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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 100-108

Stress, mental health, and resilience during the COVID-19 pandemic lockdown: Preliminary findings of an online survey in India


1 Department of Clinical Psychology, Manipal College of Health Professionals, MAHE, Udupi, Karnataka, India
2 Department of Clinical Psychology, JSS Medical College and Hospital, Mysore, Karnataka, India
3 Department of Clinical Psychology, National Institute of Mental Health and Neuro-Sciences, Bengaluru, Karnataka, India

Date of Submission17-Aug-2021
Date of Acceptance06-Nov-2021
Date of Web Publication02-Feb-2022

Correspondence Address:
B R Sahithya
Department of Clinical Psychology, Manipal College of health Professionals, Manipal Academy of health Sciences, Udupi - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_186_21

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  Abstract 


Background: The recent COVID-19 pandemic has induced a considerable degree of fear, worry, and concern in the population at large. Drastic changes in daily lives as a result of lockdown may expose individuals to high stress levels, which might make them vulnerable to mental health issues. It is important to identify and understand these difficulties, which can help mental health professionals and policy makers address these issues. Aim: The present study aimed to screen mental health problems and to gain insight into resilience among Indians during the COVID-19 pandemic lockdown. Materials and Methods: The study was cross sectional, using online survey method. Sociodemographic datasheet, a self-designed questionnaire, Patient Health Questionnaire and Brief Resilience Scale were entered into Google Form, and was sent using E-mails and WhatsApp to the personal contacts of the investigators. The link was also posted in social media groups. The participants were requested to complete the survey and then forward the link to their contacts. Inclusion criteria laid for the study included English speaking males and females, 18 years or older, and living in India. A total of 348 individuals filled in the forms, of which 327 were complete and included for analysis. Results: Fifty percent of the participants surveyed had symptoms of common mental disorders. Thirty-three percent had elevated scores needing diagnostic evaluation for somatoform disorder, 33% for generalized anxiety disorder, and 35% for depression. 8% reported developing interpersonal difficulties with family members, 17% reported financial stress, 23.5% were worried about job loss, and 35% found the lockdown very stressful. Elevated scores on patient health questionnaire-somatic, anxiety, and depressive symptoms were associated with financial stressors, worries about job loss, and lockdown stress. Ten percent of the participants indicated a need to talk to psychologist, and 40% were not aware of tele counselling facilities. Higher resilience was associated with lower odds of developing psychiatric symptoms. Conclusion: The results offer preliminary data-based insight into the impact of the lockdown, and are suggestive of increased stress and mental health liabilities. Fostering resilience may be critical to prevent or reduce mental health problems in general population during the pandemic.

Keywords: Depression, generalised anxiety, pandemic, somatoform disorder


How to cite this article:
Sahithya B R, Kashyap RS, Roopesh B N. Stress, mental health, and resilience during the COVID-19 pandemic lockdown: Preliminary findings of an online survey in India. J Mental Health Hum Behav 2021;26:100-8

How to cite this URL:
Sahithya B R, Kashyap RS, Roopesh B N. Stress, mental health, and resilience during the COVID-19 pandemic lockdown: Preliminary findings of an online survey in India. J Mental Health Hum Behav [serial online] 2021 [cited 2022 Jun 26];26:100-8. Available from: https://www.jmhhb.org/text.asp?2021/26/2/100/337165




  Introduction Top


Ever since the COVID-19 pandemic hit the globe, governments worldwide have enforced lockdown, social distancing, quarantine, isolation, and work from home as safety measure to control spread of the disease. As a result, people have suddenly been forced out of their comfort zones to face these extraordinary situations. An important concern that may arise as a result is the impact of the COVID-19 pandemic control measures on the mental health of people. Both the COVID-19 pandemic and the measures taken to contain it is spread may be stressful for most people. Although anxiety is a normal response to perceived or real threats; fear and worries about an unknown disease can be overwhelming. Stress during an infectious disease outbreak such as the COVID-19 pandemic can include anxiety about one's own health, and also, the health of loved ones, disturbances in sleep or eating patterns, difficulty in concentrating, worsening of preexisting physical and mental health problems and increased use of substance.[1] Adding to the fear of contracting the disease are the significant changes in daily lives. Faced with new challenges of restricted movements and social interactions, temporary unemployment, and the lack of physical contact with family members, friends and colleagues, the situation can have an adverse impact on the mental health of people.[2]

Resilience is the process of adapting well in the face of adversity and significant stressors such as family and relationship problems, serious health issues, and/or financial stressors.[3] Being resilient is the ability to mentally and emotionally cope with a crisis in face of different adversities, ranging from ongoing daily hassles to major life events.[4],[5],[6] Resilience can help protect individuals from various mental health conditions and has been shown to positively correlate with satisfaction with life, subjective well-being, and positive emotions.[7],[8],[9] It is an important factor during crisis such as during the pandemic and the consequent lockdown since it is associated with positive mental health, and enhancing resilience during the time of crisis can be protective to the vulnerable,[9],[10],[11],[12] and therefore, needs to be examined in the context of a pandemic.

There are hardly any studies in India that are exploring stress, resilience. and mental health correlates of the COVID-19 pandemic. Therefore, the present study aimed to screen for stress and mental health problems in adult population in India during the COVID-19 pandemic lockdown, and to also, gain insight into resilience among Indians during the lockdown.


  Materials and Methods Top


Study design

A cross-sectional, online survey design with the help of Google Forms was adopted to obtain the data. Google Forms offer the advantage of anonymity and also ensure that only one response can be generated using one E-mail ID. The survey was initiated during the lockdown from April 25, 2020 and was kept open for responses till May 10, 2020. Data collection was stopped when no new response was made despite attempts to circulate widely in all possible social media platforms. Inclusion criteria laid for the study included English speaking males and females, 18 years or older, living in India, and willing to participate in the study. Individuals below age 18 years, or who were presently not living in India were excluded from the study.

Tools

Sociodemographic data sheet

A sociodemographic data sheet was developed for the study to collect various sociodemographic information such as age, gender, location, family type, education, occupation, work status, marital status, past history of psychiatric disorders and physical health conditions.

Patient health questionnaire-somatic, anxiety, and depressive symptoms

Patient health questionnaire-somatic, anxiety, and depressive symptoms (PHQ-SADS)[13] is a validated questionnaire, which is widely used for screening and diagnosis of patients for psychiatric illnesses worldwide. It is designed for use in primary care settings, and can be used as self-reported. PHQ-SADS contains three modules to assess somatoform disorder, generalized anxiety disorder and depression. Scores of 5 and above suggest that the person needs to be evaluated for clinical diagnosis on all three scales (somatic symptoms, generalized anxiety, depression).[13],[14],[15] PHQ–SADS has exhibited significant internal consistency, and test–retest reliability and has been validated in India.[14],[15]

Brief resilience scale

The brief resilience scale (BRS)[16] is an instrument designed to assess the ability to bounce back or recover from stress, and provides information about people coping with stressors. The scale consists of six items each measuring aspects of resilience. The total scores range from 6 to 30, with higher scores indicting higher resilience. Several studies have reported BRS to be a reliable and valid means to assess resilience.[17],[18]

COVID-19 pandemic lockdown stress questionnaire

A self-designed questionnaire with seven questions was developed for the purpose of capturing stressors associated with COVID-19 lockdown. The questions assessed financial stressor, worries about job loss, and interpersonal difficulties with family members during the lockdown. Each of the questions had varying Likert scale response option such as “yes/no,” “present/absent,” and so on [Table 1] and [Table 2]. The responses were not scored, and were analyzed qualitatively.
Table 1: Stressors, symptoms of common mental disorders and resilience (n=327)

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Table 2: Mental health and resilience

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Procedure

Participant Information sheet, Sociodemographic data sheet, self-designed questionnaire, PHQ-SADS, and BRS were uploaded in Google Forms. Google Forms were sent using E-mails and WhatsApp to the personal contacts of the investigators. The link was also posted in social media groups. The participants were requested to complete the survey and then forward the link to their contacts. On receiving and clicking the link, the participants get auto directed to the information sheet and informed consent page. Those willing to consent can press the consent button and proceed to fill out the rest of the forms. Each participant took about approximately 5–10 min to complete the survey. A total of 348 individuals filled in the forms, out of which 327 were complete and met the inclusion criteria.

Ethical considerations

  1. The study was approved by the institute ethics committee of JSS Academy of Higher Education and Research.
  2. Informed consent was obtained from the participants.
  3. Anonymity was maintained
  4. Researcher contact details were given if someone wanted to seek help.


Statistical analysis

Data were analyzed using Statistical Package for Social Sciences, Version 20.0. Armonk, NY: IBM Corp. STROBE[19] reporting guidelines were followed. Resilience was examined for normality using Z (normal distribution) test for mean distribution, and was found to be normally distributed. Differences in resilience and mental disorders between the various subgroups were analyzed using independent samples t-test, one-way ANOVA, and Chi-square test. Regression analysis was used to find independent variables (sociodemographic characteristics, stressors, and resilience) that predict presence of mental disorders.


  Results Top


[Table 3] shows the sociodemographic characteristics of the participants. Majority of the participants were male (69%), graduates (54%), married (54%), living in nuclear family (78%), and came from urban area (77%). Mean age was 35.1(±9.8) years. A small proportion of participants, reported past history of physical (14%) and mental health problems (16%). A large proportion of the participants (47%) were working from home. Majority 22% of the participants were IT professionals (n = 71), 9% were into business (n = 29), 8% were students (n = 27), 5% were teachers (n = 16), and 5% were home-makers (n = 15). Remaining were of diverse fields such as allied health professionals, bankers, lawyers, journalists, doctors, and so on. A small 5% (n = 15) of the participants reported unemployment.
Table 3: Demographic characteristics, symptoms of common mental disorders and resilience (n=327)

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[Table 3] and [Table 4] show mental health profile, sociodemographic features, and resilience of the participants. Out of 327 participants, 164 (50%) had elevated symptoms requiring clinical evaluation for somatoform disorder, generalized anxiety disorder and/or, depression. Both symptoms of common mental disorders and resilience were significantly associated with gender, marital status and past history of mental illness. Females (χ2 = 7.38, P = 0.01), singles (χ2 = 8.02, P = 0.02) and individuals with past history of mental illness (χ2 = 16.74, P < 0.001) had higher incidence of symptoms of common mental disorders [Table 3]. Males had significantly higher resilience than females (t = 4.43, P < 0.001). Individuals with past history of mental illness had significantly lower resilience (t = 6.03, P < 0.001) than individuals without past history. Married or previously married individuals had higher resilience (F = 4.49, P = 0.01) compared to singles [Table 3] and [Table 5].
Table 4: Spectrum of mental disorders assessed

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Table 5: Post hoc analyses for resilience and marital status, stressors, and mental health

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[Table 1] shows the association between COVID-19 pandemic-related stressors, psychopathology and resilience. Chi-square test and t-test revealed that elevated scores on PHQ-SADS and resilience were significant associated with financial stress (χ2 = 13.72, P < 0.01; F = 8.36, P < 0.001); job loss worries (χ2 = 13.00, P < 0.01; F = 10.73, P < 0.001), and lockdown stress (χ2 = 47.92, P < 0.001; F = 5.01, P < 0.001). Although interpersonal issues were not directly associated with psychiatric symptoms, it was significantly associated with resilience (F = 14.70, P < 0.001). Pot hoc analysis [Table 5] revealed that individuals whose relationship and/or finances improved, and those who did not have job loss worries during the lockdown had higher resilience.

[Table 2] shows the analysis of resilience with respect to psychiatric morbidity. Resilience was significantly lower among individuals with symptoms of common mental disorders (t = 5.67, P < 0.001) than individuals without these symptoms. Resilience was also related to distress associated with the symptoms (F = 23.52, P < 0.001), and need to talk to psychologist. Pot hoc analysis [Table 5] revealed that individuals who were not distressed had higher resilience than those who reported that the current problems had made it very difficult (P < 0.001) or somewhat difficult (P < 0.001) for them to manage their lives. Those who needed to talk to psychologists (P = 0.005) had lower resilience than those who did not perceive this need.

An attempt was made to find variables that predicted presence of symptoms of common mental disorders using regression analysis [Table 6]. Marital status, past history of mental illness, lockdown stress, financial stress and resilience were found to significantly predict psychiatric symptoms. Singles (B = 0.61, eB = 1.83, P = 0.02, 95% confidence interval [CI]: 1.10–3.05) and individuals with past history of mental illness (B = 0.94, eB = 5.51, P = 0.02, 95% CI: 1.17–5.56) were at increased odds of reporting symptoms of common mental disorders. Resilience scores were negatively associated with psychiatric symptoms (B= −0.10 eB = 0.90, P = 0.004, 95% CI: 0.85–0.97). Individuals who reported lockdown stress were at increased odds of reporting symptoms of common mental disorders (B = 1.53 eB = 4.6, P < 0.001, 95% CI: 2.67–7.96). Finally, those who were able to save more money during the lockdown period had lower odds of developing these symptoms (B = −0.58 eB = 0.56, P = 0.04, 95% CI: 0.33–0.98).
Table 6: Predictors of symptoms of common mental disorders

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  Discussion Top


This is a brief community-based study aimed at screening for mental health and resilience among the general population using the PHQ-SADS and BRS during the initial days of COVID-19 pandemic related nationwide lockdown. According to the available knowledge, the present study is one of the first few studies to look into the mental health impact of COVID-19 pandemic lockdown and resilience in general population in India. The survey was conducted in the months of April and May 2020, when Indian government had strictly implemented lockdown and social distancing all over India, forcing many to work from home, stay indoors, and reduce social interaction with others. The following paragraphs discuss the main findings of the study.

Prevalence of mental disorders

The present study found that 50% of the sample had elevated scores on PHQ-SADS requiring diagnostic evaluation for common mental disorders during the COVID-19 pandemic lockdown. Among them, 32.5% had one or more comorbid symptoms. Further, 33% reported that these problems made it difficult to do their work, take care of things at home, or get along with other people. Elevated scores on PHQ-SADS suggesting a need for the evaluation of clinical depression was found in 33% of the sample in the present study. Anxiety and somatoform symptoms were found to be present in 33%, and 35% of the participants, respectively. A similar online survey carried out recently by Grover et al.[20] on psychological impact of COVID-19 pandemic lockdown also reported that 40.5% of the participants had either anxiety or depression. However, their study did not evaluate somatoform disorder. Nevertheless, these figures are significantly higher compared to the past studies from India, according to which about 10%–20% of the adult population in India has one or the other psychiatric morbidity.[21],[22] The present study did not evaluate substance use disorders, psychotic disorders, and obsessive–compulsive disorders, despite which half the participants in the study reported above three forms of psychopathology, suggesting that perhaps the stress associated with COVID-19 pandemic and lockdown may have had a significant impact on mental wellbeing.

Stressors and mental health during lockdown

In the present study, 8% said that they had developed interpersonal issues with family members during the lockdown period, 17% reported developing financial difficulties due to financial impact of the lockdown, and 23.5% reported worries about losing their job due to economic impact of the lockdown. Further, 25% of the participants reported that they found the lockdown very stressful. These findings imply that the COVID-19 pandemic and the aftermath has been a source of significant stressor for the general public. The results also indicated that financial stressors, worries about job loss, and lockdown stress were significantly associated with mental disorders. There was a significantly higher symptoms of common mental disorders among individuals who reported financial stress (53%), job loss worries (65%), and lockdown stress (76%). However, on regression analysis, only lockdown stress continued to be a predictor of psychiatric morbidity. Individuals who said they found the lockdown stressful were 4.6 times more likely to develop symptoms of common mental disorders than those who did not find the lockdown stressful. Very few studies at the time the present study was carried out have examined mental health and stress associated with COVID-19 pandemic. A study in West Bengal[23] which assessed the psychological impact of COVID-19 pandemic reported that nearly 70% of the respondents expressed worries about the financial loss, and about one third of the respondents reported difficulty in adjusting to the new routine during the lockdown. Another study by Grover et al.[20] also reported moderate level of stress in about three-fourth (74.1%) of their participants, and 71.7% of the participants reported poor well-being. Past studies have consistently reported that psychosocial stressors such as problems at work or at home, financial difficulties or having no social support are significantly associated with mental disorders.[24],[25],[26] These studies, along with the results of the present suggest that the stress associated with COVID-19 pandemic, and the lockdown implemented to contain the infection appears to have resulted in collateral damage to people in terms of their mental health.

Sociodemographic risk factors

In the present study, it was found that symptoms of common mental disorders were associated with sociodemographic characteristics such as gender, marital status, and past history of psychiatric illness. Females were more likely to report these symptoms than males. Gender has been reported to be a critical determinant of mental health, probably because the patterns of psychological distress and mental disorders among women are different from those seen in men.[27] Further, past studies have reported that gender differences occur particularly in the rates of common mental disorders (depression, anxiety, and somatic complaints) wherein women predominate,[27],[28] and as the present study screened only these disorders, perhaps higher prevalence among females was seen. Further, it was observed in the present study that individuals with the past history of mental illness were 2.6 times more likely to report symptoms of common mental disorder in the present compared to individuals without past history, suggesting that individuals with past history of mental illness may be especially vulnerable to develop psychiatric morbidity during stressful lockdown period. Other studies have also reported that individuals with past history of mental illness when exposed to psychosocial stressors are a higher risk for developing mental disorders.[24],[25],[29] It was also noted in the present study that singles were 1.8 times more likely to report psychiatric symptoms compared to married or previously married individuals. Similar findings have been reported by other studies as well,[21],[22] suggesting that females, individuals with past history of mental illness, and singles are more vulnerable to develop psychopathology in the face of COVID-19 pandemic stress, and may need special attention of mental health professionals. The present study also found that 45% of the individual who did not have past history of mental illness had elevated scores on PHQ-SADS requiring clinical evaluation in the present, indicating that apart from above-mentioned vulnerabilities, COVID-19 pandemic-related stress may have played an important role in these people's mental health.

Resilience and mental health

In the present study, resilience was found to be negatively associated with psychiatric symptoms. Resilience was lower among individuals with symptoms of common mental disorders, and also among individuals who reported higher levels of distress associated with their problems. In regression analysis, it was found that higher resilience was associated with lower odds of symptoms of common mental disorders. These findings are in accordance to past studies which have shown that resilience is significantly lower in people who develop psychiatric illness, and higher resilience prevents development of mental disorders or minimizes the severity of illness.[29] Resilience was lower among females, singles, and individuals with past history of mental illness, which were also associated with increased odds of symptoms of common mental disorders, suggesting that perhaps these individuals may have been vulnerable to psychiatric disorders due to poor resilience. When resilience was examined in association with COVID-19 pandemic stressors, it was found that resilience was lower among individuals who reported interpersonal difficulties, financial stressors, and worries about job loss compared to individuals who did not have these stressors. Further, relationship and financial stressors were associated with elevated scores on PHQ-SADS suggesting that perhaps, individual who had lower resilience found the situation more stressful than those with higher resilience, which may have subsequently made them vulnerable to mental health issues. These results might indicate that resilience can be a protective factor against development of mental disorders. However, in the absence of mediation analysis, this cannot be established certainly.

Positive aspects of lockdown

In the present study, it was observed that that the impact of the pandemic lockdown was not uniform across the sample. For example, a large majority of the sample (45%) were not worried about job loss despite news about global recession during the lockdown. In addition, a large proportion of participants reported positive impact of the lockdown in terms of improved relationship (34%) and savings (31%). Similar findings have been reported by Grover et al.[20] The researchers attributed the improved relationship with family members to the availability of more free time, less work pressure and possible fulfillment of long desired free time during the lockdown. It was found that resilience was higher among individuals who reported improved relationship and increased savings during the lockdown, suggesting that resilience can have positive impact on individuals even during the trying times.

Critical evaluation of the study

The findings from the present study have important clinical implications. The findings suggest that resilience is negatively associated with psychiatric symptoms, and might be acting as protective factor. Resilience is currently recognized as a multidimensional construct that includes both personal characteristics and skills, as well as external protective factors such as social support.[30] It was observed in the present study that individuals with lower resilience were more likely to want to talk to a psychologist/counselor than those with higher resilience. Since resilience is modifiable factor, psychosocial interventions may involve using techniques to enhance resilience such as teaching active problem-solving skills, enhancing interpersonal and communicant skills, and increasing social support. Mental health professionals and policy makers may collaborate to develop policies and community interventions to boost resilience in the population, especially during a time as stressful as the pandemic. Such interventions can include support for individuals who are living in COVID-19 pandemic hot spot locations, individuals who are infected and/or quarantined, and their family members. Going forward many of the psychosocial and mental health consequences of the pandemic will have to be addressed by mental health professionals, as these stressors may induce or exacerbate psychiatric problems.[31] Although National Institute of Mental Health and Neurosciences, Bangalore, and other private and public institutions have taken initiative to address these concerns through online consultation and tele counseling, it was observed in the present study that about 40% of the respondents were not aware of tele counseling facilities, which stresses the need for awareness programs. There is also a need to set up more helplines, and make them readily available to the public.

The present study is not without limitations. The data were obtained through online survey using Google Forms, and circulated using snowball type sampling through social media groups, and hence only English-speaking individuals with access to mobile or internet could participate in the study. Another main limitation associated with the online survey is that it is difficult to control the population to which it is distributed, and respondent with biases may select themselves into the sample. Further, the sample size was not calculated beforehand, data collection period was narrow, and despite attempts to circulate widely in all possible social media platforms, the response rate was low, and hence sample size turned out to be relatively small. Future studies can use large scale field studies to gather data from representative sample using cluster sampling techniques to get a more realistic picture of the mental health scenario during the COVID-19 pandemic in India. The present study used traditional assessment measures which might have led to under-diagnosis or over-diagnosis during the crisis situation. Therefore, developing and validating screening or diagnostic instruments that could help identify symptoms and examine COVID-19 pandemic-related mental health problems is the need of the hour.[32],[33] In addition, the sample size of this study limits further analysis, such as mediation/moderation analysis. It also limits the extent of generalizability to the entire population. However, given the dearth of studies, the findings from the current study are valuable in understanding the mental health impact of COVID-19 pandemic on Indian population.


  Conclusion Top


The findings from the present study offer an initial data-based glimpse into the mental health impact of the lockdown during COVID-19 pandemic, and shed light on opportunities for promoting mental health and well-being during this unprecedented and multifaceted crisis. The data suggests an increase in stressors and mental health issues during COVID-19 pandemic. Resilience was associated with better mental health and lower stress. These findings highlight the importance of psychological perspectives in understanding the individual differences in responses and approaches to deal with the pandemic situation.[34] The results also indicate an urgent need to augment mental health professional's focus on resilience and on strategies to enhance it, as resilience is pivotal to cope with the stress imposed by the virus outbreak at the individual and societal level.

Acknowledgments

We appreciate all who helped us in this research. We are also grateful to the study participants for their involvement in the research study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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