key: cord-1048784-ri67g4ze
authors: Sigdel, A.; Bista, A.; Bhattarai, N.; Poon, B. C.; Giri, G.; Marqusee, H.; Thapa, s.
title: Depression, Anxiety and Depression-anxiety comorbidity amid COVID-19 Pandemic: An online survey conducted during lockdown in Nepal
date: 2020-05-06
journal: nan
DOI: 10.1101/2020.04.30.20086926
sha: 534a97dc39286534e61c6a07a9c05a019c5bfd7e
doc_id: 1048784
cord_uid: ri67g4ze

Background: Little is known about the effect of the COVID-19 pandemic on mental health status during the lock-down period. Therefore, this study was conducted to assess prevalence of depression, anxiety and depression-anxiety comorbidity, and associated factors during the COVID-19 lock-down in Nepal. Methods A quantitative cross-sectional study was conducted among the general population of Nepal. Data was collected from April 9 to April 16, 2020 using an e-questionnaire which was shared through different popular social media. A total of 349 participants were included. Self-reported depression and anxiety were assessed using the Patient Health Questionnaire and Generalized Anxiety tools respectively. Logistic regression analysis was conducted to identify the factors associated with depression, anxiety and depression and anxiety co-morbidity. Results The prevalence rates of depression, anxiety and depression-anxiety co-morbidity were found to be 34.0%, 31.0% and 23.2% respectively. The multi-variate analysis showed that females, those living alone, health professionals and those who spent more time in accessing information about COVID-19 were significantly more likely to have depression, anxiety and depression-anxiety co-morbidity. Conclusions High rates of depression and anxiety and co-morbidity were found to be prevailing among the general population during the COVID-19 pandemic lock-down in Nepal. The results suggest that only the scientific, but contextually appropriate messages about the disease should be disseminated to reduce unnecessary fears and anxiety. Awareness interventions to promote mental well-being need to be integrated into the response interventions. Community mental health care should be made accessible to at-risk groups.

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The copyright holder for this preprint this version posted May 6, 2020. January 2020, which is the sixth time WHO has declared a PHEIC after the International Health 59

Regulations (IHR) that came into effect in 2005. Thereafter has been a rapid increase not only in 60 infections and deaths, but also anxieties, stigma, mistrust, and rumor-mongering among the public 61

(2). WHO has reported a total of 2,436,743 confirmed cases and 165,310 deaths across 206 62 countries/territories by April 22, 2020 (3). The COVID-19 pandemic is on its way to cause 63 historically significant global change (4), as it continues to rise. The World is on high alert; borders 64 are closed and strict measures are being taken to control the spread of COVID-19 (5). At the same 65 time, many countries affected by COVID-19 have implemented temporary lockdowns restricting 66 people's unnecessary movement outside the home and ensuring that people stay safe at home. 67

Multiple biological and behavioral pathways are likely contributing to the linkages between mental 68 health conditions and viral diseases, such as COVID 19 (6). Individuals or communities experience 69 . 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 May 6, 2020. . https://doi.org/10.1101/2020.04.30.20086926 doi: medRxiv preprint a mental instability along with social and economic losses which might precipitate as mental stress, 70 anxiety and depression (7). It is reported that nearly all people affected by or during such global 71 emergencies will experience some level of psychological distress, which for most will improve 72 over time. The prevalence of common mental disorders are expected to be more than double (8). 73

For instance, the estimated prevalence of mental disorders among the conflict-affected population 74 according to WHO is 13% for mild forms of depression, anxiety, and post-traumatic stress disorder 75 and 4% for moderate forms of these disorders. Depression and anxiety are found to increase with 76 age and are more common in women than in men in a conflict-affected setting (8). The burden of 77 mental problems would be even higher due to the fact that healthcare, and particularly the mental 78 health care system, is severely affected due to Several scholars have provided varied propositions why emergency situations, such as pandemics 80 are associated with the rise of mental and emotional problems. As suggested by Nilamadhav Kar, 81 based on a study conducted after a terrorist initiated bomb blast incident in India in 1996, people 82 go through different negative mental and emotional states, including helplessness, severe stress, 83 severe mood swings and forgetfulness, emotional instability, anxiety, stress reactions, and trauma 84 (9). On the contrary, Wachinger observed such mental changes, during an emergency situation, 85 domain as a protective factor (a coping mechanism) (10) and stated that such changes included 86 willingness to control the emotional extremes, self-regulation of one's emotions, inculcating hope 87 and courage, positive attitude and acceptance of the situation, concern about oneself and family 88 members and ability of the individual to prepare oneself, which could in turn solidify the emotional 89 instability (7). Among the variety of mental and emotional changes that occur during such 90 situations, some of them more strongly improve the general wellbeing of individuals, but anxiety 91 . 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 May 6, 2020. . https://doi.org/10.1101/2020.04.30.20086926 doi: medRxiv preprint and depression are among the most common problems (global prevalence is estimated to be 92 between 3.6% to 4.4%) (11). 93

Anxiety and depression as medical problems include generalized and acute anxiety, post-traumatic 94 stress disorder (PTSD), phobias, panic disorder, major depressive disorder, bipolar illness, and 95 other mood disorders. (11) There are known effective treatments for such mental disorders, but 96 unfortunately between 76% to 85% of people from low and middle-income countries receive no 97 treatment for their mental illness (12) . A study done among physicians in China (the most affected 98 country by COVID19 in early days) has shown that an estimated 25.67% of physicians had anxiety 99 symptoms, 28.13% had depressive symptoms, and 19.01% had both anxiety and depressive 100 symptoms. Poor self-reported physical health, frequent workplace violence, lengthy working hours 101 (more than 60 hours a week), frequent night shifts (twice or more per week), and lack of regular 102 physical exercise were found to be associated with anxiety and depression symptoms among 103 physicians (13). There are various other factors, for instance the displacement of the family, death 104 of a loved one, socio-economic loss, environmental loss, lack of mental preparedness for disaster, 105 lack of social support and negative coping skills, that might lead to the psychological 106 vulnerabilities of those affected (9). Several studies have evaluated the psychological status of 107 people during pre and post emergency, however there are limited studies that assess the mental 108 suffering of people during the course of epidemics. As such, there is an unmet need for greater 109 understanding of the management of anxiety and depression in any epidemic or pandemic situation 110 (14). In any pandemic, the most vulnerable communities are in developing-world cities where 111 there are huge numbers of people, with poor health systems and where millions lack access to 112 services (14). 113 . 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 May 6, 2020. . https://doi.org/10.1101/2020.04.30.20086926 doi: medRxiv preprint on January 13, 2020 and to date the situation is in control with only 45 reported cases (7 recovered, 115 38 in isolation) (15) . With the second case, Nepal announced a complete lockdown from 24 March 116 2020 as a measure to control community transmission of COVID-19. The vulnerability of Nepal 117 increases with its open border with India (with 20,178 reported cases and 645 deaths) and China 118 (being the epicenter for the COVID-19 with 82,788 cases and 4,632 deaths) as of April 22, 2020 119

(3). On one hand, the development of social media and social networking has made it easier to 120 share the severity and extent of the damages while on the other hand it has increased the higher 121 levels of indirect exposure, leading to increased risk for stress, anxiety, and depression from 122 indirect trauma (16) . The bombarding of breaking news from the media is also creating havoc on 123 people's mental status. Although the priority is to stop the transmission, provide care to those 124 infected, and to seek a treatment and vaccine for long-term management, management of mental 125 health problems has not received any attention and therefore, there is a need to investigate and 126 explain the increased burden of mental health problems and the factors associated with it. The 127 present study is aimed at generating evidence on the prevalence of anxiety and depression among 128 the general population and the factors associated with anxiety and depression during the COVID-129 19 pandemic lockdown in Nepal. 130 

This was a cross-sectional survey study to assess the prevalence and factors associated with 133 depression, anxiety and depression-anxiety comorbidity among the general population of Nepal. 134 . 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 May 6, 2020. The participants of this study were a sample of the general population with access to internet; who 135 were aged 18 years old and above, and who were able to provide written consent. 136 (98.6%) provided consent for the study, and one participant was younger than 18 years and thus 144 was excluded from the study. Hence, the total sample included in the study was 349. 145 participants (18). The PHQ-9 tool has a sensitivity of 88% and specificity of 88% for major 155 depression (18). 156 . 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 May 6, 2020. . https://doi.org/10.1101/2020.04.30.20086926 doi: medRxiv preprint the outcome variables for this study. Anxiety was ascertained using the GAD-7 tool. GAD-7 158

consists of a 7 items questionnaire that asked participants how often, during the last 2 weeks, they 159 were bothered by each symptom. Response options were "not at all," "several days," "more than 160 half the days," and "nearly every day," scored as 0, 1, 2, and 3 respectively (17). The sum of all 161 the items of GAD-7 were used to measure the level of anxiety. A score of up to 5 was considered 162 mild; 6-10 was considered moderate; 11-15 was considered moderately severe anxiety and 15-21 163 was considered severe anxiety. The score was dichotomized for logistic regression as the sum of 164 GAD-7 less than 10 was considered normal and a GAD-7 score greater than or equal to 10 were 165 considered as participants with anxiety. 166

To ascertain depression among the participants, the PHQ-9 questionnaire was used. The PHQ-9 167

consists of nine questions that asked participants how often, during the last 2 weeks, they were 168 bothered by each symptom. Response options were "not at all," "several days," "more than half 169 the days," and "nearly every day," scored as 0, 1, 2, and 3 respectively. The sum of the scores of 170 all nine items of the PHQ-9 were used to determine the level of depression. A score of up to 5 was 171 considered mild; 6-10 was considered moderate; 11-15 was considered as moderately severe 172 depression and 16 and above were considered as severe depression (19). However, for logistic 173 regression, the score was dichotomized as participants with depression (the PHQ-9 score of more 174 than 10) and normal (the PHQ-9 score of 10 and less). 175

Independent variables: Independent variables such as socio-demographic factors (sex, age, place 176 of current residence, caste/ethnicity, educational level, religion, marital status, major occupation, 177 accompanying status and household ownership), and Media Exposure (most used mass media to 178 . 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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More than half (54.2%) of participants were male and the mean age of participants was 27.8 years. 207

Nearly two-third of the participants (62.5%) belong to Brahmin or Chettri ethnic group followed 208 by Janajati/Adhibasi (26.5%). A majority of the participants (91.1%) had completed Bachelor level 209 and were Hindu by religion (90.5%) Nearly two-thirds (62,2%) were single. A majority were job 210 holders (57%), reside in urban areas (65%), were living with family (72.5%), living in their own 211 house (58.2%) and were health professionals (60%) as summarized in Table 2 . 212 Sex . 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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More than two-thirds (69.3%) used social media for accessing information on COVID-19 followed 215 by online newspapers (14.6%) and the mean time spent accessing information on COVID-19 was 216 3.4 hours per day as summarized in Table 3 . 217 . 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 May 6, 2020. 219

The overall prevalence rates of depression, anxiety and depression and anxiety co-morbidity were 220 found to be 34.1% (95% CI: 28.8-39.5), 31.2% (95% CI: 26.4-36.4) and 23.2% (95% CI: 18.9-221 27.5) respectively (see Table 4 ). The prevalence rates of depression, anxiety and depression-222 anxiety comorbidity were found to be higher among female participants than male participants (as 223 see Table 1 ). 

Normal 268 (76.8) 72.5-81.1 . 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 May 6, 2020. Forward stepwise logistic regression was carried out with depression and co-morbidity of 232 depression and anxiety as outcome variables and five predictor variables with a p value less than 233 0.2. Logistic regression was also carried out with anxiety as an outcome variable and six predicator 234 variables with a p value less than 0.20 in bivariate analysis. The final model is summarized in 235 Table 5 . Female participants were 2.4 times more likely to be depressed (95% CI: 1.48-3.89); 6.3 236 times more likely to be anxious (95% CI: 3.54-11.18) and 7.4 times more likely to have the co-237 morbid condition. Those participants who were currently living alone were found to be more 238 depressed (AOR: 3.5; 95% CI: 1.82-6.84), anxious (AOR: 3.3; 95% CI: 1.65-6.74) and have the 239 . 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 May 6, 2020. . https://doi.org/10.1101/2020.04.30.20086926 doi: medRxiv preprint co-morbid condition (AOR: 8.8, 95% CI: 3.85-20.12) compared to those who were accompanied 240 by their family. Likewise, health professionals compared to others had 1.7 times, 2 times and 3.4 241 times higher odds of being depressed (95% CI: 1.04-2.90), anxious (95% CI: 1. 16-3.69 ) and having 242 co-morbid condition (95% CI: 1.62-6.97) respectively. Also, time spent in mass media in accessing 243 COVID-19 information was found to be significantly associated with depression (AOR: 1.1, 95% 244 CI: 1.01-1.16), anxiety (AOR: 1.1, 95% CI: 1.08-1.27) and depression and anxiety co-morbidity 245 (AOR:1.2, 95% CI: 1.06-1.26). However, place of current residence of participants and household 246 ownership were not found to be significantly associated with depression, anxiety and depression 247 and anxiety comorbidity. 248 . 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 May 6, 2020. A study done in Indonesia shows that the prevalence rates of PTSD, depression, and anxiety were 264 58.3%, 16.8% and 32.1%, respectively following the earthquake in 2016(24). Another study done 265 . 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 May 6, 2020. (PHEIC) by WHO shows that 53.8% of respondents classified the psychological impact of the 267 outbreak as moderate or severe; 28.8% of respondents reported moderate to severe anxiety 268 symptoms whereas 16.5% and 8.1% reported moderate to severe depressive symptoms and stress 269 levels respectively(25). These findings are in line with the findings of the present study. 270

A recent study showed that 63.4% of victims with psychiatric disorders had comorbidity after 271

Orissa super-cyclone in India (10) and another study showed that the prevalence of comorbid 272 conditions was 14.3% between PTSD and depression, 24.9% between PTSD and anxiety and 273 13.1% between depression and anxiety in adolescents following earthquake in Indonesia (24). The 274 prevalence of depression and anxiety comorbidity was found to be 23.2% (95% CI: 18.9-27.5) in 275 this study, and this reasonably high rate of comorbidity justifies that the amount of damage to the 276 general population caused by COVID-19 disease pandemic is similar to other emergencies. 277

However, some differences in the prevalence of depression, anxiety and comorbid depression-278 anxiety might be due to the differences in tools used for assessing depression and anxiety and the 279 study setting and study design. 280

In a previous study, the risk factors of depression and anxiety in survivors of an earthquake were 281 reported to be age, pre and post-disaster traumatic incident, persisting violence, peri-traumatic 282 distress, family and street violence (22). A study conducted among college students in South 283

Korea found that female students (2.98) were more stressed than male students (2.84); also female 284 students (0.66) had higher levels of anxiety compared to male students (0.50). Existing studies 285 rigorously show that there were statistically significant differences in the risk of anxiety by sex, 286 residence type, economic status, and Body Mass Index (BMI) (16) . This is in line with the findings 287 . 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 May 6, 2020. . https://doi.org/10.1101/2020.04.30.20086926 doi: medRxiv preprint of the present study that females, compared to males, were 2.4 times (95% CI: 1.48-3.89) and 6.3 288 (95% CI: 3.54-11.18) more likely to have depression and anxiety. 289

One study found that women, who are often the main caregivers for injured, sick, elderly and 290 family members with long-term disabilities, are worried about the future, and with husbands 291 unemployed, and children out of school, they are mostly worried about feeding and taking care of 292 their families (26). Another study reported that social, cultural and existing gender norms tend to 293 make women relatively more vulnerable than men to mental health problems. Yet, women and 294 girls have less access to or control over assets/resources such as information, education, health and 295 wealth, which is necessary for the response to hazardous events (27). These might explain why 296 women have a higher risk of depression and anxiety than men, and this is exacerbated especially 297 due to the COVID-19 disease pandemic and the circumstances created by the lockdown in Nepal. 298 Accurate and up-to-date health information like treatment, local outbreak situation and 299 precautionary measures (e.g., hand hygiene, wearing a mask) were associated with a lower 300 psychological impact of the outbreak and lower levels of stress, anxiety, and depression (p < 0.05) 301 (25). Likewise, another study reported that an individual with longer exposure to disaster-related 302 news showed more symptoms of stress than those with less news exposure (16) . This finding 303 resembled the current study where the individuals who have higher exposure to media in accessing 304 COVID-19 information have higher risk of depression, anxiety and comorbidity. Hence, emphasis 305 should be given to provide correct and appropriate information on disaster events rather than 306 describing the ravages caused by events, which could lead to an increase in unnecessary 307 anxieties/fears related to transmission, testing positive, quarantine and stigma associated with 308 COVID-19 disease, (16) . 309 . 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 May 6, 2020. . https://doi.org/10.1101/2020.04.30.20086926 doi: medRxiv preprint

World Health Organization. 2019-nCoV outbreak is an emergency of international concern 361

COVID-19: Real-time dissemination of scientific information to fight a 365 public health emergency of international concern

Could coronavirus bring about the "waning of globalization

World Health Organization. Depression Factsheet

Prevalence of anxiety and 394 depressive symptoms and related risk factors among physicians in China: A cross-sectional 395 study

Why COVID-19 May be a Major Blow to Globalization

Coronavirus disease (COVID-19) outbreak updates & resource 399 materials

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Ministry of Health and Population (MoHP) NE and III. Nepal Demographic and Health 404 Survey

The PHQ-9

depressant medications in Finland found that, during the 7-year follow-up, those who lived alone 311 had an 80% higher risk of initiating antidepressant use compared to those who lived with family 312 (28). Similarly, it was found that poor housing conditions were associated with increased use of 313 antidepressants (28). In line with the findings of these studies, the present study also reported that 314 living alone was found to be associated with depression (AOR: 3.5; 95% CI: 1.82-6.84) and anxiety 315 (AOR: 3.3; 95% CI: 1.65-6.74) and the comorbid condition (AOR: 8.8, 95% CI: 3.85-20. 12 ) 316 compared to those who were living with their family during the lockdown period. 317Likewise, participants with a health professional background had 1.7 times, 2 times and 3.4 times 318 higher odds of having depression (95% CI: 1.04-2.90), anxiety (95% CI: 1. 16-3.69 ) and 319 depression-anxiety comorbidity (95% CI: 1.62-6.97) respectively. This finding resembled a meta-320 analysis which showed that one in three medical students have anxiety globally-a prevalence rate 321 which is substantially higher than general population(29). This might be because health 322 professionals perceive a higher level of risk associated with the COVID-19 disease, since they 323 have easy access to information compared to the general population. Besides being fully aware of 324 the risks, health professionals are known as the first responders to COVID-19 disease and thus, 325 are more at risk for transmission. 326

Depression, anxiety and depression and anxiety comorbidity are prevalent among the general 328 population during the COVID-19 pandemic lockdown in Nepal. We identified the specific sub-329 groups of the general population at higher risk of depression, anxiety and the comorbid condition 330 are females, those living alone during the COVID-19 pandemic lockdown, health professionals 331 . 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 May 6, 2020. 

This study had several limitations that should be considered when interpreting the data. First, the 339 use of an online survey imposes potential limitations. It is probable that the study findings under-340 represent the responses of those in certain demographics, e.g. those who are less educated, those 341 less affluent, and elder age populations. Also, the online survey is relatively uncontrolled. The 342 sample was self-selected and therefore there might be a high chance of response bias compared 343 with a sample that had been randomly selected. Finally, this study does not rule out the association 344 among COVID-19 lockdown and outcome variables but only assesses the prevalence and 345 predicators during lockdown in Nepal. 346 Acknowledgements 347The authors would like to thank all the participants who participated in the survey. We would like 348 to extend our sincere gratitude towards Ministry of Health and Population (MOHP), Nepal Public 349Health Association (NEPHA), Pokhara University and Purbanchal University for supporting in 350 data collection. 351. 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 May 6, 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 May 6, 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 May 6, 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 May 6, 2020. 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 May 6, 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. (which was not certified by peer review)The copyright holder for this preprint this version posted May 6, 2020. . https://doi.org/10.1101/2020.04.30.20086926 doi: medRxiv preprint