|Year : 2022 | Volume
| Issue : 2 | Page : 87-94
Depression, anxiety, and stress among general public of india during post-COVID-19 second wave: A web-based cross-sectional survey
Jyothi Suchitra Mekala1, Narayana Goruntla2, Bharathi Nayaka2, Kavyasree Velpula2, Raghavendra Biswas2, Kasturi Viswanathasetty Veerabhadrappa3, Bhupalam Pradeepkumar4
1 Department of Obstetrics and Gynecology, Rural Development Trust (RDT) Hospital, Anantapur, Andhra Pradesh, India
2 Department of Pharmacy Practice, Raghavendra Institute of Pharmaceutical Education and Research (RIPER) – Autonomous, Anantapur, Andhra Pradesh, India
3 Department of Pharmacognosy, Arsi University, Assela, Ethiopia
4 Department of Pharmacology, Raghavendra Institute of Pharmaceutical Education and Research (RIPER) – Autonomous, Anantapur, Andhra Pradesh, India
|Date of Submission||03-Sep-2021|
|Date of Decision||11-Nov-2021|
|Date of Acceptance||06-Dec-2021|
|Date of Web Publication||21-Mar-2022|
Dr. Narayana Goruntla
Department of Pharmacy Practice, Raghavendra Institute of Pharmaceutical Education and Research (RIPER) – Autonomous, Anantapur - 515 721, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Evidence suggests that one-third of respondents had a significant psychological impact in the lockdown period of the coronavirus disease 2019 (COVID-19) pandemic. This indicates a need for longitudinal assessment of the psychological needs of the public to plan holistic interventions. Aim: To investigate depression, anxiety, and stress (DAS) levels among the general public post-COVID-19 second wave. Materials and Methods: A web-based cross-sectional survey was conducted among the general public who were aged above 15 years. The data were collected through online mode by providing a link to fill Google Form. The survey tool was disseminated in various messenger groups and social media networks. The survey tool comprises demographics, COVID-19 stressors, and DAS Scale 21 (DASS-21). Multi and Univariate linear regression analysis was used to correlate patient characteristics and COVID-19 stressors with DASS-21 subscales. Results: A total of 2515 (males = 1274; females = 1241) people participated in this web-based survey. The mean age of the study respondents was 31.3 ± 13.4 years. The mean scores of depression, anxiety, and stress were 6.8 ± 8.6, 5.0 ± 7.3, and 7.3 ± 8.6, respectively. The majority of the participants are normal in all sub-scales of DASS-21. Very few are experiencing symptoms of severe or extremely severe depression (4.2%, 4.3%), anxiety (3.3%, 6.9%), and stress (3.0%, 2.3%). Geriatrics, females, health-care workers, homemakers/unemployed/retired people, rural residents, and people suffering from co-morbidities have a significant elevation of DAS scores with a P < 0.05. Conclusion: Even though most of the respondents are free from the DAS symptoms, few are still (post-COVID-19 second wave) experiencing symptoms of severe or extremely severe DAS subscales. More interview-based and probability sampling future studies are warranted to minimize the biases present in the study.
Keywords: Coronavirus disease 2019, Depression, Anxiety, and Stress Scale 21, public, severe acute respiratory syndrome coronavirus 2
|How to cite this article:|
Mekala JS, Goruntla N, Nayaka B, Velpula K, Biswas R, Veerabhadrappa KV, Pradeepkumar B. Depression, anxiety, and stress among general public of india during post-COVID-19 second wave: A web-based cross-sectional survey. Indian J Med Spec 2022;13:87-94
|How to cite this URL:|
Mekala JS, Goruntla N, Nayaka B, Velpula K, Biswas R, Veerabhadrappa KV, Pradeepkumar B. Depression, anxiety, and stress among general public of india during post-COVID-19 second wave: A web-based cross-sectional survey. Indian J Med Spec [serial online] 2022 [cited 2022 May 21];13:87-94. Available from: http://www.ijms.in/text.asp?2022/13/2/87/340030
| Introduction|| |
Coronavirus disease 2019 (COVID-19) is an emergent respiratory infection caused by the most newly discovered severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), and it was first detected in December 2019 in Wuhan, China. The World Health Organization (WHO) declared the COVID-19 outbreak as a pandemic on March 11, 2020, due to its alarming levels of spread across the countries. The global number of new cases reported from July 12 to 18, 2021, was over 3.4 million; there was a 12% rise in COVID-19 cases compared to the previous week. In India, up to date (July 23, 2021, 08:00 IST (GMT +5:30), a total of 405,513 active cases, 30,468,079 cured/discharged, and 419,470 deaths were reported according to the Ministry of Health and Family Welfare, Government of India.
The COVID-19 pandemic created a great fear among citizens of our country due to its severity, contagiousness within the community, lack of specific treatment, and risk of re-infection. The symptoms of SARS-CoV-2 infection vary widely, from asymptomatic disease to pneumonia and life-threatening complications, including acute respiratory distress syndrome, multisystem organ failure, and ultimately death.,, Older patients and those with preexisting respiratory or cardiovascular conditions appear to be at the greatest risk for severe complications., The wide variation in symptomology and the vulnerable population had created a sense of panic among the public, prone to mental illnesses.
In India, the first case was reported on January 30, 2020. To control the spread of SARS-CoV-2 infection, the nation was under lockdown (Phase 1 to Phase 4) from March 24, 2020 to May 31, 2020. Since the middle of March 2021, the second wave has started, and on April 9, the highest number of cases (144,829) has been identified in India. COVID-19 mortality rate increased 40% during the second wave post-June 2021. The overall COVID-19 mortality rate increased from 7.2% in the first wave to 10.5% in the second wave. This increase was seen in both men (10.8% from 7.4%) and women (9.8% from 6.8%). Global and national evidence shows that, COVID-19 pandemic caused a significant impact on depression, anxiety, and stress (DAS) levels among the public during the lockdown period. Prolonged lockdown is not a feasible long-term solution due to its adverse economic implications. Irrespective of the lock or unlock phase, the public must follow preventive measures to decline the rate of COVID-19 cases and prevent the spread toward the vulnerable population. There was a requirement of balance between mental state and adherence toward infection control measures to reduce the spread of infection.
The Government made the availability of the COVID-19 vaccine to the general public of India in June 2021. Even vaccine is available, initially, it was made available for only frontline health-care workers who deal with COVID-19 patients. Hence, there was a need for continuous assessment of the psychological needs of the general public of India.
The new realities of working from home, temporary unemployment, and children's home-schooling can positively impact the public., During the initial stages of COVID-19 in India, almost one-third of respondents had a significant psychological impact., This indicates a need for a more systematic and longitudinal assessment of the psychological needs of the population, which can help the government in formulating holistic interventions for affected individuals. There is a need to reveal the mental health burden and its associated factors among the public in the post-COVID-19 second wave. The study aims to assess the DAS, and associated factors among the general public of India.
| Materials and Methods|| |
This is a web-based cross-sectional survey that was conducted for a period of 15 days from July 1 to July 15 2021. Even the nation was under unlock, to avoid ongoing health threats due to COVID-19, we adopted an online platform for collecting data. The study proforma, survey tool, and informed consent procedure were approved (RIPER/IRB/PP/2021/005) by the institutional review board before the commencement of the survey. No financial incentive was provided to respondents, and anonymity was maintained to ensure confidentiality and reliability of data. The study was conducted online in compliance with the provisions of the Declaration of Helsinki regarding research on human subjects.
People who belong to the Indian nation, aged more than 15 years, and willing to participate in the study by opting “Yes” for the first question (are you willing to join in this online survey) were eligible in this survey. Foreign nationals and people already suffering from psychiatric illness are not eligible to participate in this survey.
Sample size estimation
A single population proportion formula was used to estimate the number of respondents included in this survey by assuming 50% of the people have mental health issues, 2% margin of error, 80% power, and 1% design effect and calculated as 2395. By considering 10% of nonresponse rate, the final sample size was determined as 2634. A nonprobable convenient sampling technique was used to catch respondents for this online survey.
The data were collected through online mode by providing a link to fill Google Form. A questionnaire/survey tool comprising demographics, COVID-19 stressors, and DAS Scale 21 (DASS-21) was used. The survey tool was disseminated in various messenger groups (WhatsApp, We Chat, and IMO) and social media networks (Facebook, Twitter, and LinkedIn). The first page of the form describes the background, core objectives, and expected outcomes of this online survey. The respondent needs to opt “yes” for the first question (are you willing to join in this online survey) to enter into this online survey. A total of 2714 respondents completed the survey; in these, 199 responses were removed due to incompleteness. A total of 2515 responses were taken into final data analysis.
The sociodemographic profile of the participants was obtained through both open- and close-ended questions relating to their age, gender, marital status, location, number of family members, education level, occupation, family income, history of comorbidities, history of psychiatric illnesses before the COVID-19 pandemic, and health-care job.
Coronavirus disease 2019 stressors
COVID-19-related stressors information was collected by using close-ended questions. These include worry due to closeness toward an infected person, worry due to being infected with COVID-19, under prolonged quarantine/self-isolation, perceiving COVID-19 symptoms, noncompliance with infection control measures, worry about getting medical services, fear of infection, financial uncertainty, and exposure to COVID-19 news in social and mass media.
Depression, anxiety, and stress
DASS-21 was used to assess the prevalence of DAS among the general public of India. The scale contains 21 items divided equally with 7 items into 3 subscales of depression (items: 3, 5, 10, 13, 16, 17, and 21), anxiety (items: 2, 4, 7, 9, 15, 19, and 20), and stress (1, 6, 8, 11, 12, 14, and 18). Participants' responses on each item are graded on a 4-point Likert scale (did not apply to me at all = 0, applied to me to some degree = 1, applied to me to a considerable degree = 2, and applied to me very much = 3). After assessment of scores, subscales were categorized according to the Lovibond and Lovibond version of DASS-21 as follows: normal (0–9), mild (10–12), moderate (13–20), severe (21–27), and extremely severe (28–42) for depression; normal (0–6), mild (7–9), moderate (10–14), severe (15–19), and extremely severe (20–42) for Anxiety; and normal (0–10), mild (11–18), moderate (19–26), severe (27–34), and extremely severe (35–42) for Stress.
IBM SPSS Statistics for Windows, version 22.0 (IBMCorp., Armonk, NY, USA) was used to analyze the data collected from the respondents. The data were cleaned, sorted, and processed prior start of analysis in an Excel spreadsheet. The study's findings were presented in descriptive statistics such as frequencies and percentages for categorical variables and means and standard deviations for continuous variables of socio-demographics, COVID-19 stressors, and severity levels of DASS-21 of the study respondents. Multivariate linear regression analysis was used to determine the strength of association between the independent variable (sociodemographics) and scores on the three sub-scales (DAS). Univariate linear regression analysis was used to associate COVID-19 stressors with DASS-21 subscales. All tests of associations were carried out at <0.05 level of significance and 95% confidence interval.
| Results|| |
A total of 2515 people participated in this study. The mean age of the participants was 31.3 ± 13.4 years; most of them were aged between 20 and 29 years (52.5%). The majority of the participants in this study were males (50.6%), unmarried (55.9%), graduate (45.8%), residing in an urban location (40.0%), pursuing nonhealth-care jobs (58.8%), and without having comorbidities (78.2%). Most participants live with five or more members in the same household (45.4%), with a gross family income ranging between 20,001 and 40,000 INR (25.6%). Characteristics of the study participants are depicted in [Table 1]. The distribution of COVID-19 stressors among study participants is represented in [Table 2].
|Table 2: Distribution of coronavirus disease-2019 stressors among the study participants (n=2515)|
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The mean score of DASS-21 subscales was as follows: depression (6.8 ± 8.6), anxiety (5.0 ± 7.3), and stress (7.3 ± 8.6). On the DASS-21 scale, the majority of the participants are normal in the sub-scale of depression (71.3%), anxiety (75.6%), and stress (84.9%). Very few of the respondents are experiencing symptoms of severe or extremely severe depression (4.2%, 4.3%), anxiety (3.3%, 6.9%), and stress (3.0%, 2.3%), as shown in [Table 3].
|Table 3: Respondents performance on three subscales of Depression, Anxiety, and Stress Scale (n=2515)|
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Participants' characteristics such as an age between 30 and 59 years, living with 3 or less in the same house, education of middle school or illiterate, doing clerical/shop/farm, semi-skilled work, gross family income 40,000 or less, nonhealth-care profession, and not suffering from comorbidities are having a significant very low DAS scores. Participants who were unmarried, female gender, living in a rural location, completed intermediate as higher education, acting as a student, and housewife/unemployed/retired/others, doing health-care job, and suffering from co-morbidities had high scores of DASS-21 subscales. All patient characteristics associated with DASS-21 subscales are represented in [Table 4].
|Table 4: Association of demographic variables toward Depression, Anxiety, and Stress Scale in coronavirus disease-2019 pandemic|
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Findings of univariate regression analysis revealed that history of COVID-19, close one got infected with COVID-19, under quarantine or self-isolation, having symptoms of COVID-19, worrying about family members getting infected with COVID-19, trouble in getting medical services, and anxious about COVID-19 news in media were associated with high scores of DASS-21 subscales. Participants who are financially stable in this pandemic have fewer scores of DASS-21 subscales, as shown in [Table 5].
|Table 5: Univariate regression analysis of factors associated with Depression, Anxiety, and Stress Scale in coronavirus disease-2019 pandemic|
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| Discussion|| |
Global and national evidence suggest that the lockdown of the public services had a significant impact on people's mental health during the COVID-19 pandemic. To combat the financial constraints and to escalate the revenue, the nation was entered into phase-wise unlock of several activities to meet the demands of various public sectors in India. The unlock of public services may decline the severity of the symptoms associated with DAS, but the risk of getting an infection and pursuit of reporting new cases and deaths remain unchanged. This will encompass the mental health issues in the general public and vulnerable population. Ours is the first study that was conducted during Post-COVID-19 second wave to assess the mental health concerns of the general public in India. This will give insights for implementing public health interventions to reduce the burden of mental health issues at the population level.
Our study findings revealed that very few people are experiencing severe or extremely severe symptoms of depression (4.2%, 4.3%), anxiety (3.3%, 6.9%), and stress (3.0%, 2.3%). Contrary to the findings of our study, a severe form of DAS was reported in various studies conducted in Iran, China, Saudi Arabia, and India during the lockdown period.,,, The lower prevalence in our study is attributed with time point (post-COVID-19 second wave) effect, where the public are accessible to all types of services, and there were no or few restrictions toward running of small- or large-scale businesses and doing jobs or other public activities by strict adherence to the infection control measures. The low levels of DAS scores are also associated with the availability of a vaccine against COVID-19 in India.
Participants aged between 30 and 59 years had shown a significantly low score of DAS compared to participants aged >60 years. Similar findings are also observed in studies conducted in India. These findings are supported by evidence of reporting a high death rate among the geriatric population. Hence, the rate of mental health issues among geriatrics will be very high. Participants aged <20 years also showed a significantly low score of distress. In addition to this, the female population had a high distress score, as it was consistent with a study conducted in China.
We found that being unmarried was associated with a high score of all DASS-21 subscales. Similar findings were also observed in an Iranian study. Less number of people (≤3 members) living in the same house is associated with a low score of all DASS subscales. This may be because participants were aware that the chances of infection spread are rare in less crowded home settings.
Our study revealed that high scores of DASS-21 subscales were examined in rural residents in relation to urban residents. This may be due to the widespread of COVID-19 cases in urban and rural areas of the country. In addition, the public may have a sort of fear about the available facilities to manage active COVID-19 cases in the rural settings of India. Similar findings are observed in the study's findings conducted in India between May 23 and May 29, 2020.
Education of primary school, middle school, high school, and no education level participants showed low DASS-21 subscales in relation to a professional degree. These results are nearly similar to findings of the studies conducted in the first phase of the lockdown of India., Our study findings revealed that participants doing an occupation (clerical/farm/shop, and semi-skilled work) had a significantly low DAS score. This may be due to the re-opening of all types of businesses and works during the unlock phase. The results of our study contrast with the findings of the study conducted in the lockdown phase in India. Participants (homemaker/unemployed/retired/others) had a high score of DASS-21 subscales in relation to the professional or managerial job. This could be due to sustainable transmission of DAS from lockdown to unlock phase among homemakers/unemployed/retired/others. Participants exposed to the job environment may divert their minds from the COVID-19 pandemic and get relieved from the distress.
Participants pursuing health-care jobs had a high score of DAS about the non-healthcare profession. These findings are similar to the results of previously conducted in Oman and India., The evidence generated from our study and previous studies signifies the need for interventions to cope with the DAS among frontline warriors (health-care workers) during the lockdown and unlock period of the post-COVID-19 second wave.
Our study findings reveal a significant rise in DAS among people suffering from comorbidities. This may be justified because the novel coronavirus was found to be more violent on people with comorbidities, which may result in excessive worry and psychological burden. Our study results are found to be similar to a finding of a study conducted in Saudi Arabia.
COVID-19-related stressors such as participants tested positive for COVID-19, close contact got infected with COVID-19, under home quarantine or self-isolation, having symptoms of COVID-19, worrying about family members prone to infection, trouble in getting medical services during a pandemic, financial instability, and anxiety about COVID-19 stuff presented in media were shown high score of DAS. Similar triggers associated with DAS are explored in the findings of a study conducted in the Austrian population. Planning of educational programs on DAS-sensitive COVID-19 stressors identified in this study will bring positive outcomes among the general public of India.
Strengths and limitations
The major strength of this study lies in its large sample size that was recruited in the post-COVID second wave in India. This will generate new evidence on mental health issues among the general public in the post-COVID-19 second wave. Most importantly, our findings will assist health authorities globally in identifying the target population and COVID-19 stressors toward mental health issues and implementing relevant measures. Certain limitations need to be carefully understood before the interpretation of the findings of our study. First, as this is an online web-based survey, it might not capture the responses from the locations where there was restricted access to social media and internet facilities. Even, financially weaker sections of the society who do not have Android phones or laptops are not captured in our study sample; this may result in coverage bias. Second, as this survey is not interview-based, respondents may give bias information in the self-administered online questionnaire of DASS-21 and COVID-19 related stressors. Third, the voluntary nature of the online survey might have led to a selection bias, and the respondents may not represent well the entire population. Finally, respondents unable to understand English are not covered in this online survey.
| Conclusion|| |
Even though most of the respondents are free from the DAS symptoms, few are still (post-COVID-19 second wave) experiencing symptoms of severe or extremely severe DAS subscales. Our findings reveal that geriatrics, females, healthcare workers, homemakers/unemployed/retired people, rural residents, and people suffering from comorbidities have a significant elevation of DAS scores. COVID-19-related stressors such as tested positive participants, close contact got infected, under home quarantine or self-isolation, having symptoms, worrying about family members getting infected, worrying about getting medical services, financial crisis, and anxiety about COVID-19 stuff presented in media were shown high scores on DAS subscales. More interview-based and probability sampling future studies are warranted to minimize the biases present in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Weiss P, Murdoch DR. Clinical course and mortality risk of severe COVID-19. Lancet 2020;395:1014-5.
Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E, Villamizar-Peña R, Holguin-Rivera Y, Escalera-Antezana JP, et al.
Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel Med Infect Dis 2020;34:101623.
Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al.
Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med 2020;180:934-43.
Andrews MA, Areekal B, Rajesh KR, Krishnan J, Suryakala R, Krishnan B, et al.
First confirmed case of COVID-19 infection in India: A case report. Indian J Med Res 2020;151:490-2.
] [Full text]
Rehman U, Shahnawaz MG, Khan NH, Kharshiing KD, Khursheed M, Gupta K, et al.
Depression, anxiety and stress among Indians in times of covid-19 lockdown. Community Ment Health J 2021;57:42-8.
Chowdhury R, Luhar S, Khan N, Choudhury SR, Matin I, Franco OH. Long-term strategies to control COVID-19 in low and middle-income countries: An options overview of community-based, non-pharmacological interventions. Eur J Epidemiol 2020;35:743-8.
Shepherd-Banigan M, Bell JF, Basu A, Booth-LaForce C, Harris JR. Workplace stress and working from home influence depressive symptoms among employed women with young children. Int J Behav Med 2016;23:102-11.
Blustein DL, Duffy R, Ferreira JA, Cohen-Scali V, Cinamon RG, Allan BA. Unemployment in the time of COVID-19: A research agenda. J Vocat Behav 2020;119:103436.
Chakraborty K, Chatterjee M. Psychological impact of COVID-19 pandemic on general population in West Bengal: A cross-sectional study. Indian J Psychiatry 2020;62:266-72. [Full text]
Varshney M, Parel JT, Raizada N, Sarin SK. Initial psychological impact of COVID-19 and its correlates in Indian Community: An online (FEEL-COVID) survey. PLoS One 2020;15:e0233874.
Mondal C, Adak D, Majumder A, Bairagi N. Mitigating the transmission of infection and death due to SARS-CoV-2 through non-pharmaceutical interventions and repurposing drugs. ISA Trans 2020;104:S0019-0578(20)30389-X.
Moghanibashi-Mansourieh A. Assessing the anxiety level of Iranian general population during COVID-19 outbreak. Asian J Psychiatr 2020;51:102076.
Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al.
Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020;17:1729.
Alkhamees AA, Alrashed SA, Alzunaydi AA, Almohimeed AS, Aljohani MS. The psychological impact of COVID-19 pandemic on the general population of Saudi Arabia. Compr Psychiatry 2020;102:152192.
Verma S, Mishra A. Depression, anxiety, and stress and socio-demographic correlates among general Indian public during COVID-19. Int J Soc Psychiatry 2020;66:756-62.
Vahedian-Azimi A, Moayed MS, Rahimibashar F, Shojaei S, Ashtari S, Pourhoseingholi MA. Comparison of the severity of psychological distress among four groups of an Iranian population regarding COVID-19 pandemic. BMC Psychiatry 2020;20:402.
Nathiya D, Singh P, Suman S, Raj P, Tomar B. Mental health problems and impact on youth minds during the COVID-19 outbreak: Cross-sectional (RED-COVID) survey. Soc Health Behav 2020;3:83. [Full text]
Alshekaili M, Hassan W, Al Said N, Al Sulaimani F, Jayapal SK, Al-Mawali A, et al.
Factors associated with mental health outcomes across healthcare settings in Oman during COVID-19: Frontline versus non-frontline healthcare workers. BMJ Open 2020;10:e042030.
Elbay RY, Kurtulmuş A, Arpacıoğlu S, Karadere E. Depression, anxiety, stress levels of physicians and associated factors in Covid-19 pandemics. Psychiatry Res 2020;290:113130.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al.
Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.
Traunmüller C, Stefitz R, Gaisbachgrabner K, Schwerdtfeger A. Psychological correlates of COVID-19 pandemic in the Austrian population. BMC Public Health 2020;20:1395.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]