|Ahead of print publication
Impact on anxiety of COVID-19 and lockdown
Vinay Singh Chauhan1, Kaushik Chatterjee1, Kirti Singh Chauhan2, Jyoti Prakash1, Kalpana Srivastava1
1 Department of Psychiatry, Armed Forces Medical College, Pune, Maharashtra, India
2 Indira Gandhi National Open University (IGNOU), Maidan Garhi, New Delhi, Delhi, India
|Date of Submission||19-Jul-2020|
|Date of Decision||04-Aug-2020|
|Date of Acceptance||20-Aug-2020|
|Date of Web Publication||09-Sep-2020|
Vinay Singh Chauhan,
Department of Psychiatry, Armed Forces Medical College, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: India was placed under “lockdown” since March 25, 2020, to curb the spread of COVID-19 pandemic. Faced with this unprecedented situation, many individuals reported mounting apprehensions and some sought medical relief of anxiety. This study was carried to assess the impact of anxiety on COVID-19 pandemic and lockdown on the general public (18–65 years of age) and to assess its correlates. Materials and Methods: An online survey was conducted during lockdown. Using a survey form, a link was circulated using social media and E-mail. The survey included bilingual informed consent, sociodemographic data, characteristics specific to lockdown, and a self-rating anxiety scale. The survey link was circulated from April 1, 2020, to April 30, 2020. Results: A total of 987 responses were collected and analyzed. The study revealed minimal-to-moderate anxiety in 28.5%, marked-to-severe anxiety in 3.3%, and extreme anxiety in 0.1% of the participants. Anxiety scores were significantly correlated with younger age, students, currently employed, male gender, and lower income. Conclusions: The current survey indicates that 31.9% are experiencing significant anxiety due to lockdown and COVID-19 pandemic. Younger age, students, currently employed, male gender, and lower income are associated with higher anxiety. These findings suggest that there is a need of expanding the mental health services in society during and immediately after the pandemic situation.
Keywords: Anxiety, COVID-19, lockdown
| Introduction|| |
Infection caused by novel coronavirus (COVID-19) was first detected in December 2019 at Wuhan in Hubei Province of China. In January 2020, the World Health Organization announced this outbreak as a public health emergency of international concern and declared as pandemic on March 11, 2020. Available evidence indicates that COVID-19 infection causes mild disease (i.e., nonpneumonia or mild pneumonia) in about 80% of cases who recover, 14% have moderately severe disease, and 6% experience severe/critical illness. The Government of India declared a 3-week nationwide lockdown from midnight March 25, 2020, as an essential and effective measure for preventing the spread of infection and interrupting the infection cycle. Subsequently, lockdown was extended till May 31, 2020, in most of the cities across India. With exponential rise in cases across the world, most of the countries enforced lockdown as the same was found to be effective in remarkable reduction of cases in China. The Oxford dictionary describes the meaning “Lockdown” is “an official order to control of movement of people and vehicles in a dangerous situation.” A stochastic model by Indian researchers also predicted that nonpharmacological interventions such as social distancing and lockdown will reduce the total cases, hospitalizations, intensive care unit requirements, and deaths by almost 90% in India. The team of the same researchers later simulated postlockdown scenario and concluded that partial community containment measures will have to be continued.
The cognitive dissonance between our thoughts (social distancing) and feelings (social connection) results in mental discomfort and apprehension. After the SARS epidemic, a review of 24 studies on the psychological impact of quarantine revealed significant levels of anxiety, anger, confusion, and stress. The most relevant psychological reactions in the general population due to the current pandemic and lockdown restrictions reported to be uncontrolled fear, pervasive anxiety, frustration, boredom, and disabling loneliness. A web-based survey from China, which evaluated psychological problems (n = 1074) close to the COVID-19 epidemic peak and subsequent lockdown, reported anxiety in 29% of participants. Another online survey by Wang et al. (n = 1210) reported that 53.8% of respondents rated the psychological impact of the outbreak as moderate or severe and 28.8% reported moderate-to-severe anxiety symptoms. A systematic review and meta-analysis of articles that have focused on stress and anxiety prevalence among the general population, which included 17 studies (12 Asian studies), revealed anxiety among 31.99% of participants.
There are only a few studies in the available literature on psychological impact of both COVID-19 and lockdown. Psychological impact of COVID-19 and lockdown in the general public have not been studied in India except for one online survey, which was formulated almost the same time as our study. Like the above survey, we also conceived the study in the initial period of lockdown. That study has not correlated psychological impact with sociodemographic factors and characteristic specifics to lockdown, which is an essential requirement to plan psychological intervention. Hence, this study was conducted to evaluate the impact on anxiety due to COVID-19 and lockdown among adults through an online survey. The study also evaluated the correlation of anxiety with sociodemographic variables and characteristics of exposure.
| Materials and Methods|| |
The study proposal was approved by the institutional ethics committee. The study design was of a cross-sectional online survey. The sample included all consecutive participants who submitted their response in the online form during the study period. A bilingual (English and Hindi) Google form was circulated, which included informed consent, sociodemographic data, characteristics with respect to COVID-19 and lockdown, and Zung Self-Rating Anxiety Scale (SAS). Participants included Indian citizens experiencing lockdown in the age group of 18–65 years, who had Google accounts and consented to participation in the study. The study was conducted from April 1, 2020, to April 30, 2020. The Google forms were given wide publicity through social media and E-mail to include population from across the country.
Zung Self-Rating Anxiety Scale
Designed by William Zung to quantify the level of anxiety, this is a 20-item self-report assessment scale based on scoring of four symptom domains, namely cognitive, autonomic, motor, and central nervous system. The total raw scores range from 20 to 80, which is converted to an “Anxiety Index” which determines the clinical interpretation of one's level of anxiety. The score of 20–44 is suggestive of normal range, 45–59 suggestive of mild-to-moderate anxiety levels, 60–74 suggestive of marked-to-severe anxiety levels, and 75 and above suggestive of extreme anxiety levels. The SAS has good internal consistency with a Cronbach's alpha of 0.82. It has fair concurrent validity, correlating significantly (0.30) with the Taylor Manifest Anxiety Scale. It can distinguish both between clinical and nonclinical groups and between patients diagnosed with anxiety disorders and those with other psychiatric diagnoses.
Data were analyzed using the Statistical Package for the Social Sciences program version 21 (IBM Corporation, Armonk, NewYork, USA). Qualitative data variables were described using frequency and percentage (%). Quantitative data variables were described using mean and standard deviation. Anxiety scores were correlated with selected variables using the Pearson correlation coefficient (r). P < 0.001 was considered as highly significant and <0.05 considered significant.
| Results|| |
A total of 987 participants completed the survey. The sociodemographic characteristics of the participants are depicted in [Table 1]. The age of the participants ranged from 18 to 65 years, with a mean age of 34.28 ± 12.27 years. 62.3% were males and 37.7% were females. A majority (61.6%) of participants were employed and 30% of the participants were students. Most of the participants were graduates or postgraduates (50.4% – master's degree and 37.2% – bachelor's degree). About 46% of the participants had a monthly income of more than Rs. 50,000/- and 32% were not employed.
The characteristics regarding COVID-19 lockdown status revealed that majority (81.9%) of the participants live with their families [Figure 1]. Most (68.6%) of the participants stayed confined indoors during lockdown [Figure 2]. 59.9% responded to the survey during initial period (<14 days of lockdown) and 40.1% during next 15 days of lockdown [Figure 3]. Sixty-three percent were staying in cities which were designated as red zones [Figure 4]. 23.3% of the participants suffered financial losses due to COVID and lockdown [Figure 5]. Anxiety scores of participants revealed that 68.1% of the participants were found to have no anxiety on Zung SAS and 28.5% reported minimal-to-moderate anxiety [Figure 6].
The correlation (Pearson coefficient, r) of anxiety scores with selected variables is depicted in [Table 2] and [Figure 7]. Age of participants negatively correlated with anxiety score (r=−0.217, P < 0.001). Male participants had higher anxiety scores than females (r=−0.090, P < 0.005). Students and employed participants had higher anxiety scores than the retired and unemployed (r = −0.166, P < 0.001). Monthly income of participants was negatively correlated with anxiety scores (r = −0.198, P < 0.001).
| Discussion|| |
The COVID-19 pandemic has resulted in some form of lockdown to about 3.9 billion people (more than half of the world's population) by the first week of April 2020. The challenges in dealing with the pandemic in India relate to diversity of culture, wide social and economic disparities, and the consequent health inequity. The aim of lockdown in India was to buy time to gear up health-care and administrative responses to combat the pandemic, as also to spread information about protective measures toward behavior change. Epidemics, extended quarantine, or lockdown in the past have shown a negative impact on mental health of the population.
The mean age of participants was 34.28 ± 12.27 years. The median age of the Indian population comprising all age groups is 28 years. According to the Indian census (2008–2018), 66% of the population fell into the age group of 15–64 years and almost the same range of the population participated in the study, thus accounting for larger representative sample. Our study had 62.3% of males and 37.7% of females. The greater number of male participants could be due to the fact that males (60%) have more access to the Internet compared to females (40%) in India. Majority of the participants were employed (61.6%) and graduate (37%)/postgraduate (50%). The online survey on psychological impact by Grover et al. revealed a similar composition of people who were employed and postgraduates.
Monthly income of about 46% (out of 60% employed) of the participants was more than Rs 50,000/- per month. The average monthly salary of an employed Indian is Rs 31,900/- in 2019–2020. This suggests that majority of the participants had above average monthly salary. Majority (81.9%) of the participants were staying with family and were staying indoors (68.6%) during lockdown. This probably would have acted as a protective factor against mental stress. 23.3% of the participants suffered financial loss due to pandemic and lockdown, which could have contributed to their perception of stress. The same was also reported in the mental health perspective on industrial impact of COVID-19 pandemic.
Our study revealed minimal-to-moderate anxiety in 28.5% of the participants, marked-to-severe anxiety in 3.3% of the participants, and extreme anxiety in 0.1% using Zung SAS. The online survey conducted by Grover et al. also revealed similar findings of 31% having mild-to-moderate anxiety and 7% severe anxiety among analyzed 1685 Indian participants using the Generalized Anxiety Disorder-7 scale. The finding of larger numbers with anxiety may be attributed to a large number of health-care workers in the above study. The study found 31.9% of the participants to be significantly anxious during the COVID 19 pandemic and lockdown, which was substantially more than the estimated 3.7% prevalence of anxiety spectrum disorders by the National Mental Health Survey 2015–2016. The difference in the prevalence rates cannot be completely attributed to the difference in the methodology as screening instruments have high sensitivity and specificity. Hence, it is possible that the epidemic and lockdown have contributed to an increase in anxiety of mild intensity among the general public. Our findings were also comparable (29% of the participants reported anxiety) with a web-based survey from China using the Beck Anxiety Inventory. A recently published meta-analysis of 17 studies also replicated our findings of anxiety (31.99% of the participants reported anxiety).
Younger age (18–40 years – 66% of the participants) was associated with higher anxiety scores. Students and employed participants also had high anxiety scores compared to retired and unemployed participants. Although aging increases the risk of COVID-19 infection and mortality, the results of existing studies show that during the pandemic, the levels of anxiety, depression, and stress are significantly higher in the age group of 21–40 years. The main reason for this seems to be that this age group is concerned about the future consequences and economic challenges caused by the pandemic, as they are the working forces in a society and are, therefore, most affected by redundancies and business closures. Some researchers have argued that a greater anxiety among young people may be due to their greater access to information through social media, which can also cause stress.
Male participants in our study experienced higher anxiety than females. This could be due to more males than females going outside their homes for work or buying essential commodities, thus risking themselves and also worrying about possibly passing on the infection to family members at home. Those with lower incomes and higher financial losses had higher anxiety scores. A study of migrant workers in India showed similar findings.
This survey has some limitations. Despite attempts to circulate widely in all possible social media platforms, wider participation was expected. The survey yielded a majority of graduates and postgraduates, which suggests that the survey did not achieve the expected level of penetration to homogenously represent the population. The survey was limited to those with access to smartphones. Thus, the study participants may not be representative of people from various economic strata in the country. However, considering the lockdown situation, this was the best possible methodology to reach people to assess psychological impact without physical contact. These limitations suggest that the findings may not be generalizable to every stratum of the society.
| Conclusions|| |
The present survey suggests that 31.9% of the people experienced significant anxiety due to lockdown and the prevailing COVID-19 pandemic. Younger age, students, currently employed, male gender, and lower income are associated with higher anxiety. These findings suggest that there is a need of expanding the mental health-care services in society during and immediately after the pandemic.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]