Keywords
COVID-19 - home confinement - psychological distress
Introduction
Since December 2019, coronavirus disease 2019 (COVID-19) emerged in Wuhan city of
China and quickly disseminated across China, then later on as it is known today, throughout
the globe.[1] On March 11, 2020, the World Health Organization categorized coronavirus as pandemic,
enforcing necessary guidelines to break the transmission cycle and minimize morbidities
and mortalities.[2]
The emerging and remerging of these pathogens are always a challenge for global public
health services affecting both individual as well as health care system levels. Although
the possible origin of COVID-19 is still a debatable notion, possibility has been
given to bats, which later on affected the mammalian hosts.[3] Furthermore, previous outbreak of Middle East respiratory syndrome and severe acute
respiratory syndrome (SARS) has also proved to be a difficult confrontation for the
public health authorities and health care workers.[4]
Regarding transmission of coronavirus, the primary route has been through direct human
to human close contact via respiratory droplets.[5]
[6] Due to this, global health communities in collaboration with government authorities
decided to impose lockdown to promote social distancing, hence hindering the transmission
cycle of this virus. The initial incubation period of the infected person has been
noted to be anywhere between 2 and 14 days, which may vary.[7]
[8] Symptomatic patients mainly present with fever, dry cough, sore throat, myalgia,
and later on shortness of breath, with disturbed smell sensation and stomach upset
seen in some patients.[9]
[10] Moreover, these symptoms may tend to worsen with time or some patients may not even
present with any symptoms and yet still be COVID-19 positive.[11]
[12] The latter scenario is more problematic for the health care community because these
asymptomatic individuals tend to circulate the virus around themselves without knowing
it. Different age groups in the society may have different susceptibility as well
as fatalities rates when affected by the novel coronavirus.
Additionally, elderlies and those with underlying comorbidities such as hypertension,
diabetes, chronic respiratory ailment, and immunosuppression are known to contract
the virus more readily as well as may even suffer a severe infection.[13]
[14] Habit such as smoking is also associated with negative progression as well as adverse
outcomes in a patient suffering from COVID-19.[15] Although all age groups are susceptible to contracting the virus, young healthy
individuals are less likely to contract the virus as well as to suffer from severe
infection as compared with the elderlies and those with comorbidities.[16]
Throughout the globe, countries have imposed lockdown of different criteria mainly
focusing on social distancing as individuals are not allowed to leave their house
unless it is necessary. This has led to home confinement of the general population
which has been previously unknown in generality. These massive quarantine measures
imposed by the authorities have led to common mental health problems such as anxiety
and depression along with fear of contracting COVID-19 as well as being in close contact
with anyone. Moreover, individuals are handling this home confinement differently
with mental health status or psychological distress being a concern. Besides all these
points, the current generation is not accustomed to handle such social distancing
protocols primarily due to increased number of social activities and gatherings, therefore,
perceiving it as home imprisonment. Additionally, the idea of home confinement perceived
as imprisonment wrecks a havoc among all of the population, but young adults experience
greater social gatherings as compared with middle-aged and older adults, hence the
younger adults are more prone to develop psychological distress.
Economical downfall has led to earning deficit on both employers as well as employees,
hence delay in wages. Unemployment amidst COVID-19 outbreak is another contributing
factor which may lead to uneasiness and a constant fear.
The temperamental nature of this pandemic has been amplified by myths and misleading
information, often driven by counterfactual news reports and the population’s wrong
understanding of the health care messages, thus generating more worry.
This study has aimed to provide an assessment of the psychological distress among
the adult population residing in Pakistan facing home confinement ever since the lockdown
was imposed officially by the government. Risk factors that may exacerbate mental
uneasiness of the adult population have been addressed in this study such as age,
gender, level of education, province, and socioeconomic status.
The rationale of our study is to evaluate the psychological impact of COVID-19 on
adults in home confinement. Evaluating it might prevent any negative outcomes inflicted
by this pandemic in future. Therefore, this investigation might aid in providing counseling
and treatment plans for those who are affected. Furthermore, similar studies have
been conducted assessing similar aims to our study.[17]
[18]
Materials and Methods
In Pakistan, general population was restricted to home starting from March 23, 2020,
marking the beginning of official lockdown and was allowed to visit outside only on
necessary basis as stated by the government. A well-structured questionnaire consisted
of closed-ended questions was constructed. The questionnaire was uploaded to Google
forms and an online link was created. OpenEpi sample size calculator was used to calculate
the sample size of this study with the participants’ response rate of 178,417 and
desired percentile of 50. Keeping the confidence interval of 95% and α error of 5%,
the total sample size calculated was 1,000 participants.
The simple random sampling technique was applied in this study. The participants were
invited to join through short messaging services. Those who accepted to participate
were formally requested to fill a well-structured online questionnaire through different
social media platforms such as WhatsApp, Instagram, Facebook messenger, Viber, Zalo,
Telegram, and e-mails by direct sharing of the online link. Consent statement was
included in the questionnaire for voluntary participation and response was recorded.
The study included adult population only residing in different provinces of Pakistan
currently being under lockdown situation. Children and adolescents were excluded from
this study. The participants were anonymous, and their information were kept confidential.
Ethics and review committee of Altamash Institute of Dental Medicine (AIDM) approved
this study (AIDM/EC/04/2020/01).
The questionnaire was focused on symptoms of anxiety and depression using validated
measurement tools.[19]
[20] Section 1 included information regarding demographic data which includes age group,
gender, location, level of education, occupation, earnings, and general questions
regarding optimism about the current pandemic and if worried about being infected
by COVID-19 was also part of this questionnaire.
Section 2 comprised specific questions on depressive and anxiety symptoms using Patient
Health Questionnaire-9[19] (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) scales,[20] respectively. Each question in both scales denotes four options as follows: 0 =
not at all, 1 = several days, 2 = more than half the days, and 3 = nearly every day.
Each option had its own numerical value to provide total score at the end.
The total mean scores were interpreted as PHQ-9, normal (0–4), mild (5–9), moderate
(10–14), moderately severe (15–19), and severe (20–27) depression and GAD-7, normal
(0–4), mild (5–9), moderate (10–14), and severe (15–21) anxiety. All these questions
were formulated in the questionnaire and made in English language.
The data analysis was performed on SPSS statistical software version 25. The p-value of ≤ 0.05 was considered as statistically significant. Descriptive statistics
was used to determine frequency, percentages, mean, and standard deviation of the
quantitative and qualitative variables. Furthermore, to analyze confounders, any relation
of age, gender, earnings, education, and occupation with PHQ-9 and GAD-7 scores, independent
t-test, cross tabulation, and regression analysis tests were performed.
Results
In this study, a total of 1,080 filled questionnaires were received after scrutiny;
80 forms were excluded on the basis of irrelevance and partially filled forms. The
response rate of the participants was 92.59%. The internal consistency of items in
questionnaire was tested by intraclass correlation with a strong relation of 0.85.
As presented in [Table 1], of the 1,000 participants, majority were males and belonged to 18 to 30 years age
group. Predominantly, individuals had undergraduate and graduate levels of education.
Students, business, health care workers, and engineers were most selected occupation
of the participants. Furthermore, more than one-third participants believed that their
earning is affected during COVID-19. Moreover, in our study, majority of subjects
were currently unemployed during this pandemic. While two-third of participants were
confined to home for more than 40 days and worried during the current COVID-19 outbreak
but with a strong believed that normal situation will be restored soon ([Table 2]). The main characteristics of PHQ-9 and GAD-7 scales are described in [Table 3].
Table 1
Demographic characteristics of participants (N = 1,000)
|
Variables
|
n (%)
|
|
Age, y
|
|
18–30
|
569 (56.9)
|
|
31–40
|
210 (21.0)
|
|
41–50
|
102 (10.2)
|
|
51–60
|
61 (6.1)
|
|
Above 60
|
58 (5.8)
|
|
Education
|
|
Undergraduate
|
375 (37.5)
|
|
Graduate
|
346 (34.6)
|
|
Postgraduate
|
187 (18.7)
|
|
Below undergraduate
|
92 (9.2)
|
|
Occupation
|
|
Business
|
178 (17.8)
|
|
Health care worker
|
139 (13.9)
|
|
Engineer
|
108 (10.8)
|
|
Student
|
327 (32.7)
|
|
Labor work
|
15 (1.5)
|
|
Unemployed
|
96 (9.6)
|
|
Others
|
137 (13.7)
|
|
Gender
|
|
Male
|
573 (57.3)
|
|
Female
|
427 (42.7)
|
|
Province
|
|
Sindh
|
550 (55.0)
|
|
Punjab
|
237 (23.7)
|
|
Baluchistan
|
93 (9.3)
|
|
Khyber Pakhtunkhwa
|
120 (12.0)
|
Table 2
Responses pertaining to home confinement and financial situation of participants (N = 1,000)
|
Variables
|
n (%)
|
|
Abbreviation: COVID-19, coronavirus disease 2019.
|
|
You are in confinement from how many days?
|
|
1–10 d
|
59 (5.9)
|
|
11–20 d
|
56 (5.6)
|
|
21–30 d
|
76 (7.6)
|
|
31–40 d
|
157 (15.7)
|
|
More than 40 d
|
652 (65.2)
|
|
Do you think the normality will be restored nearly?
|
|
Yes
|
511 (51.1)
|
|
No
|
199 (19.9)
|
|
Do not know
|
290 (29.0)
|
|
Does COVID-19 affect your earning?
|
|
Yes
|
424 (42.4)
|
|
No
|
491 (49.1)
|
|
Maybe
|
85 (8.5)
|
|
What is your current earning?
|
|
Rs. 10,000–20,000
|
40 (4.0)
|
|
Under Rs. 10,000
|
50 (5.0)
|
|
Rs. 20,000–30,000
|
64 (6.4)
|
|
Rs. 30,000–40,000
|
79 (7.9)
|
|
Rs. 40,000–50,000
|
101 (10.1)
|
|
Above Rs. 50,000
|
228 (22.8)
|
|
Currently unemployed
|
438 (43.8)
|
|
Are you worried about current financial situation?
|
|
To a large extent
|
42 (4.2)
|
|
To a moderate extent
|
329 (32.9)
|
|
To a little extent
|
453 (45.3)
|
|
Not at all
|
176 (17.6)
|
|
Does COVID-19 affect your earning?
|
|
Yes
|
424 (42.4)
|
|
No
|
491 (49.1)
|
|
Maybe
|
85 (8.5)
|
Table 3
Characteristics of PHQ-9 and GAD-7 scales (N = 1,000)
|
|
Not at all, %
|
Several days, %
|
More than half the days, %
|
Nearly everyday, %
|
|
Abbreviations: GAD, Generalized Anxiety Disorder; PHQ, Patient Health Questionnaire.
|
|
PHQ-9 scale
|
|
PHQ-1
|
Little interest or pleasure in doing things
|
33.1
|
44.4
|
11.3
|
11.2
|
|
PHQ-2
|
Feeling down, depressed, or hopeless
|
32.1
|
46.8
|
11.1
|
10.0
|
|
PHQ-3
|
Trouble falling or staying sleep or sleeping too much
|
43.4
|
31.7
|
11.4
|
13.5
|
|
PHQ-4
|
Feeling tired or having low energy
|
40.8
|
35.6
|
12.9
|
10.7
|
|
PHQ-5
|
Poor appetite or overeating
|
52.3
|
27.3
|
11.5
|
8.9
|
|
PHQ-6
|
Feeling bad about yourself
|
64.1
|
20.1
|
7.8
|
8.0
|
|
PHQ-7
|
Trouble concentrating on things
|
58.8
|
21.8
|
10.3
|
9.1
|
|
PHQ-8
|
Moving or speaking slowly
|
65.7
|
20.7
|
9.2
|
4.4
|
|
PHQ-9
|
Thoughts about hurting yourself
|
71.7
|
16.4
|
7.5
|
4.4
|
|
GAD-7 scale
|
|
GAD-1
|
Feeling nervous, anxious
|
36.4
|
45.2
|
12.7
|
5.7
|
|
GAD-2
|
Not being able to stop or control worrying
|
35.8
|
41.5
|
13.5
|
9.2
|
|
GAD-3
|
Worrying too much
|
30.3
|
44.8
|
15.1
|
9.8
|
|
GAD-4
|
Trouble relaxing
|
49.1
|
31.1
|
12.1
|
7.7
|
|
GAD-5
|
Being restless
|
52.9
|
29.9
|
10.3
|
6.9
|
|
GAD-6
|
Being easily annoyed or irritable
|
45.7
|
32.0
|
11.8
|
10.5
|
|
GAD-7
|
Feeling something awful might happen
|
43.1
|
34.1
|
12.5
|
10.3
|
In our study, the PHQ-9 scores of the 1,000 adults fall in the following categories
for depression: none, 460; mild, 254; moderate, 165; moderately severe, 74; severe,
47 and GAD-7 categories for anxiety: none, 520; mild, 284; moderate, 139; severe,
57. A considerable number of participants reported to have depressive (540, 54%) and
anxiety (480, 48%) symptoms, with females responding with more depressive (611, 61.1%)
as well as anxiety (532, 53.2%) symptoms as compared with males. Considering age group,
participants belonging to the age group of 18 to 30 years divulged to suffer from
more anxiety (522, 52.2%) as well as depressive (611, 61%) symptoms with increasing
age leading to less anxiety as well as depressive symptoms among adults. In view of
level of education, it was found that adults having undergraduate and postgraduate
educational backgrounds had most anxiety (489, 48.9% and 530, 53%, respectively) and
depressive (570, 57% and 670, 67%, respectively) symptoms in comparison to those belonging
to graduate and below undergraduate educational levels. Labor workers had the highest
anxiety (930, 93%) and depressive (870, 87%) symptoms. The students, health care workers,
and those currently unemployed individuals report similar symptoms. Furthermore, those
earning above Rs. 50,000 had less anxiety (400, 40%) and depressive (460, 46%) symptoms
as compared with ones earning below Rs. 50,000.
The mean value of PHQ-9 and GAD-7 were 6.91 and 6.14, respectively, which falls in
mild psychological distress category as described in [Table 4]. As far as the effect of gender is concerned, we noted a significant difference
PHQ-9 (p = <0.00) and GAD-7 (p = 0.03) between the responses of two scales. Additionally, in our study, the participants
belonged to the mean age bracket of 18 to 30 years and when the effect age was compared
with GAD-7 and PHQ-9 scores, we found a significant difference (p = 0.001) and (p = 0.004), respectively, among the participants as described in [Table 3].
Table 4
Effect of gender and age groups on PHQ-9 and GAD-7 scales (N = 1,000)
|
Variable
|
Gender
|
p-Value
|
|
Male (mean, SD)
|
Female (mean, SD)
|
Sample (mean, SD)
|
|
Abbreviations: GAD, Generalized Anxiety Disorder; PHQ, Patient Health Questionnaire;
SD, standard deviation.
|
|
PHQ-9 score
|
6.14 ± 5.83
|
7.94 ± 6.22
|
6.91 ± 6.06
|
0.000
|
|
GAD-7 score
|
5.65 ± 4.87
|
6.81 ± 5.39
|
6.14 ± 5.13
|
0.030
|
|
Age (y)
|
|
|
18–30
|
31–40
|
41–50
|
51–60
|
Above 60
|
|
PHQ-9 score
|
7.78 ± 6.26
|
6.39 ± 5.23
|
6.07 ± 5.99
|
5.42 ± 6.20
|
3.31 ± 4.89
|
0.004
|
|
GAD-7 score
|
6.72 ± 5.44
|
5.5 ± 4.34
|
5.57 ± 4.88
|
5.88 ± 5.16
|
4.03 ± 4.10
|
0.001
|
The linear regression analysis revealed a significant association of occupation, current
earnings, and earnings affected during outbreak with GAD-7 and PHQ-9 mean scores amid
COVID-19 pandemic as presented in [Table 5]. However, there was no significant difference between education levels and psychological
distress.
Table 5
Linear regression of financial, occupation, and education levels amid COVID-19 outbreak
and its psychological impact during home confinement (N = 1,000)
|
Acronym of study scales
|
Variables
|
Unstandardized coefficients
|
Standardized coefficients beta
|
t
|
p-Value
|
95% confidence interval for B
|
Collinearity
|
|
B
|
Std. error
|
Lower bound
|
Upper bound
|
Tolerance
|
VIF
|
|
Abbreviations: B, the rate of change per unit between dependent and independent variables; COVID-19,
coronavirus disease 2019; GAD, Generalized Anxiety Disorder; PHQ, Patient Heath Questionnaire;
Std., standard deviation; t, test of the regression coefficients; VIF, variance inflation factor, denotes the
amount of multicollinearity in model.
Notes: Beta denotes the correlation between variables. For PHQ-9, the constant for
R-squared (R2) = 0.058 and adjusted R-squared (AR2) was 0.055, while for GAD-7, R2 = 0.048 and AR2 was 0.044.
a
p-Value < 0.001.
b
p-Value < 0.05.
|
|
PHQ-9
|
Education
|
̵0.353
|
0.196
|
̵0.056
|
̵1.795
|
0.073
|
̵0.738
|
0.033
|
0.970
|
1.031
|
|
Occupation
|
0.414
|
0.099
|
0.133
|
4.173
|
0.000a
|
0.219
|
0.609
|
0.928
|
1.078
|
|
Current earnings
|
̵0.667
|
0.113
|
̵0.193
|
̵5.931
|
0.000a
|
̵0.888
|
̵0.447
|
0.898
|
1.113
|
|
COVID-19 affected earnings
|
̵0.798
|
0.318
|
̵0.083
|
̵2.508
|
0.012b
|
̵1.422
|
̵0.173
|
0.872
|
1.146
|
|
GAD-7
|
Education
|
̵0.349
|
0.167
|
̵0.066
|
̵2.091
|
0.037b
|
̵0.677
|
̵0.021
|
0.970
|
1.031
|
|
Occupation
|
0.190
|
0.084
|
0.072
|
2.253
|
0.024b
|
0.025
|
0.356
|
0.928
|
1.078
|
|
Current earnings
|
̵0.509
|
0.096
|
̵0.173
|
̵5.317
|
0.000a
|
̵0.697
|
̵0.321
|
0.898
|
1.113
|
|
COVID-19 affected earnings
|
̵0.773
|
0.271
|
̵0.095
|
̵2.855
|
0.004b
|
̵1.304
|
̵0.242
|
0.872
|
1.146
|
Discussion
This cross-sectional study had enrolled 1,000 participants, unraveling 54% of the
adult population reporting depressive symptoms and 48% with anxiety symptoms. Most
participants were males. To conclude, our study reported that female gender experienced
more depressive and anxiety symptoms as compared with males which could be due to
increased work burden alongside being confined to home.[21] Female gender is further affected mentally and being overburdened physically by
looking after their children and family. Additionally, parents are further stressed
by children staying at home, since their future remains uncertain due to closure of
schools, colleges, and universities as part of lockdown currently imposed.
Most of the participants in our study belonged to 18 to 30 years age group and this
age group responded with highest depressive and anxiety scores in comparison with
other age groups. Young adults as found in our study are suffering more anxiety and
depressive symptoms. One of the reasons could be that this age group participates
more in social activities, making home confinement for long periods of time a mental
havoc. On one hand, elderly in our study reported to experience less depressive and
anxiety symptoms, and on the other hand, the literature states elderlies do experience
it especially during COVID-19 outbreak.[22]
[23] This can be due to higher maturity and more understanding nature with regard to
the current situation.
Adult populations are involved in various occupations in Pakistan. We deduced in our
study that students, labor workers, health care workers, and unemployed individuals
reported higher anxiety and depressive scores. Unemployment among daily wage earners
especially labor workers is a major concern. Socioeconomic factor has been of significant
importance in adult’s mental well-being. Primary mode of transmission of COVID-19
is direct human to human because health care workers work in close approximation with
patients, this generates further worry among close family members in home confinement
due to increased risk of contracting the virus.[24] In students mainly belonging to young adults age group, unaccustomed to be in home
confinement, this creates mental health disturbance symptoms. Moreover, companies
have been cutting short their employers count due to current financial crises of the
country, so unable to cope up during these tough times is a further contributing factor.
COVID-19 has taken a heavy toll on economic pillar of different countries. Low- and
middle-income countries such as Pakistan have health care systems not being well established
to cater such challenges.[25] Countries ranking in low gross domestic product (GDP) categories have been affected
more substantially as compared with those belonging to high GDP rankings. In addition
to this, those with high GDP can economically compensate their residents so as to
reduce financial as well as mental stress. Losing jobs as well as salary reduction
make matters worse for individual’s family especially when they are the lone earner
in a family of multiple dependents. As the adult’s monthly earnings decreased from
Rs. 50,000 to Rs. 10,000, more depressive and anxiety symptoms presented among them.
Additionally, it has been reported that hoarding of personal protective equipment
has made availability as well as cost of these a major hurdle to protect oneself,
generating further anxiety and depression.[26] Furthermore, shortage of basic personal necessities due to its hoarding is another
contributing factor to generate stress among the population.[27] Many people have also initiated the practice of “panic buying” large stocks of basic
necessities in the midst of this outbreak.[28]
Various information regarding coronavirus pandemic are available on different platforms,
although its creditability is questionable. Moreover, misinformation regarding the
coronavirus pandemic has been known to generate mental health disturbances.[29] Overwhelming flow of headline news as well as images and videos regarding COVID-19
and its infectives can be a stress boosting factor. Majority of the adults are worried
regarding the current circumstances, but they are remaining optimistic hoping that
situation will resolve. Although current literature states varying information on
when the pandemic will end, the previous pandemic, Spanish flu, ~100 years ago, lasted
for 2 years which can act as a predictor for the COVID-19 pandemic.[30]
Psychological distress is a worrying notion these days since the beginning of this
pandemic. In literature, it is reported that various countries are implementing protocols
by forming authorities that are responsible to cater individual’s mental health problems,
although we found no such authorities working here.[31] This can be due to bigger dilemmas being faced by authorities here such as economic
burdens and implementing protection protocols against COVID-19.
We have deduced that coronavirus pandemic has a major impact on mental health of adults.
Literature states individuals have started avoidance behavior regarding social gathering
as well as maintaining strict hygiene measures.[32] Adults are currently experiencing fear of contracting the virus as well as boredom,
health changes, loneliness, and anger during these tough times.[33]
[34] Mandatory tracing of contacts of COVID-19 positive patient’s friends and relatives
as well as undergoing 14 days of quarantine has enhanced already present stress.[33]
In accordance with Xiang et al, mental health care needs to be timely managed to prevent
psychological impact on one’s life.[35] Previously, during 2003 SARS outbreak, similar conditions have been reported as
currently being experienced.[36] So far mental health of the general population as well as the patients suffering
from COVID-19 seems to be under-addressed.
We evaluated psychological impact of COVID-19 in adults and found some limitations.
First, this study can be conducted between adults of different countries which can
provide better results and comparison regarding mental health status as home confinement
is being performed globally. Finally, inclusion of children and adolescents can increase
the scope of assessing psychological impact since mental health disturbance is also
found in this age group. Avoiding these limitations can aid in further studies being
carried on.
Conclusion
To conclude, COVID-19 pandemic does have a psychological impact on the adult population
in home confinement, although education levels have no significant association with
psychological distress. This study proposed that mental health disturbance is a concerning
yet addressable issue if proper measures are instituted. Special interventions to
encourage mental health support in adults need immediate implementation to avoid any
potential psychological impact of the current situation in the future.
