|Year : 2020 | Volume
| Issue : 2 | Page : 101-106
Psychological distress during early phase of COVID-19 pandemic among Indian adults
Aditya Somani1, Suhas Chandran2, Ashirbad Satapathy3, Ajay Kumar1, Azhar Mahmood Farooqui4, Johnson Pradeep2, Priya Sreedaran2, Debasweta Purkayastha2
1 Assistant Professor, Department of Psychiatry, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
2 Assistant Professor, Associate Professor, Senior Resident, Department of Psychiatry, St. John's Medical College Hospital, St John's National Academy of Health Sciences, Bengaluru, Karnataka, India
3 Assistant Professor, Department of Psychiatry, Bhima Bhoi Medical College and Hospital, Balangir, Odisha, India
4 Assistant Professor, Department of Psychiatry, Integral Institute of Medical Sciences and Research, Lucknow, Uttar Pradesh, India
|Date of Submission||28-Oct-2020|
|Date of Acceptance||23-Nov-2020|
|Date of Web Publication||14-Jan-2021|
Dr. Aditya Somani
Department of Psychiatry, All India Institute of Medical Sciences, Raipur - 492 099, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Introduction: Novel coronavirus disease (COVID-19) pandemic and resultant lockdown are likely to cause a significant negative impact on mental health of people all over the world.
Aim: To assess psychological distress due to COVID-19 pandemic among Indian adults and its possible correlates.
Subjects and Methods: An online survey using nonprobability snowball sampling technique was carried out. The survey included willing adult residents of India with access to internet. Health-care professionals, people with COVID-19 or those with a relative having COVID-19, and those receiving treatment for any psychiatric disorder currently were excluded. Psychological distress was assessed using COVID-19 Peritraumatic Distress Index (CPDI).
Results: Majority of participants were young (age group, 18–40 years) (71.8%), males (72%), married (69.9%), graduate (51.8%), and semiprofessionals and professionals (56.5%). Majority of the participants did not have family members of age up to 5 years or less (64.8%) or age 60 years and above (61.9%) in their families. There was no COVID-19-positive patient in town or district of majority of participants (53.9%). Based on CPDI score, 22% of the participants had mild psychological distress and 1.6% had severe distress. CPDI score showed a positive correlation with size of family of participants. Other demographic variables did not show any association/correlation with CPDI score.
Conclusions: Nearly a quarter of participants were found to have psychological distress due to COVID-19 pandemic. Anxiety and psychological distress might worsen with further worsening of pandemic and downfall of global economy. It is imperative to implement preventive and early intervention measures to safeguard mental health of people.
Keywords: COVID-19, India, lockdown, psychological distress
|How to cite this article:|
Somani A, Chandran S, Satapathy A, Kumar A, Farooqui AM, Pradeep J, Sreedaran P, Purkayastha D. Psychological distress during early phase of COVID-19 pandemic among Indian adults. Arch Ment Health 2020;21:101-6
|How to cite this URL:|
Somani A, Chandran S, Satapathy A, Kumar A, Farooqui AM, Pradeep J, Sreedaran P, Purkayastha D. Psychological distress during early phase of COVID-19 pandemic among Indian adults. Arch Ment Health [serial online] 2020 [cited 2021 Feb 25];21:101-6. Available from: https://www.amhonline.org/text.asp?2020/21/2/101/306870
| Introduction|| |
Within months of its origin, the novel coronavirus disease (COVID-19) has spread across the globe and has been declared a pandemic by the World Health Organization (WHO)., This pandemic is being considered by the experts as the worst crisis being faced by the humanity since the World War-II. Most of the countries have enforced a state of lockdown to curtail the rate of spread of the disease and also to buy time to discover treatment protocol, vaccine, or any other measure to mitigate the calamity. Till date, there is no clear treatment protocol for COVID-19.
Experience gained from natural calamities, man-made disasters, epidemics, and pandemics in the past suggests that COVID-19 pandemic is likely to have a serious impact on minds of people. Experts all over the world are expecting COVID-19 to cause significant psychological distress and have issued a warning regarding the same.,,,,,, The manifestations could vary from simple distress to serious ones such as depression, anxiety disorders, substance use disorder, domestic violence, child abuse, and suicide., Studies assessing psychological impact of COVID-19 on general public during the early phase of pandemic have been published from China, India, and Iran.,,, Depending on timing of the study and tool used, the prevalence of psychological distress in these studies varies from 35% to 61%.,,, Psychological impact seems to be more severe in females and young population.,
Despite its huge population, India was able to limit spread of COVID-19 during the early phase of pandemic. The number of cases as well as deaths due to COVID-19 in India was significantly less compared to some of the most advanced countries of the world during the early phase of pandemic. On March 25, 2020, when the number of confirmed COVID-19-positive cases stood at 519, India entered a complete lockdown for 21 days. During this phase, only essential services such as hospitals, pharmacies, dairies, and grocery stores were allowed to operate. During lockdown, majority of people stayed at their homes and spent their time reading/watching figures and rising graphs of COVID-19 cases. During this period, they also heard a lot about COVID-19 from politicians, bureaucrats, journalists and medical experts over electronic and social media.
At this point of time, this study was planned and carried out. At the time of initiation of this study and collection of data, people of India had already spent 2 weeks under lockdown and had received large amount of information about COVID-19 through print, electronic, and social media. This study aimed to assess psychological distress due to COVID-19 pandemic among Indian adults and its possible correlates.
| Subjects and Methods|| |
Procedure and participants
This study was a cross-sectional survey, which was carried out as an anonymous online questionnaire administered through Google Forms®. Nonprobability snowball sampling strategy was used to recruit participants. The survey was carried out from April 10, 2020, 09:00 AM IST, to April 14, 2020, 09:00 PM IST. The online survey was disseminated by the investigators to their contacts, using WhatsApp® and E-mail with request for participation as well as for further dissemination among their contacts. The first webpage of the survey provided detailed information about the survey (including inclusion and exclusion criteria). Participants were expected to check if they were eligible to participate in the study and provide consent for participation.
The participants were included if they were aged 18 years or above, any gender, resident of India, had access to internet, could read/understand Hindi or English, and were willing to give consent for participation. Health-care workers and those who had suffered from COVID-19 or had a relative who had suffered from COVID-19 were excluded. People who were currently receiving treatment for any psychiatric disorder were also excluded.
The study was approved by the institutional ethics committee.
The first part of the survey collected demographic information and inquired about the presence of children of age up to 5 years, elderly aged 60 years or above in the family, and any COVID-19-positive patient in the town/district of the participant. The second part of the survey dealt with assessment of psychological distress.
Psychological distress due to COVID-19 was assessed using COVID-19 Peritraumatic Distress Index (CPDI). CPDI is a scale developed and verified for content validity by scholars at Shanghai Mental Health Center, China. It consists of 24 questions that explore anxiety, depression, specific phobias, cognitive changes, avoidance and compulsive behavior, physical symptoms, and loss of social functioning due to COVID-19 in the past 1 week. For each question, participants could choose one among the five options, i.e., never, occasionally, sometimes, often, and most of the times, which were scored as 0, 1, 2, 3, and 4, respectively. Findings of CPDI are reported as display score, i.e., total score of responses of all 24 questions plus 4. The display score up to 28 is considered normal, 29–52 shows mild distress, and the score of 53 or more shows severe distress. The Cronbach's alpha of CPDI is 0.95. Permission was obtained from the original developers of CPDI for its translation into Hindi and use in the current study. The English version of CPDI was translated into Hindi by following step 1–3 of the WHO recommended process for translation and adaptation of instruments. The information about survey, consent form, and survey questionnaire were presented to participants in Hindi and English.
Descriptive statistics were calculated for demographic variables. Continuous variables were reported as mean with standard deviation (S. D.) and categorical variables were reported as number with percentage of total. Based on the cutoff values for display score of CPDI, participants were divided into two groups: those with psychological distress and those without psychological distress. Statistical significance of pattern of distribution of various variables among these two groups was assessed using Chi-square test. Pearson's correlation (r) was used to assess the correlation between CPDI score and age and number of family members. The analysis was carried out using Statistical Package for the Social Sciences 20.0 (IBM® SPSS® Statistics, New York, United States).
| Results|| |
The survey received 387 responses, of which 386 completed the survey and one participant denied to participate. The participants were distributed across 23 states and union territories among the total 36 states and union territories of India. The demographic details of participants are described in [Table 1].
Majority of participants were young (age group, 18–40 years) (71.8%), males (72%), married (69.9%), graduate (51.8%), and semiprofessionals and professionals (56.5%). Majority of the participants did not have family members of age up to 5 years (64.8%) or age 60 years and above (61.9%). Furthermore, majority of participants reported that there was no COVID-19-positive patient in their town or district (53.9%). The mean CPDI score for all participants was 22.05 (S. D. = 11.66). Based on the cutoff values for CPDI scores, 23.6% of participants had psychological distress. Among these, 22% had mild distress and 1.6% had severe distress. There was no statistically significant difference in the distribution of individuals with distress and individuals without distress across groups based on age, gender, marital status, education, occupation, presence of young children, or presence of COVID-19-positive patient in the town/district of the participant. CPDI score showed a positive correlation with size of family of participants (r = 0.101, P = 0.048), but not with age (r = −0.47, P = 0.358).
| Discussion|| |
This study has assessed psychological distress among lay adult people of India due to COVID-19 pandemic at the time when the country has spent 2 weeks in lockdown enforced by the government to limit the spread of this virulent condition. This survey records prevalence of psychological distress as 23.6%. This is notably different from other countries. The study by Qiu et al., 2020, in China has found the prevalence of distress as 35%. Another study from China during the early phase of COVID-19 outbreak has noted that 53.8% of the participants had moderate-to-severe psychological impact. The prevalence of psychological distress among adults of Iran was 61.1%, higher than either India or China. The study by Qiu et al., 2020, in China showed that the score of CPDI was associated with age, gender, education, and occupation. The study by Wang et al., 2020, which was also from China, showed a significant association of psychological impact with female gender and student status. Higher distress level was noted among female participants in Iran too. However, age and education level did not predict distress in Iranian population. Distress level was higher among unemployed participants in Iran. This study did not find any association of experienced distress with age, gender, marital status, education, or occupation. Furthermore, presence of young children, elderly, or presence of COVID-19-positive patient in town/district did not make any difference. Level of distress showed a positive correlation with size of family. This finding could possibly be explained by the fact that families are relatively intact in India and there are strong ties among family members, compared to Western world. People are probably worried for themselves as well as their family members. This aspect has not been assessed in other studies.
The causes of psychological distress due to COVID-19 pandemic could be varied.,, The distress could be due to the fear of contraction of serious disease to oneself or to near and dear ones and possible loss of life. Extensive media coverage and dramatic presentation of figures on news channels as well as social media platforms have possibly contributed to worsening of anxiety and distress. Implementation of lockdown has contributed to psychological distress in its own way. Strict restrictions on movement and gathering have forced people to spend their time indoors, curbed the avenues for entertainment and coping, led to postponement of social/family functions, curtailed possibilities of family reunion, and have fueled a sense of insecurity in minds of people. Loss of income/salary/jobs due to lockdown is huge. These are only few among the long list of contributing factors. Varying contribution of these and maybe other factors could possibly explain the difference in the prevalence of psychological distress and its predictors across countries. Probably, the most important factor is the number of patients suffering from COVID-19 in each of the countries and deaths due to the same. In terms of number of cases and deaths due to COVID-19, India was doing better than most of the advanced countries of the world at the time of this survey. These figures could have possibly generated some solace due to which the manifestation of distress and/or anxiety was less compared to other parts of the world. Next important factor that could influence findings is the timing of assessment. Each point of time of assessment in pandemic situation comes with its own issues. As time passes, rising figures might increase distress, and better preparedness and handling of crisis might decrease distress, and on the other hand, mounting financial difficulties due to continued lockdown and resultant loss of job/business/salary might have negative impact on minds of people. Thus, the permutation and combination of multiple operating factors shall lead to variation in the results of such studies depending on what factors are dominating the scene at that time. Studies by Qiu et al., 2020, and Wang et al., 2020, were also carried out in the early phase of pandemic., Timing for the current study has possibly allowed people to gather sufficient information about the problem and to mount a balanced response. Other contributing factors include availability of amenities of daily living, handling of situation by the government of the country, and perceived trust of public in government/authorities/leaders., A recent survey showed that people of India have faith in their current leadership and believe that government of India will handle this crisis well. Thus, there are multiple factors that are shaping response of people in each country. Therefore, each country is required to assess situation for its people and prepare roadmap for action accordingly.
Before rolling-out of this survey, only one study was published from India on this subject. This study had reported that 80% of the participants were preoccupied with the COVIID-19 pandemic, 72% were worried about themselves and their close ones, and 12% had sleeping difficulty due to worries about the pandemic. However, it is to be noted that half of the participants of this study were health-care professionals (HCP). HCPs are likely to have higher anxiety due to occupational risk of exposure and disease contraction. Furthermore, this study was conducted just before implementation of lockdown, a period when confusion and apprehension of imminent danger was high in the public. Further, the prevalence of distress reported in this study is based on the response to a single question, in a self-designed semistructured questionnaire. This study had not used any valid screening/diagnostic tool for assessment of psychological distress or anxiety among respondents.
The findings of the current study point toward a significant psychological impact of COVID-19 pandemic in general public of India. The findings are noteworthy for clinicians as well as public health officials/experts. Clinicians are likely to see a spurt of mental health problems and need to equip themselves with suitable tools so as to deal with all possible demands. While internists are already overburdened, mental health professionals shall also see huge workloads for themselves in near future. Public health experts and officials have even greater challenge to face. They have to take care of both spread of pandemic and mental health of people. Peace of mind, if lost, can have serious short-term, intermediate, and long-term health implications. The WHO has already issued important guidelines about this issue.
The study was a cross-sectional survey and could not capture dynamic nature of psychological reactions. Repeated surveys would be needed for this purpose. The survey could capture only people who had access to internet. It could not have any representation from masses who are poor and do not possess smartphones but are facing extreme hardships currently. Due to limitation of time, validation of Hindi translation of CPDI could not be carried out. Representation of senior citizens was limited. Furthermore, children and adolescents could not be assessed in this survey. Assessment of different segments of society and their unique set of issues could not be carried out in this study. Due to inherent design of Google Forms® platform, number/details of nonresponders/dropouts could not be figured out.
| Conclusions|| |
Nearly a quarter of respondents reported psychological distress due the pandemic. While the proportion of distressed individuals is less than other countries, it is still large enough to justify planned action. No predictors/correlates of psychological distress due to COVID-19 were identified in this study. According to experts, the pandemic is still evolving and the worst is yet to come. In addition, the impending global financial depression and resultant loss of income and jobs is another disaster about to unfold. Together, these issues are likely to take a heavy toll on minds of people not only in India but also across the globe. Timely implementation of preventive and early intervention strategies for the same is extremely important. In this rush to control the spread of COVID-19, mental health of people must not be ignored.
The authors express their gratitude to Dr. Jianyin Qiu and her colleagues who have developed CPDI, for permitting translation and use of this tool in the current study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mahase E. China coronavirus: WHO declares international emergency as death toll exceeds 200. BMJ 2020;368:m408.
Nishiura H, Jung SM, Linton NM, Kinoshita R, Yang Y, Hayashi K, et al.
The extent of transmission of novel coronavirus in Wuhan, China, 2020. J Clin Med 2020;9:330.
Pfefferbaum B, North CS. Mental health and the COVID-19 Pandemic. N Engl J Med 2020;383:510-2.
Banerjee D. The COVID-19 outbreak: Crucial role the psychiatrists can play. Asian J Psychiatr 2020;50:102014.
Cullen W, Gulati G, Kelly BD. Mental health in the COVID-19 pandemic. QJM 2020;113:311-2.
Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: The need for prevention and early intervention. JAMA Intern Med 2020;180:817-8.
Lima CKT, Carvalho PMM, Lima IAAS, Nunes JVAO, Saraiva JS, de Souza RI, et al
. The emotional impact of coronavirus 2019-nCoV (new coronavirus disease). Psychiatry Res 2020;287:112915.
Rajkumar RP. COVID-19 and mental health: A review of the existing literature. Asian J Psychiatr 2020;52:102066.
Torales J, O'Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J Soc Psychiatry 2020;66:317-20.
Jahanshahi AA, Dinani MM, Madavani AN, Li J, Zhang SX. The distress of Iranian adults during the COVID-19 pandemic-More distressed than the Chinese and with different predictors. Brain Behav Immun 2020;87:124-5.
Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Gen Psychiatr 2020;33:e100213.
Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Kaushal V. Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic. Asian J Psychiatr 2020;51:102083.
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.
Andrade C. COVID-19: Humanitarian and health care crisis in a third world country. J Clin Psychiatry 2020;81:20com13383.
Lee SA. Coronavirus anxiety scale: A brief mental health screener for COVID-19 related anxiety. Death Stud 2020;44:393-401.
Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA 2020;323:2133-4.