key: cord-0944048-ls6z0zr9
authors: Ahmed, Faria; Sifat, Ridwan Islam
title: Strategic assessment of mental health and suicide amid COVID‐19 pandemic in Bangladesh
date: 2021-02-04
journal: Int J Health Plann Manage
DOI: 10.1002/hpm.3121
sha: 87078f019a5564586848052b8525fecf0ce55f40
doc_id: 944048
cord_uid: ls6z0zr9

The purpose of this study is to explore how the coronavirus disease 2019 pandemic has affected the mental health of our society in Bangladesh as a thorough assessment of mental health is salient during this pandemic crisis. The study seeks to ensure that their unheard voices are reached to both national and international academic discourse, which has so far been uninhabited. It adopted qualitative interpretative methods of social research through content analysis. The study found that the pandemic did not affect all groups of society uniformly, rather the intensity of its impact varied depending on factors such as economic status and family institutions. The lower socioeconomic class is the worst affected as the pandemic made them unemployed, leading them to an uncertain future. Despite such variations, the general population has experienced a subsequent increase in workload, and challenges in using routine health facilities that increased behavioural changes, higher levels of stress, anxiety, depression and suicides.

concerned public health emergency. 3 As a means of combating the pandemic, the lockdown following the unexpected outbreak of COVID-19 has turned people from being social to isolated human beings. 2 The consequences of the pandemic have already killed 1.5 million people worldwide, and new cases of infected individuals continue to increase. 4 It has been estimated that 300 million world's population is struggling with mental health problems while managing the challenges of daily life. 2 Unfortunately, the direct and indirect vulnerability of people to threats can increase the risk of a mental health crisis. 5 

The study adopted qualitative and interpretive methods, including content analysis. Interpretive explanations were looked for from content analysis focussing on language, signs and meanings from the point of view of the media imaging of the social phenomenon through identifying patterns of recorded communication. To triangulate the interpretative approach, we pursued data verification and reliability through confirming similar findings in a comparable context in a wide range of texts, including books, newspapers, web content and social media. In the interpretative method, subjective perspective is taken, and for this research, media imaging is the subjective perspective. Lastly, we analysed through the 'sense-making' approach.

From the National Mental Health Survey 2018-19, we find that almost 17% of adults in Bangladesh suffer from mental health problems, with 16.8% men and 17% women. Of these, 92.3% do not seek medical attention. 6 The National Institute of Mental Health, with a technical guide from the WHO, revealed the findings of the National Mental Health Survey, Bangladesh 2018-19. Survey shows that 6.7% have a depressive disorder, 4.5% anxiety, 2.1% somatic symptoms and related disorders, while 0.9% have a sleepwalking disorder. Moreover, 14% of children aged 7-17 years suffer from mental health problems. 6 

Everyday life has been halted as the COVID-19 pandemic unfolded around the world. Lockdowns, travel bans, school closures, job disruptions and social distancing have created a previously unprecedented level of social isolation across the globe. 7 Fears of lack of savings, money and food shortages have been a stimulus to anxiety and stress. 8 When Bangladesh entered the critical 'community transmission stage', an epidemic of rumour, fear and hatred in the country also exploded, side by side. Not only in Bangladesh, but COVID-19 positive patients around the world have experienced social stigma-intolerance, revulsion and denial of treatment, which has led to deterioration of the mental health status of individuals. 9 A survey found that, during the COVID-19 pandemic, 72.6% of Bangladeshis suffer from insomnia. 10 Furthermore, the new reality of social isolation and other security measures puts everyone to the test, and people with mental illness may face even more difficulties this time. It is common for individuals to feel stressed and worried about a pandemic. Typical responses of affected people include quarantine, fear of ill and dying, loss of livelihood, separation from loved ones and caregivers. 11 Another survey was conducted that shows the relation of COVID-19 pandemic amassing mental health problems. The study had a sample of 340 Bangladeshi adult population of which 65.90% were male with mean age 26.23 among them 85.60% of participants are affected by COVID-19-related stress, resulting in sleep shortness, 2 -AHMED AND SIFAT short temper, family chaos and even becoming suicidal idolators. 12 Fear of infection, barriers to formal education and future careers and financial difficulties are identified as the main causes of stress. 12 Moreover, quarantine and lockdown aggravate pre-existing mental health problems. 13 Millions of people face financial problems, loss, or risk of losing their income and livelihoods. Misinformation and frequent rumours about the epidemic and deep uncertainty make people anxious and hopeless about the future. It was expected that a record of 3.3 million people would only lose their jobs in the United States during and after this pandemic. 14 The situation in a lower-middle-income country like Bangladesh is worse than in high-income countries. Psychological issues relating to economic insecurity are also a direct consequence of people being locked down. Due to the multifaceted effects of the pandemic, many people are losing work or facing a crisis in their employment and family lives. 15 When educational institutions are closed, many students are becoming addicted to technology, such as online gaming on smartphones, which interrupts their everyday activities. Most of these problems cause depression and anxiety in people that harm mental health issues. Chronic or insomnia problems will make the body more vulnerable to life-threatening COVID-19 disease. 16 The urban cultural, economic and socially disadvantaged populations in Dhaka have found a prominent level of anxiety, panic and fear due to COVID-19. One of the most disadvantaged groups, millions of 'urban poor' live in squalid slums centred in Dhaka. The urban poor in Bangladesh is mostly slum dwellers who work daily, including rickshaw pullers, bus drivers and garment factory workers, with an average income of about 250 Taka a day. In a similar case reported on 16 April, a 30-year-old auto-rickshaw driver committed suicide because he was unable to provide food for his family during the lockdown due to loss of income. 8 Reading more negative news during quarantine creates a negative effect on people. Mental pressure increases health risk and triggers various illnesses and long-term psychological complications. 17 A group of mental health professionals from Lancet Psychiatry recently indicated that anxiety and stress are still impacting people. A study of more than 2198 online participants revealed increased social isolation as a significant adverse effect of COVID-19 among respondents, increasing feelings of loneliness closely correlated with fear, self-harm, depression and suicide. 18 A study was conducted by using online social media with a total of 10,660 participants during the time of lockdown in Bangladesh. The study showed that about 91% of respondents were worried about this pandemic situation. A total of 72% of respondents had insomnia, 61.7% were upset and angry at the pandemic situation and 83.5% expressed frustration and anxiety about the future. On an average 68.2% said they were overall terrified of the epidemic, and almost 59.4% said life becomes meaningless to them. 10 Another cross-sectional web-based survey among 1427 participants included in this survey. The research found that 59.7% suffered from stress symptoms, but mild (28.0%) and moderate (22.0%) symptoms were more common. One-third (33.7%) of the participants reported symptoms of anxiety. Among them, 11.6% showed moderate anxiety symptoms and 11.6% had extreme anxiety symptoms. More than half of respondents (57.9%) suffered depressive symptoms, including mild (14.5%), moderate (21.2%) and severe (13.2%) levels. 19 In male adults, lack of regular socialisation and personal interaction, work from home and social distance makes them more vulnerable and depressed. Future uncertainties regarding COVID-19 are beginning to cause symptoms of depression and reduced quality of life. Females usually work as caregivers in Bangladesh and may suffer mental, physical and socioeconomic harm because of significant crises of the COVID-19 situation. They suffer from depression and anxiety disorders, and lack of supportive relationships with family, friends and well-wishers affects mental health and ultimately to physical health as well. 5 Students who are used to going to school, college, university and mingling with peers every day may be a massive victim of mental health issues as they are confined to their homes. For the first time in the history of the country, the results have only been published online, not physically in the institutions. The New Age youth story on April 19 showed how tertiary students entered a new education system amid the pandemic, which was to attend online classes and exams during the crisis. But in Bangladesh Internet availability is scarce in remote areas and students have moved to their hometowns and villages after the declaration of nationwide lockdown from 15 March AHMED AND SIFAT -3 2020. 20 A study found that about 43% of the students are mentally stressed, anxious and unable to attend the online class format. This new education created an added frustration among the students. The authorities need to set out a consistent set of guidelines on online classes and assessments to reduce uncertainty and related anxiety. 16 As mental pressure may lead to various illnesses, health experts have recommended the implementation of tele-counselling services during this pandemic. 17 These included redressing systemic underinvestment in psychiatric care, delivering 'emergency mental health' by online support, such as tele-counselling for frontline health staff, and engaging proactively with people reported having depression and anxiety, including others at substantial risk of domestic abuse as well as extreme poverty.

Economic and social impacts have given rise to many psychological consequences for individuals and in serious cases, these consequences have led to suicidal behaviour among individuals. The highest number of suicides occurred in June 2020 and males were more likely than females to commit suicide for reasons related to pandemic. 21 Although males are more likely to commit suicide, females are thought to have more suicidal behaviour, is argued 22 as the negative consequences of lockdown that make males stay at home direct more anger and frustration on their female counterparts that weakens the psychological status of females. Furthermore, the study reports that having no or broken marital status is highly associated with suicidality as married people have less suicidal tendencies than divorced and single people. 22 On contrary, a study found a total of 37 suicide cases of whom 65% were male and married were found. A total of 73% of the suicides were attempted by hanging themselves. 21 Suicidal thoughts occur due to the excessive loneliness and social distancing in the lockdown. Social distancing is coped with technology dependency that creates excessive technological addiction which directly or indirectly threatens people to suffer from psychological problems. Aggregate fear of contagion, loneliness, anxiety, phobia, economic crisis, fear of not being treated properly during an emergency is contributing factor for 90% of suicide occurred due to mental disorders and traumatic suffering. 22 During the COVID-19 pandemic, 32 confirmed cases of COVID-19 suicide was reported for mental stress and depression in the study of which 21 were male and 11 were female. Just under half of the suicides were economically related due to lockdown unemployment. A total of 45.9% of suicides were committed due to loss of jobs amid COVID-19 lockdown as they were day-earners and were unable to go to work. 21 

Positive mental well-being or mental health has recently appeared as a significant indicator of overall health and longevity. There is no doubt that mental health services will be a key element of response to and recovery from the pandemic situation of COVID-19. 24 The government has formulated guidelines for mental health based on directives from the WHO and recommended that local government officials be gentle on COVID-19 safety measures. Several organisations and youth-led projects, such as the Bangladesh Red Crescent Society, have launched a hotline to help people suffering from mental distress. 25 In this situation, policy makers, leaders, politicians, experts and individuals need to take steps to win the fight against mental health disruption. Motivating health providers and other front-line staff to develop mental health-friendly strategies for people living in poverty, ensuring nutrition, job stability and healthy Internet use should be given priority in the fight against mental health disruption. It is essential to put in place a time-based policy that can help manage the pandemic situation and support public mental health through careful monitoring. Moreover, honest, transparent communication is vital in eliminating the risk of confusing or contradictory health messages. 23 Healthy use of the Internet can be ensured by eradicating misinformation from social media and electronic media. In addition,

AHMED AND SIFAT special emphasis should be placed on crop protection, food insecurity risk reduction, relief and rehabilitation in vulnerable areas to achieve healthy nutrition, minimise anxiety of food security and combat disease by strengthening the immune system. In addition, strong family institutions with emotional combined with mental support, and a sense of belongingness should be given when a patient is in isolation. Moreover, to restrict the disease spread the families have to act responsibly by taking care of the waste disposal through the national and international guidelines for the disposal of infectious biological hazardous materials for extermination of spread and allowing normal life. It is imperative that the government address people's fears and anxieties with outmost concern and integrate it in their policy making. Even mental health awareness needs potential system adaptations, and outcome measures that can help to turn the crisis into a room for improvement and concerns for the future. 13 Awareness of mental well-being, self-care, strong family institutions and peer support should be part of mental health protection strategies, which should involve multi-agency collaboration with government, general population, media and civil society agencies.

Bangladesh's psychological reactions to the COVID-19 pandemic are spreading to the population with fear, anxiety, sleep disturbances, depression and suicidal thoughts. There is a need for widespread education campaigns across the country, both to increase knowledge and belief about mental illness and to create change about mental health and to reduce discrimination against people who have a mental illness. Besides, there are some on-line counselling facilities and initiatives by the government and other nongovernmental organisations to help citizens cope with the difficulties caused by the outbreak of COVID-19. Therefore, we must recognise the seriousness of this issue and develop a strategy and initiative-taking policies at the national and local levels.

None.

Impact of the COVID-19 pandemic on domestic violence in Bangladesh

COVID-19 pandemic: mental stress, depression, anxiety among the university students in Bangladesh

World Health Organization. Mental health and psychosocial considerations during the COVID-19 outbreak

COVID-19 coronavirus pandemic: deaths

Psychological well-being: a challenge in Covid-19 regime. The Financial Express

19: provisional fact sheet

Mental health crisis due to Covid-19 pandemic

The impact of the COVID-19 pandemic on the mental health of the rickshaw-puller in Bangladesh

Fear, hatred and stigmatization grip Bangladesh amid Covid-19 outbreak. The Business Standard

Lockdown policy dilemma: COVID-19 pandemic versus economy and mental health

Mental health and psychosocial support (MHPSS) in COVID-19 outbreak

Exploring COVID-19 stress and its factors in Bangladesh: a perceptionbased study

How mental health care should change as a consequence of the COVID-19 pandemic

The global macroeconomic impacts of COVID-19: seven scenarios. CAMA Working Paper

Coronavirus and insomnia: how to sleep well during COVID19 pandemic. United News of Bangladesh

Preparedness of online classes in developing countries amid COVID-19 outbreak: a perspective from Bangladesh

Mental health during coronavirus: experts for avoiding overuse of gadgets. United News of Bangladesh

Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science

The impact of the COVID-19 pandemic on the mental health of the adult population in Bangladesh: a nationwide cross-sectional study

COVID-19 and mental health around the world. New Age

The demography and apparent risk factors of COVID-19-related suicides in bangladesh in a seven-month period of the pandemic. medRxiv

COVID-19 suicidal behavior among couples and suicide pacts: case study evidence from press reports

Psychosocial and socio-economic crisis in Bangladesh due to COVID-19 pandemic: a perception-based assessment. Front Public Health

Substantial investment needed to avert mental health crisis

Pandemic takes toll on mental health in Bangladesh

Strategic assessment of mental health and suicide amid COVID-19 pandemic in Bangladesh

The authors have no conflict of interests associated with this publication.

The authors declare that they comply with the principles of ethics in research.

Data sharing is not applicable to this article.

https://orcid.org/0000-0003-0278-1990Ridwan Islam Sifat https://orcid.org/0000-0001-9897-0870