key: cord-1028658-8m1gh2bz
authors: Chaudhary, A. P.; Sonar, N. S.; Banerjee, M.; TR, J.; Yadav, S.
title: Impact on Mental Health of students due to restriction caused by COVID-19 pandemic: Cross-sectional study
date: 2021-02-09
journal: nan
DOI: 10.1101/2021.02.07.21250695
sha: 145955c6b4798934dadfafea9a1426baa308d97d
doc_id: 1028658
cord_uid: 8m1gh2bz

Abstract Background: The goal of the study was to investigate fear, depression and anxiety symptoms among students of India due to COVID-19 pandemic and its restriction. Method: The cross-sectional web-based research was conducted between mid-November and mid-December 2020 with the objective of understanding the psychological and behavioral consequences of the COVID-19 pandemic effect on students due to the constraint of forced control. The study included a) socio-demographic questions such as age, gender, degree enrolled and any member of the family infected with COVID-19, b) psychometric scales evaluating the psychological and behavioral impact caused by COVID-19 pandemic restrictions such as fear of the COVID-19 scale (FCV-19S), depression by the Brief Patient Health Questionnaire (PHQ-9) depression scale, and anxiety by the Generalized Anxiety Disorder scale (GAD-7). Results: Total number of 324 students participated in this study in which 44.4% were male and 55.6% were female. Fear of COVID-19 scale showed 68.8% student had high fear among students, 24.4% had moderate to severe depression and 51.5% had moderate to severe anxiety. The correlation between fear of COVID-19 scale (FCV-19s) and Generalized Anxiety scale (GAD-7) was found to be 0.474 and 0.492 was found between fear of COVID-19 (FCV-19s) scale and brief patient health questionnaire (PHQ-9) Conclusion: This research concludes that there is a very strong fear of COVID-19 among students, along with anxiety and depression. This study also concludes that the fear of the COVID-19 scale and the GAD-7 and PHQ-9 scales have a strong positive correlation.

difficulties, annoyance and discomfort, loss of resources and ineffective coordination (Davide et al. 2020) .

However, intensive fear may lead to decreased responsiveness and diminished mental well-being. Fear of getting the disease could prompt eruptions, similar to overprotection or rivalry with measurements mavericks or stigmatization of patients (Tsipropoulou et al. 2020) .

Scientific reviews and analyses concentrate on identifying the various effects of COVID-19 not only on physical wellbeing, but also on mental wellbeing. Individuals even point out that the most vulnerable parts of the population can be estimated to have more or less anticipated effects on mental and physical health. The primary purpose of this research was therefore to examine students' psychological responses, i.e. fear of COVID-19, anxiety and depression during the COVID-19 pandemic in India, and to also clarify causes of something which amplify the magnitude of COVID-19's psychological effect. The second goal was to examine three possible causes linked to COVID-19 for enhanced levels of fear (personal experience with COVID-19;

Age, Gender, Degree enrolled. Mallige College of Pharmacy students responded the questions and completed the scales in the following order: socio-demographic data, Fear of COVID-19 scale , The Brief Patient health Questionnaire depression scale (PHQ-9) and

Generalized Anxiety Disorder-7 scale (GAD-7).

The cross-sectional web based study was carried out between mid-November to mid-December 2020 with the objective of understanding the psychological and behavioral impact caused on students due to restriction forced (physical distancing, use of face mask, online study, avoid gathering and going to public places, etc.) to control the COVID-19 pandemic effect. The survey questions and scale were selected on the basis of the available literature, author's experience, and professor and clinician experience about the pandemic.

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For this study, students of Mallige college of Pharmacy in Bangalore is selected with the access to internet and physical media.

The study included a) socio-demographic questions like Age, Gender, Degree Enrolled and Any of family members got infected with COVID-19, b) psychometric scales assessing the psychological and behavioral impact caused due to COVID-19 restrictions like fear, depression and anxiety.

: a self-report, unidimensional, reliable and valid scale developed recently to understand the fear of COVID-19 caused due to this pandemic. This scale consists of seven items which tries to explain the fear of COVID-19. The responses are recorded in 5 Likert scale ranging from 1 to 5 points (Strongly Agree =5, Agree=4, Neutral=3, Disagree=2, Strongly Disagree=1). The total Score ranges from 7 to 35. The higher the score is, the greater is the fear of COVID-19 among participants. The initial development of the scale has shown strong reliability of Cronbach alpha of 0.88 among the Iranian population (Kwasi Ahorsu et al. 2020) . The Greek version of COVID-19 scale, have shown significant concurrent validity with GAD-7 scale (r=0.71, P-value <0.001) and moderate correlation with PHQ-9 Scale (r=0.47, P-value < 0.001). The cut off score for this score is 19, the participant having score of 19 or more is considered to have high fear of COVID-19 and participant having score less than 19 is considered to have low fear of COVID-19 (Tsipropoulou et al. 2020; Parlapani et al. 2020 ).

: is self-report, 9 item scale which is used to diagnose the major depression and subthreshold depression. The total score ranges from 0-27 which helps in interpretation of severity of depression. The responses of the participant are recorded in 4 points Likert Scale (not at all=0, several days=1, more than half the days=2, nearly every day=3). The cutoff score of 10 and above signifies moderate to severe depression with significant clinical concern whereas below score of 10 signifies minimal to mild depression (cutoff score: 0-4= minimal depression, 5-9=mild depression, 10-14=moderate depression, 15-19=moderately severe depression, 20-27= severe depression). The current study applied English for India version of PHQ-9 (D. R. L. Spitzer, Williams, and Kroenke n.d.).

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: is a self-report scale which was developed for initially diagnosing the Generalized Anxiety Disorders. The scale consists of 7 items for which the responses of the participant was recorded in 4 points Likert Scale (not at all=0, several days=1, more than half the days=2, nearly every day=3). The score of the participant ranges from 0 to 21. The threshold score of 10 has 89% sensitivity and 82% specificity for GAD (cut off score: 0-5= mild, 6-10= moderate, 11-15= moderately severe, 16-21= severe). The current study applied English version of GAD-7(R. L. Spitzer et al. 2006 ).

The questionnaire was completed using the Rasoft sample size calculator for the analysis("Sample Size Calculator by Raosoft, Inc." 2020). The minimum of 306 sample is required for 95% confidence interval, 5% margin of error for the population distribution of 1500 students at 50% response distribution. Total of 324 students have taken part in this online study.

All the students studying diploma, undergraduate, graduate and post-graduate were selected for the study.

The questionnaire was designed using Google forms and was distributed to the students through the various physical media platforms like Whatsapp, Facebook, Messenger, Telegram, etc. The form was sent to various student groups and to the class representative of the particular batch for proper distribution of form and to restrict the filling of form by unqualified participants. By filling in the Google form without time constraint, the students were invited to participate in the survey. Multiple responses and double submission were eliminated by Google feature limit to one submission.

The purpose of the study was explained to the participating students and, prior to participating in the study, they were requested to submit their voluntary consent. All the procedures accomplished for this study was to adhere to the declaration of Helsinki 1964 and its later . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Human Subjects -WMA -The World Medical Association" n.d.). The online research was conducted and stated that the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines were strictly agreed ("Checklist for Reporting Results of Internet E-Surveys (CHERRIES) Item Category Checklist Item Explanation Design," n.d.).

All the data was recorded in Microsoft excel (Microsoft Corporation) and was assessed for the accuracy of the data. The statistical analysis was completed by using IBM SPSS software, version 25 (IBM Corporation). Descriptive statistics was carried out to understand the characteristics of the data (mean, standard deviation, range, maximum value, minimum value, skewness and kurtosis). Statistically, to understand the strength of relationship of fear of COVID-19 scale with Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 scale (GAD-7) Correlation was used. To understand the effect of independent variables like Age, Gender, Degree enrolled and Any of family members got infected with COVID-19 on these scales linear regression was used. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The socio-demographic characteristic of the participant is summarized in Table1. Among the total respondents of 324, 144 (44.4%) were male and 180 (55.6%) were female. The male respondents are less in comparison with the female respondent. The majority of the participants fall in the age group between 18-21 (58.6%) and 22-25 (35.8%). Most of the participants were enrolled in bachelor's degree (79%) very few respondents were from any other degrees (diploma, Master's degree and PHD). Among 324, 37(11.4%) reported that someone from their family member got infected with COVID-19 which seems to be low while comparing the transmission of this virus in urban population

Descriptive statistics were studied for all three psychometric scales to understand the characteristic of the data which is summarized in Table 2 . The magnitude of COVID-19 fears, symptoms of depression and anxiety were graded according to their cutoff ranking, which is explained in Table 3 . There seems to be significant fear of COVID-19 (68%) and moderate to . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21250695 doi: medRxiv preprint severe anxiety (51.5%) among the respondent. Only 28.7% of the respondent showed moderate to severe depression. There was found to be significant concurrent correlation between these scales. The Pearson correlation between FCV-19s and PHQ-9 was found to be 0.474 (P-value= 0.000) and 0.492 (p-value=0.000) between FCV-19s and GAD-7 respectively. This strong relationship helps to predict an increase in fear of COVID-19 will ultimately increase the anxiety and depressive symptoms in students. The fear of COVID-19 scale can give the overall idea regarding fear of COVID-19, depression and anxiety among the students.

The linear regression of these scales with independent variables and its impact is summarized in Table 4 . There seems to be not much impact of the independent variable like Age, Gender and Degree enrolled on any of the scale scores of participants. There seems to be a strong association between the PHQ-9 scale and any family member who got infected with COVID-19 which explains that there is an increase in depressive symptoms when the number of COVID-19 infection increases in family. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21250695 doi: medRxiv preprint Table 4 : Correlation of key Variables using linear Regression with these scales

In the report, most of the respondents (63.7 percent) are found to be afraid of COVID-19, watching COVID-19 stories and reports on physical media seems to have had a major effect on their mental health such that they become nervous or anxious. When they think about COVID-19 and sleep properly due to fear of COVID-19, about half of the respondents seem to feel uneasy.

Many people believe that their hands don't become clammy or heart races when thinking of COVID-19. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Many respondents (28%) think they have no motivation or enjoyment in doing stuff and feel down, sad or hopeless (21.9 percent). Approximately 20% of respondents appear to have difficulty falling asleep or sleeping for a long time or sleeping too much and find it difficult to focus on stuff (reading or watching television). About one fifth of the participants have shown the depressive symptoms of feeling tired and having less energy and feeling bad about themselves. Very few respondents have thoughts of better off dead or hurting themselves and poor appetite or overeating. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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Approximately one-fifth of the participants cannot stop or manage worrying, worrying about too much trouble relaxing, getting quickly irritated or irritable, and feeling afraid as though anything bad will happen almost every day for more than half a day. Very few people, for more than half a day or almost every day, appear to be restless. ) . Women are found to have greater mental literacy and are more involved than men in engaging in health-related online studies (Furnham and Swami 2018; Eysenbach and Wyatt 2002) .

The cross-sectional study found that one in every three participants had moderate to severe symptoms of anxiety during the initial phase of the pandemic in China . Only after the outburst of the pandemic, a cross-sectional analysis conducted in Shanghai and Wuhan showed that the incidence of mild to extreme anxiety increased 4-5 times (Qian et al. 2020 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101 https://doi.org/10. /2021 pandemic found that 77.4% of participants had moderate to serious anxiety symptoms and 22.8% had moderate to severe depressive symptoms . The COVID-19 pandemic has been shown to cause increased anxiety, which is similar to other infectious diseases outburst.

This study found that one in two students (51.5%) had moderate to serious symptoms of anxiety and 28.7 percent had moderate to severe depressive symptoms due to this pandemic and its limitations.

Fear is considered a biologically "reflex" emotion, an automatic "basic" reaction to a specific external threat. There is a broad correlation between fear and anxiety, with an unknown, unclear or future risk being more associated with both. Via an evolutionary perspective, fear is related to risk-avoiding activities, while anxiety is linked to preparation. Adaptation and consciousness promote both emotional states. It may elicit behavioral regulation and promote self-protective responses, because fear is connected to self-perseverance (Schimmenti, Billieux, and Starcevic 2020; Steimer 2002 ).

On the FCV-19S scale, a recent study measured fear of COVID-19 in 324 United Kingdom volunteers. According to the findings, more public health practices were employed by participants displaying greater levels of anxiety. Therefore, the findings showed that this "efficient" form of fear could be carefully used by health authorities to nurture safety behaviors.

It should be recalled, however, that fear not only facilitates self-protective acts, but also offensive responses to control fear, such as denial (e.g., 'I am not at risk of being infected').

These two opposing responses are significantly negative, i.e. the more apprehension in denial or defensive avoidance is rejected; the less guidelines are followed to avoid the real danger(R. L.

The research conducted in Greece found that 35.7% displayed a higher degree of fear of COVID-19 ). This research found that 68.7% had a greater degree of fear of COVID-19. This finding can be explained by the fact that although personal view with the virus was not associated with fear, a nearby person's COVID-19 disease was correlated with greater fear.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 9, 2021. ; https://doi.org/10.1101/2021.02.07.21250695 doi: medRxiv preprint

The psychological effect of COVID-19 in Indian students during the near pandemic year was analyzed in this study, and even the specific connections among fears, depression and anxiety of COVID-19. This research concludes that, along with anxiety and depression, there is a very strong fear of COVID-19 among students. This study also concludes that the fear of the COVID-19 scale and the GAD-7 and PHQ-9 scales have a strong positive correlation.

Comprehensively, although past experiences with the 2003 SARS epidemic has shown that infectious disease crises can have fast mental health effects, the long-term impact of COVID-19 needs to be assessed for the population of India. In order to mitigate fear and encourage healthier lifestyles during the pandemic, strategic public health interventions are needed.

Some of the constraints are included in this report. In this sample, there is an unequal distribution of respondents and it is a cross-sectional study so that casual intervention cannot be done. There are very few respondents from diploma students, so the survey result cannot generalize the student population as a whole. The questionnaire was self-administered and recorded in this review, so it is difficult to understand whether it was reasonably completed (i.e. social desirability bias and the answers do not show the reality). Since it is an internet-based survey, the study will not actively collect the responses of learners who are not linked to social media.

Checklist for Reporting Results of Internet E-Surveys (CHERRIES) Item Category Checklist Item . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity

The Impact of the COVID-19 Pandemic on Patients with OCD: Effects of Contamination Symptoms and Remission State before the Quarantine in a Preliminary Naturalistic Study

Using the Internet for Surveys and Health Research

Mental Health Literacy: A Review of What It Is and Why It Matters

The Fear of COVID-19 Scale: Development and Initial Validation

A Review: Pandemic Novel Coronavirus (Covid-19)

Psychological and Behavioral Responses to the COVID-19 Pandemic in Greece

Psychological Responses, Behavioral Changes and Public Perceptions during the Early Phase of the COVID-19 Outbreak in China: A Population Based Cross-Sectional Survey

Sample Size Calculator by Raosoft, Inc

The Four Horsemen of Fear: An Integrated Model of Understanding Fear Experiences during the COVID-19 Pandemic

The Biology of Fear-and Anxiety-Related Behaviors

Psychometric Properties of the Greek Version of FCV-19S

Fear of COVID-19 Scale: Psychometric Characteristics, Reliability and Validity in the Israeli Population

WMA Declaration of Helsinki -Ethical Principles for Medical Research Involving Human Subjects -WMA -The World Medical Association

No funding has been granted for this study by any institution and organization. We are very thankful to the volunteers of this study and the college staff for making this study possible .

No conflict of interest declared.