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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 26  |  Issue : 2  |  Page : 153-160

Depression, Anxiety, and Stress among Indian Youth during the COVID-19 Lockdown A Cross-Sectional Survey


1 Ramaiah International Centre for Public Health Innovations, Bengaluru, Karnataka, India
2 Department of Psychiatry, Center for Global Health, University of Illinois at Chicago, Chicago, IL, USA
3 Ramaiah International Centre for Public Health Innovations; Department of Community Medicine, Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Submission23-Mar-2021
Date of Decision01-Jul-2021
Date of Acceptance03-Jul-2021
Date of Web Publication02-Feb-2022

Correspondence Address:
Ruchi Vaidya
Ramaiah International Centre for Public Health Innovations, MS Ramaiah Nagar, MSRIT Post, Bengaluru - 560 097, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_65_21

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  Abstract 


Purpose: The psychological effects of the unprecedented global emergency due to COVID-19 are a significant concern worldwide. The present study aims to investigate the prevalence of stress, anxiety, and depression among Indian youth during the COVID-19 lockdown. Methods: A cross-sectional survey was conducted online across India during the COVID-19 lockdown. A total of 1641 Indian youth between the ages of 15–24 years across 23 states and 3 union territories were analyzed for their mental health status. Depression, anxiety, and stress (DAS) levels of the Indian youth were measured using DAS scale 21. The study was approved by the Institutional Review Board (IRB Reference number: DRP/EFP 530/2020: 08/06/2020). Results: Moderate to higher levels of depression and anxiety were observed among 45% and 49% of Indian youth, respectively, during the COVID-19 lockdown. DAS was significantly higher among youth preparing for competitive examinations, those who had an acquaintance infected with COVID-19 and those who perceived COVID-19 as a risky infection (P < 0.01). School-going students showed significantly lower levels of depression and stress compared to college-going students (P < 0.01). Conclusion: The high levels of DAS during the COVID-19 pandemic indicate a significant mental health burden among Indian youth. These findings indicate the need for a multisectoral approach to cope with stresses and to improve psychological well-being among youth during the pandemic.

Keywords: Anxiety, COVID-19, depression, Indian youth, stress, students


How to cite this article:
Vaidya R, Kaza SK, Gupta P, Weine SM, Nooyi SC, Chaudhury N. Depression, Anxiety, and Stress among Indian Youth during the COVID-19 Lockdown A Cross-Sectional Survey. J Mental Health Hum Behav 2021;26:153-60

How to cite this URL:
Vaidya R, Kaza SK, Gupta P, Weine SM, Nooyi SC, Chaudhury N. Depression, Anxiety, and Stress among Indian Youth during the COVID-19 Lockdown A Cross-Sectional Survey. J Mental Health Hum Behav [serial online] 2021 [cited 2022 Jun 26];26:153-60. Available from: https://www.jmhhb.org/text.asp?2021/26/2/153/337174




  Introduction Top


Mental health problems affect approximately 20% of adolescents and young adults every year.[1] Globally, depression is the fourth and anxiety is the ninth leading cause of years lived with disabilities among adolescents aged 15–19 years.[2] Signs of poor mental health are often unobserved and untreated for several reasons such as lack of knowledge of mental health among parents, elders, teachers, and health workers and also the stigma that prevents individuals from seeking help.[3] India has the world's largest young population among whom around 7% of adolescents aged 13–17 years suffer from psychiatric disorders.[4] Furthermore, the findings from a meta-analysis of epidemiological studies on psychiatric disorders among children and adolescents from India revealed the prevalence rate of depression as 6.5% among adolescents.[5] Nonetheless, the attention paid to the mental health issues of this age group in India is sparse.

The onset of COVID-19 pandemic has immensely affected the lives of people worldwide, and adolescents and young people are not indifferent to the dramatic impact of this epidemic. This pandemic accentuated psychological stressors because of infection fears, lockdown, social isolation, financial fears, closure of businesses, and educational institutions. Such unprecedented health emergencies have been known to result in a 22% rise in mental health problems among residents in the affected areas, including young people and adolescents.[2] Moderate-to-severe levels of anxiety and depression were observed among the students of the regions affected with COVID infections in China,[6] United States,[7] and countries of Europe.[8] Several cohort studies have also shown long-term effect on the mental health in the general population of countries impacted by the Ebola and severe acute respiratory syndrome coronavirus pandemics.[9]

Because youth are in a crucial period of physical and emotional development, they may have long-term adverse consequences of these inexorable circumstances.[10],[11] Young children and adolescents are more likely to experience distress, disturbed sleep, poor appetite, and separation-related anxiety during the outbreak.[12] However, psychological resilience using positive coping strategies can help to mitigate stress during the adverse events.[13]

India announced an unprecedented nationwide lockdown in March 2020 to contain the spread of COVID-19 infection, which had later extended multiple times resulting in home confinement, social cut off, and closure of educational institutions across the country.[14] A prolonged period of lockdown, school and college closures, fears of infection, frustration and boredom, inadequate information, lack of in-person contact with classmates, friends, and teachers, and family financial loss can have enduring effects on the social and emotional life of the youth.[15] One of the preliminary studies conducted during the pandemic highlighted drastic changes in academic routines and events as reasons for increased anxiety among older adolescents and youth.[16] In India, almost 320 million students faced uncertainty about education and career prospects, of which 167 million students belonged to the secondary and tertiary levels of education.[17] The impact of the closure of the academic year and educational institutions following lockdown on students' mental health have been either reported or guessed by sporadic studies in India.[18],[19],[20] Furthermore, the available literature on the psychological impact of COVID-19 on youth primarily comes from specific regions of the country[19],[20],[21] and is sparse. Thus, a nationwide response to address the burgeoning concerns of adolescents and young adults is imperative. On this ground, the present study aimed at investigating the depression, anxiety, and stress (DAS) levels and the factors associated with it among Indian youth during COVID-19 lockdown.


  Methods Top


Study design

A cross-sectional online survey was carried out among Indian youth from June 15 to July 4, 2020, to study their mental health status during COVID-19 lockdown. The study was approved by the Institutional Review Board (IRB Reference number: DRP/EFP 530/2020: 08/06/2020).

An electronic consent was obtained from all the study participants before administering the questionnaire. In addition, participants of the age group 15–18 years were asked to give contact details of their parents, and a confirmatory email about their participation in the survey was sent to their parents. The study excluded responses of those participants who had not given their parents' contact details or whose parents had not agreed for their participation.

Study procedure

Since the government of India had imposed certain travel restrictions, and one had to maintain social distancing due to the pandemic, a purposive snowball sampling was used for the survey. A list of educational organizations from different zones of the country was identified, approached formally to participate in the study, and was requested to share the survey link to their eligible students. The survey link was also sent to the eligible participants through the contacts of the research team through emails and social messaging platforms (WhatsApp and Instagram). The participants were also asked to share the survey link further with their contacts and peer groups. Utmost care was taken to ensure that the participants represent various groups in terms of geographical location [Table 1], gender, and age.
Table 1: Distribution of the respondents across different zones and states of India

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Study participants

A total of 1750 participants took part in the survey. After cleaning the data and excluding incomplete questionnaires, the present study analyzed 1641 responses across 23 states and 3 union territories of India. Of 1641 participants, about 33% were from north and central zones of India, 28% were from southern, 21% from western, and remaining 18% were from the eastern or north-eastern zone of India [Table 1].

The study participants were students from grade 8th to 12th and those studying graduation, of the age group 15–24 years, from all genders, residing in urban areas of India, having access to mobile/computer/laptop, internet connection, and could understand English language. They self-reported to be physically healthy and did not have any morbidity related to physical and cognitive abilities. Youth from rural/tribal areas, nonresidential Indians, and differently-abled were excluded from the survey because they would need special assistance which was not in the scope of the study.

Study tool

The data were collected using an online structured survey form. The study survey form was developed using available published literature,[22] and standardized scales were adapted.[23] The survey form had logical checks and data validation mechanisms in place to ensure internal validity. Consultations with subject experts were carried out to ensure the content validity of the tool. The test-retest reliability of the tool in the pilot study was found to be 0.90.

Measurements

The stress, anxiety, and depression levels of the respondents were assessed using standardized DAS scale 21 (DASS-21).[23] The DASS-21 is self-administered with well-established psychometric properties in clinical and community samples and has been designed to measure the emotional states of DAS. The scale is divided into three subscales, each consist of seven items assessed on 4-point Likert scale (0 – did not apply to me at all and 3 – applied to me very much or most of the time), to measure DAS disorders. Scores for DAS were calculated by summing the scores for the relevant items and multiplied by two. Cronbach's alpha for DASS-21 scale internal consistency was 0.88

Qualitative interviews

The qualitative in-depth telephonic interviews were conducted with 15 youths. Semi-structured guide with open-ended questions was used to understand how they feel during lockdown. Qualitative data collected through in-depth interviews were transcribed and transliterated in English and were coded manually according to the emerging themes/subthemes. Important responses highlighting the thematic codes were reported as verbatim.

Covariates

The following covariates were included in the study: age, gender, educational status, place of accommodation during the lockdown period, and known relatives/friends diagnosed with the COVID-19 infection. Perception of youth toward COVID-19 risk and severity was categorized as “risky,” “less risky,” and “normal” to identify the mental health implications of restrictions.

Statistical analysis

We used SPSS 21.0 (IBM Corp, Armonk, NY) for statistical computations. Chi-square test was performed to observe the association of sociodemographic characteristics of youth with DAS levels. Further, a binary logistic regression model with odds ratio (OR) and 95% confidence interval (CI) was used to examine the adjusted effects of sociodemographic characteristics and perception toward COVID-19 on the levels of DAS among youth.


  Results Top


The sociodemographic characteristics of the respondents are shown in [Table 2]. The majority of the participants were in the age group 15–19 years (61%) with the mean age of 18.9 years. There were slightly higher number of females (52%) compared to males, and half of the participants were college-going students. Eighteen percent of the participants were preparing for the competitive examinations in the COVID-19 lockdown. Most of the participants were staying with their families; however, 5% of the participants were in hostels or alone in the lockdown period. Nearly, one-fourth of the participants (22%) reported knowing any relative/friend infected with COVID-19 at the time of the survey.
Table 2: Sociodemographic characteristics of the respondents

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When we asked the participants about how they felt in the lockdown, nearly half of the youth, most often felt that they were stuck at home (59%) and cut off (47%) due to COVID-19 lockdown. Almost 80% of the youth were worried most of the time about their studies and future job opportunities post-COVID scenario (data not shown).

Depression, anxiety, and stress levels

DAS levels of the participants were categorized into five mental health levels from normal to extremely severe, as shown in [Table 3]. The mean scores of depression and anxiety were at moderate level, while the average scores of stress levels were at mild category. Further, 45% of the youth were suffering from moderate to higher levels of depression, and almost half (49%) showed moderate to higher levels of anxiety. Among those, there were 23% and 24% of youth with severe and extremely severe depression and anxiety levels, respectively, while 36% and 34% of the youth had mild-to-moderate depression and anxiety levels. Analysis of the stress score showed elevated stress levels among 42% of youth during the lockdown. The study also found high and positive inter-correlations between DAS levels of youth, varying between 0.69 and 0.81 (P < 0.01) (data not shown).
Table 3: Depression, anxiety, and stress levels among Indian youth (n=1641)

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Relation of depression, anxiety, and stress levels and sociodemographic characteristics of the Indian youth

Depression and stress levels were found higher among youth from the eastern/north-eastern zone of India, followed by the northern/central and the southern zone (P < 0.01). Depression and anxiety levels are found similar among adolescents (15–19 years) and young adults (20–24 years). Males showed considerably higher levels of depression compared to females (P = 0.01), whereas stress and anxiety levels were not significantly different by gender.

The college-going students showed a significantly higher level of depression and stress compared to the school-going students (P < 0.01). Stress levels were also higher among those preparing for competitive examinations compared to the School going students (P < 0.01).

Nearly, 3/5th of participants whose relatives or friends diagnosed with COVID-19 had higher levels of stress (P < 0.01), anxiety (P < 0.05), and depression (P < 0.01) when compared to those who did not have any known infected person. In addition, youth's perception toward COVID-19 was strongly associated with the DAS levels as youth who perceived COVID-19 as a risky disease had higher levels of depression (62%), anxiety (62%), and stress (46%) (P < 0.01) compared to those who perceive it normal or not risky at all [Table 4].
Table 4: Depression, anxiety, and stress levels among Indian youth by sociodemographic characteristics and perception toward COVID-19

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[Figure 1]a, [Figure 1]b, [Figure 1]c shows the results of logistic regression analysis for DAS. The likelihood of depression was higher among youth preparing for the competitive examinations compared to school-going youth (OR = 1.58; 95% CI = 1.10–2.15). Similarly, the odds of having anxiety and stress were 1.37 (95% CI = 1.08–1.92) and 1.61 (95% CI = 1.15–2.27) times higher among youth preparing for the competitive examinations. It was found that the DAS levels were higher among youth who had any known person infected with COVID-19 (depression OR = 1.48, 95% CI = 1.14–1.93; anxiety OR = 1.55, 95% CI = 1.20–2.01; stress OR = 1.84, 95% CI = 1.42–2.37). Further, youth who perceived COVID-19 as a risk were more likely to have anxiety (OR = 2.71, 95% CI = 1.32–5.53) and stress (OR = 2.67, 95% CI = 1.17–6.07). Participants from the western region were found to have significantly lower levels of depression (OR = 0.57, 95% CI = 0.40–0.81), and stress (OR = 0.62, 95% CI = 0.43–0.88). No statistically significant relationship was found between DAS and age, gender, and place of stay during the lockdown.
Figure 1: Odds ratio (95% CI) for depression, anxiety and stress, and sociodemographic characteristics of youth. (a) Depression (normal (R) vs. any depression). Note: The predictors found significantly associated with depression levels in the unadjusted analysis were included in the adjusted model; first category of predictors was considered as the reference category. (b) Anxiety (normal (R) vs. any anxiety). Note: The predictors found significantly associated with anxiety levels in the unadjusted analysis were included in the adjusted model; first category of predictors was considered as the reference category. (c) Stress (normal (R) vs. any stress). Note: The predictors found significantly associated with stress levels in the unadjusted analysis were included in the adjusted model; first category of predictors was considered as the reference category

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Case vignettes

In-depth interviews were also conducted with several participants across the country, and some of the major reflections are Shown in [Table 5] to support the study findings.
Table 5: List of case vignettes identified in qualitative interviews

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  Discussion Top


Both the scales of the COVID-19 pandemic spread, and the preventive measures taken by India to contain it, have been massive and unprecedented. One such preventative measure was nationwide lockdown aimed at flattening the epidemic curve by restricting the movement of people. In the present national survey carried out during the lockdown, 45% of the participants of age 15–24 years showed moderate to higher levels of depression whereas 49% showed moderate to higher levels of anxiety during COVID-19 lockdown. DAS levels were particularly higher among youth preparing for competitive examinations, those who had an acquaintance infected with COVID-19 and those who perceived COVID-19 as a risky infection. The stress and depression levels were also significantly higher among college-going students compared to school-going students.

The results of our study were similar to a study carried out in South India, in which 34% of pharmacy students suffered from moderate-to-severe levels of depression and 42% suffered from moderate-to-severe levels of anxiety.[24]

The anxiety and depression were highly prevalent among adults as similar to youth during the initial phase of COVID-19 lockdown. A nationwide cross-sectional survey observed 40.5% of adults suffering from anxiety or depression, and 74% showed moderate stress levels during the COVID 19 lockdown.[25] The high prevalence of poor mental health was associated with the reduced sleep duration among adults.[26] The results were similar to our findings among youth. However, another cross-sectional survey carried out across India among 354 adults aged more than 18 years during April 2020 showed 25%, 28%, and 11.6% prevalence of moderate-to-severe DAS levels among the participants.[27] The prevalence of DAS levels of youth in our study was higher compared to the study, which can be attributed to different time periods of data collection during pandemic and severity of impact on population. Moreover, our study was carried out in the month of June when the total number of active COVID-19 cases almost doubled in the country compared with those in April. The rapid growth phase of COVID-19 curve may be one of the reasons for higher levels of DAS among youth. In the initial phase of pandemic, COVID-19 cases were observed in just a few pockets of India. The number of cases appeared to be exponentially high in the northern and southern zones of India at the time of the study. This could be one of the reasons for higher levels of DAS among north/northeastern zones followed by south and west zones.

Adolescents and young adults are vulnerable age groups, and during health emergencies like the COVID-19 pandemic, they experience a period of insecurity about their health, education, and social well-being.[28] The uncertainty of examinations, closures of schools and colleges, the ubiquitous issue of illness and death, and sudden separation from friends further exaggerate their fear.[28] The competitive examinations such as the entrance examinations for the colleges and national level examinations were repeatedly postponed during the pandemic. The uncertainty of the examinations and lack of clarity about their future studies could have led to increased levels of stress and anxiety among these youth.

The study findings indicate an urgent need for the prevention and management of mental health issues among youth during the pandemic. Awareness of mental health problems and availability of mental health services are the key for their effective management. A study carried out in South India on adolescents aged 15–19 years has reported poor mental health literacy (MHL) levels,[29] i.e., knowledge and belief about recognition and prevention or management of mental health disorder were only about 8% among adolescents aged 15–19 years. They preferred a family member (mother) or friend for help than a psychologist or school teachers.[29] Primary reasons cited for not taking a professional help were stigma and insufficient knowledge about mental health services.[29],[30] The National Mental Health Survey (2015–2016) reported 85% gap in the management of the mental health disorders among Indians with a 2½ month gap from the onset of symptoms to reaching out to an expert consultation.[31] A cohort study conducted on children in the age group 16–17 years reported that addressing mental health issues of the youth will not only reduce the chances of substance abuse and delinquent behaviors but also ensure smooth progress and well-being in later life.[32],[33] There is a need to understand the MHL levels among youth and their caretakers. Effective interventions to increase awareness about mental health need to be planned for this vulnerable group to ensure timely help-seeking and prevent morbidity due to untreated disease. Furthermore, better functioning of the families, supportive peer groups, and a healthy social environment have shown positive effect on mental health of the adolescents and young adults.[34] This indicates the increased demand to adopt strategies to mitigate the mental health issues among youth by including families, peer groups, and developing a healthy social environment.

Findings of the present study will significantly contribute to the existing literature on mental health among youth during the pandemics. However, it has several limitations. The purposive snowball sampling brings a certain degree of selection bias though we have ensured representation of maximum number of states in reaching out to participants across India. Some of the questions in the tool were self-reported; however, checks and balances such as skip logics, age range check based on study inclusion criteria, controls to avoid multiple responses from the same IP address, email ID, and phone number were incorporated in the questionnaire to increase the internal validity of the tool and to minimize information bias. Our study design did not allow us to determine all the stressors associated with higher DAS levels. Therefore, future studies should consider a wide range or risk and protective factors associated with adverse mental health outcomes among Indian youth.


  Conclusion Top


Almost 45% of the study participants showed moderate-to-severe levels of anxiety and depression. The flattening of the infection curve during the COVID-19 pandemic requires strict public health measures, such as social distancing, closure of public and educational institutions, and a reduction of social life. Nevertheless, when implementing such measures nationally and at schools and colleges, there is also a need to pay attention to its effect on the youth's mental health. Effective strategies to mitigate adverse mental health among youth should be an integral part of the public health policies to combat the pandemic.

Acknowledgments

We sincerely acknowledge the Gokula Education Foundation (Medical), Bangalore, for the financial support. We thank Dr. N.S. Murthy, Research Director, Department of Research at and Patents at Ramaiah Medical College (RMC) for his guidance in developing study design. We also acknowledge Ms. Mridula Bhargava, Public Relations Officer, RICPHI, for her support in designing the online questionnaire for this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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