key: cord-1056503-0zcnj2pj
authors: Ali, Mohammad; Uddin, Zakir; Amran Hossain, Kazi M.; Uddin, Turjo R.
title: Depression, anxiety, stress, and suicidal behavior among Bangladeshi undergraduate rehabilitation students: An observational study amidst the COVID‐19 pandemic
date: 2022-03-09
journal: Health Sci Rep
DOI: 10.1002/hsr2.549
sha: c772cc255d945a697ecec6a7584d664398fc3e8b
doc_id: 1056503
cord_uid: 0zcnj2pj

BACKGROUND AND AIMS: Common mental health symptoms (CMHS) like depressive moods, anxiety, and stress are the underlying causes of suicidal behavior. The incidence of suicide is higher among Bangladeshi students. Due to the pandemic, students of health/rehabilitation sciences are at the most significant risk. This study aimed to measure the prevalence rate and predicting factors for depression, anxiety and stress, suicidal ideation, and suicide attempts in Bangladeshi undergraduate rehabilitation students. METHODS: This cross‐sectional study included data from 731 participants. Descriptive analyses estimated prevalence, and multivariate logistic regression models identified the factors associated with CMHS and suicidal behavior after adjusting the confounders. RESULTS: The result shows a high prevalence of moderate to very severe CMHS and a higher risk of suicidal ideation among rehabilitation students. Sociodemographic factors, illness, behavior, institution, and subject‐related issues were identified as the predicting factors of CMHS and suicidal behavior. The students suffering from mental health symptoms reported suicidal ideation and attempted at a significantly higher rate. CONCLUSION: To deal with CHMS and suicide risk, a holistic, supportive approach from government and academic institutions are essential for minimizing the predicting factors identified by this study. The study is helpful for the government regulatory body and policymakers to take immediate steps for preventing CMHS and suicidal behavior among rehabilitation students in Bangladesh.

Physiotherapists, Occupational therapists, and Speech and Language therapists are the three significant professionals representing a rehabilitation team. 1 Bangladesh has a few (about 12/million) rehabilitation professionals, and they are poorly regulated, merely recognized, and have yet to be included in mainstream health services. [2] [3] [4] [5] The country started the undergraduate program in rehabilitation since her independence as a part of the government initiative. The development's initiatives include unification of course curriculum, determining eligibility criteria, and regulating education, employment, and clinical practice through the government regulatory body. 2, 6 However, most of these initiatives are poorly monitored and filed on official paper only without proper implementation. As a result, large-scale rehabilitation services are provided and patronized by nongovernment organizations as a charity model. Qualified professionals mainly serve in private chambers, but lack of regulation, physician dominance, and professional conflict with physicians drag them to challenges and lower their credibility. 2 However, the strength of the rehabilitation professionals arises from the extensive service demand: 10%-15% of the population are persons with disabilities, 7 increment of the elderly population, 8 and survivors of non-communicable disease. 9 Students of rehabilitation have the dream of serving as a health professional inspired by this colossal service demand. The undergraduate programs are affiliated with the university, and the professional scope of health service contribution for the imposed social demand motivates them to enter a rehabilitation degree program.

Gradually, they observe poor staffing, a lower standard of the educational environment, and poor regulation. 6 These professional issues and comparative inequality with other health professionals are driving factors for depressive symptoms. There is a higher chance of developing mental health symptoms or even suicidal behavior among rehabilitation students. The reason might not be solely professional issues, but mental health issues are a growing concern among university students in Bangladesh. These common mental health symptoms (CMHS) can be evident through depression, anxiety, and stress.

In Bangladesh, depression, anxiety, and stress prevalence are as high as 54.3%, 64.8%, and 59.0%, respectively. 10 Previous studies suggested that other factors, academic environment, and subjectrelated future worries are strongly associated with mental health problems in Bangladeshi undergraduate universities. 10, 11 Additionally, the COVID-19 pandemic poses an enormous threat to the mental health of the world population. This unprecedented situation has victimized students by putting them at a higher risk of mental health problems. 12 A study conducted among Bangladeshi university students suggested that at the time of the COVID-19 pandemic rise, 62.9%, 63.6%, and 58.6% of university students showed depression, anxiety, and stress symptoms, respectively. 13 CMHS is found to be the underlying factor for most suicide cases. [14] [15] [16] [17] The incidence of suicide is even higher among the student cohort in Bangladesh. 18, 19 Specifically, health science students are at the most significant risk, 20 and this pandemic fueled the fire. Our previous study among Bangladeshi rehabilitation professionals and Pakistani rehabilitation students revealed a remarkably high prevalence of CMHS. 6, 21 Given this high prevalence among these cohorts suggested additional study among Bangladeshi rehabilitation students. Therefore, the current study aimed to (1) measure the prevalence rate of depression, anxiety and stress, suicidal ideation, and suicide attempt; (2) identify the factors predicting depression, anxiety, stress, suicidal ideation, and suicidal attempt among undergraduate rehabilitation students in Bangladesh.

This cross-sectional study was conducted between January 7 and March 27, 2021. We have collected data from the students studying Bachelor of Science in Physiotherapy, Occupational Therapy, and Speech and Language Therapy. Students from all the institutes of Bangladesh had participated in this study. A margin of 2.5% error, a confidence level of 95%, and a response distribution of 50% were used to calculate the sample size to target a population of 1200 students and secure a minimum sample size of 675 participants. This sample size calculation technique was found suitable in a previous Bangladeshi study. 22 

This study used the Bangla version Depression, Anxiety, and Stress Scale-21 (DASS-21) 10,13,23 to assess depression, anxiety, and stress.

Predefined thresholds for mild, moderate to severe, or extremely severe symptom levels were used to categorize depression, anxiety, and stress levels. For depression symptoms, cutoff points were as follows: normal 0-9, mild 10-13, moderate 14-20, severe 21-27, and extremely severe +28. For anxiety, 0-7, 8-9, 10-14, 15-19, and +20 points were considered as normal, mild, moderate, severe, and extremely severe symptoms, respectively. Stress symptoms were categorized as normal (0-14), mild (15) (16) (17) (18) , moderate (19) (20) (21) (22) (23) (24) (25) , severe (26) (27) (28) (29) (30) (31) (32) (33) , and extremely severe +34. 6,13

To measure suicidal behavior, a suicidal behavior questionnaire contained two items that were included: (1) suicidal ideation (have you seriously considered suicide in the last 12 months?), and (2) attempted suicide (have you attempted suicide in last year?). 11, 24, 25 The response options were yes and no.

SPSS version 22.0 software was applied for data analysis. For descriptive analysis, moderate, severe, and very severe were combined to calculate depression, anxiety, and stress scores on the DASS-21. 6, 26, 27 Descriptive statistics (e.g., frequencies, percentages, and χ 2 /Fisher's exact tests) were used for categorical data.

After adjusting the confounders, multivariable logistic regression models were employed to identify the factors associated with mental health symptoms. The results were interpreted with 95% confidence intervals (CIs) and p values. We consider a p-value less than or equal to 0.05 as significant. 3.2 | Sociodemographic, behavior, and health-related factors, and mental health symptoms and suicidal ideation Around half (48.56%) of the participants were female; the mean age was 22.20 (SD = 2.33). Significantly higher prevalence has been found among female participants for depression (p = 0.050), anxiety (p = 0.008), stress (p = 0.001) and suicidal ideation (p = 0.025). In this study, 76% of students were single, 80% have come from a nuclear family, 39% lived in their own house, 45%

were from a middle-class family (monthly family income 15,000-30,000 [currency?]), 46% were from rural villages. However, those who lived in a rented house reported anxiety (p = 0.027) and stress (p = 0.006) at a higher rate. Similarly, participants from middle-income family showed higher stress symptoms (p = 0.050) and suicidal ideation (p = 0.005).

A total of 68% of participants said they do not perform regular exercise, 69% practice religion, and only 7% smoke regularly. Statistically, a significantly higher rate of depression, anxiety, stress, and suicidal ideation has been found in those who do not perform the exercise and religious practice regularly, p = 0.001/0.023, p = 0.008/ 0.111, p < 0.001/0.001, and p = 0.026/0.022, respectively for depression, anxiety, stress, and suicidal ideation.

In this study, 50% of participants said that they had suffered from physical illness last year, while 40% and 70% had faced mental health conditions and hard times, respectively. Though 30% of the participants were not satisfied with their sleep quality, only less than 7% use sleeping pill or similar drugs. Only 33% of participants said they used to sleep <7 h at night, and 18.2% spent >6 h on screen. However, all the participants mentioned above showed a statistically significant higher prevalence of depression, anxiety, stress, and suicidal ideation. Details can be found in Table 1 . Additionally, the participants were questioned whether they are suffering from identity crisis and inferiority complex as RS students.

Surprisingly, 52% and 24% answered yes, respectively. A 16% of participants said that admitting to this subject was not correct.

Unsurprisingly, a significantly high number of these subgroup participants reported all mental health symptoms with suicidal ideation. Table 1 depicts the statistics in detail.

Finally, one-third of the participants thought that the mental health problems they were suffering from were due to the COVID-19 pandemic, while one-fourth thought these were due to the subject they were studying. However, those who thought the mental health problems they are suffering from due to their subject have reported in significantly high rate for all the given mental health problems (p ≤ 0.001) and suicidal ideation (p = 0.001). Detailed results can be found in Table 1 .

Multivariable logistic regression suggested that being female, living in a rented house, not performing physical exercise, physical illness, facing mental health conditions, and challenging times, using the sleeping pill or similar drugs, sleeping less than regular hours, dissatisfaction with sleeping quality, high onscreen time (>6 h), inferiority complex, poor academic performance and changing profession after graduation were statistically significantly associated with mental health symptoms and suicidal ideation. Furthermore, from the logistic regression, it has been revealed that subject-related mental health was the common factor for all given mental health symptoms and suicidal ideation. Details have been given in Tables 3-6.

It was revealed that a higher portion of participants who were suf- 

This study found a high prevalence of moderate to very severe CMHS and a higher risk of suicidal ideation among Bangladeshi rehabilitation science students. These higher levels of prevalence and risk were clustered by gender, resident type, family income, physical exercise, institute related-factors, and psychological health-related factors. The students suffering from mental health symptoms reported suicidal ideation and attempted at a significantly higher rate.

The study is helpful for the government regulatory body, and policymakers take an immediate step for preventing CMHS and suicidal issues.

A recent systematic review and meta-analyses suggested that the global prevalence rate of depression and anxiety among health science students was 28% and 34%, respectively. 28, 29 Another systematic review suggested that the prevalence of depression and anxiety in South Asia during this pandemic was 34% and 41%, respectively. 30 In contrast, we found that about 50% of the participants were suffering from moderate to very severe types of depression and anxiety symptoms, which is much higher than the global and pandemic time rate in South Asia. Similar to our study, another evaluation conducted during the pandemic among Bangladeshi medical college students also suggested that 50% and 65% of the participants were suffering from at least a mild type of depression and anxiety, respectively. 31 Furthermore, an additional study conducted during the pandemic among Indian medical students revealed that around one-third were suffering from mild to very severe types of anxiety and stress, while 50% reported mild to very severe depression. 32 Another study conducted during the pandemic in the United States among medical college students reported a lower rate of depression (24%) and anxiety (30%) prevalence. 33 Prepandemic

Bangladeshi data-based systematic review estimated up to 31% prevalence of CMHS among the general population. 34 Our previous study with Bangladeshi rehabilitation professionals (not students)

found the prevalence of depression, anxiety, and stress 51.0%, 58.6%, and 33.6%, respectively. 6 CMHS was associated with economic stressors, professional and employment-related factors in that study. 6 A 2016 systematic review and meta-analysis suggested that the overall global prevalence of suicidal ideation among medical students was 11.1% (95% CI: 9.0%-13.7%). 35 Another recent systematic review revealed that the annual prevalence of suicidal ideation amongst adolescent students was 14.0% (95% CI: 10.0%-17.0%). A prepandemic Bangladeshi study suggested that the annual prevalence of suicidal ideation in university students was 14.7%. 36 However, recent reports suggested that the prevalence of suicidal behavior has been significantly increased globally since last year due to the pandemic. 37, 38 Nonetheless, a study conducted in the pandemic among undergraduate Bangladeshi university students found that the annual prevalence of suicidal ideation was 12.8%. 39 A similar study among healthcare workers and the general population found the prevalence of suicidal behavior at 6.1%. 40 In contrast, we found a significantly higher prevalence of suicidal ideation (16.3%) and suicidal attempts (3.0%) among rehabilitation students in Bangladesh. Our study also revealed that above half of the participants suffer from an identity crisis as rehabilitation students. However, one-third of the participants were not satisfied with the academic environment, and onefourth suffered from inferiority complex as rehabilitation students.

Further, many rehabilitation students thought they were suffering from mental health issues because they were studying rehabilitation.

Unsurprisingly, a large number of these subgroup students reported mental health symptoms and suicidal ideation. Our regression models suggested that suicidal ideation is more than two times higher among participants who wanted to leave the profession after completing their degree in a rehabilitation program (study subject-selection reasons). These subject-selection reasons explained the higher prevalence rates of suicidal ideation among Bangladeshi students. 11 Additional research is warranted to find in-depth relations between subject-related factors and suicidal behavior. Besides subject-related factors, this study revealed a range of subgroups associated with CMHS and suicidal behavior. In line with the previous study findings, 13, [41] [42] [43] [44] [45] [46] [47] this study also found gender, resident type, monthly family income, regular exercise, regular practice of religion, facing hard times and mental health issues, sleeping pill use, sleeping quality, sleeping hour and onscreen time factors were associated with CMHS and suicidal behavior.

A systematic review and meta-analysis concluded that CMHS undermine suicide globally. 48 A study using the psychological autopsy attempts were associated with suicide. 50 Our study found that depression and stress symptoms significantly predicted suicidal thought; however, only stress symptoms significantly predicted suicide attempt(s). In line with our findings, a recent study found that depression and stress were significantly associated with suicidal behavior among Chinese university students. 51 Additionally, a 2017 systematic review and meta-analysis also suggested that depression was associated with suicidal behavior among university students. 52 Recent systematic reviews and meta-analyses suggested that the prevalence of COVID-19 pandemic time CMHS and suicidal behavior was higher among different cohorts worldwide. 12, 53 Previous studies have found the association between COVID-19 related factors and CMHS and suicidal behavior among students and young adults in Bangladesh. 54, 55 Furthermore, another systematic review and meta-analysis confirmed that COVID-19 related factors were associated with suicidal behavior among

Bangladeshi. 56 However, we did not find a significant association between COVID-19 related factors and CMHS and suicidal behavior among rehabilitation students. Subject-related factors might outweigh the impact of COVID-19 among this cohort.

Additional study is warranted to find the in-depth relation between COVID-19 related factors, subject related factors, and CMHS and suicidal behavior among rehabilitation students in Bangladesh.

Universal limitations of cross-sectional study and methods bias of self-reported data collection must be recognized for this study. We did not take the participants' family history of mental health symptoms and suicidal behavior that could confound the result in this study. Data regarding substance abuse could further strengthen the study result. Additionally, limitations of subjective questions used in this study must be acknowledged. Despite these limitations, this study sets baseline evidence from a lower-middle-income country regarding the prevalence and predicting factors for CMHS and suicidal behavior among rehabilitation students.

This study reported a significantly high prevalence of CHMS and suicidal behavior among Bangladesh's relatively less prioritized student cohort. Sociodemographic factors, illness, behavior, institution, and subject-related issues were identified as the predicting factors of CMHS and suicidal behavior. To deal with CHMS and suicide risk, a holistic, supportive approach from government and academic institutions is essential to reduce this study's identified predicting factors. Implementing appropriate government regulation on the rehabilitation profession can ensure career dignity, social status, and better job opportunities, which helps minimize CHMS and suicide risk.

All the authors acknowledge the participants for providing us the information to conduct the study. The authors also thank the institution offices and those who provided email addresses and helped in the data collection process.

The authors declare no conflicts of interest. 

Data were available from the corresponding author upon reasonable request.

http://orcid.org/0000-0002-4685-5050

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