we conducted a Facebook-based online survey among the general population not diagnosed with COVID-19 living in Bangladesh. People aged more than and equal to 15 years, not infected by COVID-19, and having no diagnosed psychiatric illness with or without treatment using J o u r n a l P r e -p r o o f Facebook with minimum proficiency to Bangla to answer the questions of the current study online were primarily targeted. A Google form was created and circulated on Facebook (mostly used social media in Bangladesh). Online informed written consent was obtained from all the participants before they answered the questions.

Sampling technique and study sample: The actual prevalence of anxiety, depression or stress disorder in the general population has not yet been estimated. Therefore, considering a 50% prevalence with a 95% CI and agreeing 5% error, the total sample size was estimated to be 384.

In this survey, a total of 1038 responses were received, and among them, 1031 agreed to participate and completed the questionnaire. Among them 57 responses were also excluded due to incomplete information. Excluding all, a total of 974 responses were considered for final analysis. (20) . We used the validated Bengali versions of the questionnaires (21) (22) (23) . All these scales showed acceptable reliability among our participants (Cronbach's Alpha was 0.858, 0.794 and 0.630 respectively for GAD-7, PHQ-9 and PSS scales, respectively)

The severity of anxiety was measured by the generalized anxiety disorder-7 (GAD-7). The response options were as follows: 0 = "not at all", 1 = "several days", 2 = "more than half the days", and 3 = "nearly every day" for two weeks. The total score ranged from 0 to 21, with a higher score indicating severe anxiety disorder. For the GAD-7, a total score of 0-4 indicates minimal anxiety, 5-9 indicates mild anxiety, 10-14 indicates moderate anxiety and [15] [16] [17] [18] [19] [20] [21] [22] indicates severe anxiety.

Depression was measured using the PHQ-9 based on the diagnostic criteria for depression from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). This is an independent structured mental health professional (MHP) interview including 9 depression modules from the full PHQ. The response options were as follows: GAD-7, 0 = "not at all", 1 = "several days", 2 = "more than half the days" and 3 = "nearly every day". A two-week recall period was used. The total score ranged from 0 to 27, where depression severity was characterized as 'none' if the score was 0-4, mild if 5-9, moderate if 10-14, moderately severe if [15] [16] [17] [18] [19] and severe in cases 20-27.

The Perceived Stress Scale (PSS) is a 14-tool containing structured measure designed to determine "the degree to which situations in one's life are appraised as stressful." Here, 0never,1 -almost never, 2sometimes, 3 -fairly often, 4 -very often where two-week recall period was used. Individual scores on the PSS can range from 0 to 40. Higher scores indicating higher perceived stress. Scores ranging from 0 to 13 are considered low stress. The moderate stress ranges from 14-26, and 27-40 is considered high.

For predictor outcome relationship assessment outcome were defined as follows. Anxiety was considered present when the score in GAD-7 scale was ≥5 (mild to severe anxiety). Depression was considered present when the score in PHQ-9 scale was ≥5 (mild to severe depression).

Finally, stress was considered present when the score in PSS scale was ≥ 14 (moderate to high stress). A score below these cut-off points were deemed as absence of the corresponding mental health problem.

Demographic variables recorded at baseline were considered candidates for predictors of outcome. The variables included were age, sex, residence, education, occupation, employment status (if employed), business status (if doing business), being health care worker or not, and monthly income. Table 1 .

The overall prevalence rates of anxiety, depression and stress were 4.1%, 73.3% and 69.4% respectively (Figure 1) . Young adults had significantly higher proportion of anxiety (67.2% vs 61.1%), and depression (78.2% vs 68.7%) than adults (p=0.045 and p<0.001, respectively).

However, prevalence of stress (70.8% vs 68.1%) was statistically similar between those groups (p=0.350) ( Table 2) . Female participants had significantly higher proportion of anxiety (76.6% vs 60.2%), depression (82.7% vs 70.4%) and stress (66.9% vs 77.5%) than male (p<0.001, p<0.001 and p=0.002, respectively). Depression was significantly more common in single participants than married ones (76.4% vs 66.0%, p=0.001). Unemployed participants had significantly higher proportion of depression and stress than others (p=0.001 and p=0.034, respectively). Those who lost job during lockdown were significantly more likely to have anxiety and depression than others (p=0.043 and p=0.008, respectively). No impact of information source on anxiety, depression and stress was noted. See table 2 for details.

Most of the participants had mild depression (n=295, 30.3%), minimal anxiety (n=350, 31.4%), and moderate stress (n=657, 67.5%). However, severity of depression and anxiety was significantly higher among young people than adults (p<0.001, and p=0.015 respectively).

Severity of stress was statistically similar across age groups (p=0.623) ( Table 3 ).

In the univariable logistic regression analysis, age ≤24 years, female sex and unemployment were associated with anxiety ( 

The COVID-19 pandemic has provoked a worldwide emergency and havocked the day-to-day lives of the general population. Countries around the world are going through a challenging situation as the number of infected patients is increasing daily. Like so, the government of Bangladesh implemented countrywide lockdowns at the initial stage of the pandemic to prevent any further spread of the virus. However, the fear of contracting the virus on the one hand and an apprehension of economic uncertainty on the other riddled with 'infodemic' from social media led to a mixed range of psychological and emotional reactions among the general population. Therefore, we aimed to assess the prevalence and predictors of anxiety, depression and stress among the adults not diagnosed with COVID-19 in Bangladesh amidst the pandemic In our study most of the participants were aged ≤24 years with minimum age being 16 years.

According to United Nations secretariate people with an age 15 -24 years are considered youth or young people (24) . Therefore, we focused on the mental health status of young in the middle of COVID-19 pandemic with a comparison to adults who were predominantly at their early middle age.

We found that 64.1% of the participants had anxiety (mild to severe), 73.3% had depression (mild to severe) and 69.4% had stress (moderate to high). Our findings are higher than those found by These seem to indicate an adaptation of people with the novel situation over time. However, the differences among these studies might be due to differences in instruments used and participants selected.

We also noted that the youth were significantly more affected by anxiety and depression than adults which is the supported by the findings of Banna et al (15) who reported the prevalence of anxiety and depression was high among those aged ≤23 years compared older participants.

Interestingly a study conducted among job-seeking young graduates (mean age 24.12 ±1.55 years) of Bangladesh in 2018 (26) found that 53.2%, 49.6% and 26.4% of them had anxiety, depression and stress, respectively. While we found 67.2%, 78.2% and 70.8% of our youth participants (≤24 years) had anxiety, depression and stress, respectively. This clearly indicates an increase in the mental health problems during the COVID-19 pandemic associated lockdowns which might have been precipitated by the uncertainty of earning amidst an environment where people were already loosing jobs and business.

Our study was conducted only among individuals not diagnosed with COVID-19. In comparison, the first report on COVID-19 patients by Hasan et al (27) found anxiety and depression among J o u r n a l P r e -p r o o f 60% and 52.9% of participants, respectively. This is similar to that of people without COVID-19 infection found in our study and indicates a comparable impact of the pandemic in people irrespective of their infection status. Social and electronic media exposure might have been an important contributor to perceived anxiety, as evidenced by Hossain and colleagues (28) . Our finding that more than half of the participants searched and/or found their information regarding COVID-19 from social media endorses this assumption. However, the overall proportion of people suffering from anxiety, depression, and stress symptoms in our country seems to be higher than that found in developed countries (29) .

In the past, during other outbreaks, such as 'Ebola' or 'SARS', individuals and communities at the national and international levels had a wide spectrum of psychosocial consequences due to the sudden outbreak of the disease. It is likely that people were afraid of falling sick, being helpless, hopeless and stigmatized and even dying. Constant support of mental and psychosocial wellbeing in different groups during the pandemic should be the highest priority in such situations (30, 31) . The provision of government support for the general population to the highest extent during the lockdown lessened the mental health consequences in developed countries.

Demographic variables showed that anxiety, depression and stress were more prevalent in young people. On univariate analysis, depression was found to be significantly more common among people youth aged ≤ 24 years (OR 1.639; CI: 1.228-2.188), female sex (OR 2.009; CI: 1.380-2.924), and unemployed (OR 2.121, CI: 1.587-2.835). One study conducted among youth in the Middle East (32) found that being female, being in quarantine for two weeks, and increased use of the internet were important determinants of stress, anxiety and depression. The reason might as well fit in our youths.

Similar to the Chinese community (30), we found that females had a greater psychological impact J o u r n a l P r e -p r o o f on the COVID-19 outbreak than their male counterparts. Similarly, Hamadani et al (33) found that COVID-19 lockdowns caused significant economic, psychosocial, and physical risks to the wellbeing of women in Bangladesh. Women, in general, are at a higher risk for psychological events and report more severe symptoms of depression, anxiety, and distress (34) . Social, cultural and existing gender norms tend to make women relatively more vulnerable than men to mental health disorders.

Unemployed participants were significantly more likely to be anxious, depressed, and stressed than employed participants, and unemployment was the single most important factor for depression, and stress in the current study. We found that a considerable percentage of people lost their jobs (6.1%) and lost investments (0.9%) during this pandemic. Hamadani and colleagues (31) noted a sizable reduction in median family income in rural areas. All of these results indicate that people, particularly those who were not infected by COVID-19, were influenced in a negative way by the socioeconomic consequences of the lockdown.

The major limitation of the study was that it represented a relatively young population using Facebook, thus making the results non-generalizable to the adult population of the country. Randomization of participants was not possible either.

We found a high proportion of anxiety, depression and stress symptoms among the young people not diagnosed with COVID-19 infection during the pandemic associated lockdown in Bangladesh. Unemployment was one of the single most notable predictors for depression and J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f Anxiety was defined as having a GAD-7 scale score ≥5 (mild to severe anxiety). Depression was defined as having a PHQ-9 scale score ≥5 (mild to severe depression). Stress was defined as having a PSS scale score ≥14 (moderate to high stress). A score below these cut-off points were considered negative for 

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