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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 100-104

Mental health concerns related to COVID-19 outbreak in the middle-aged and elderly population: A web-based, cross-sectional survey from Haryana, North India


1 Department of Psychiatric Nursing, College of Nursing, Pt. B.D. Sharma University of Health Sciences, Rohtak, Haryana, India
2 Department of Psychiatric Nursing, National Institute of Nursing Education, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission06-Jun-2020
Date of Decision14-Jun-2020
Date of Acceptance22-Jul-2020
Date of Web Publication21-Jan-2021

Correspondence Address:
Mr. Jaison Joseph
College of Nursing, Pt. B.D. Sharma University of Health Sciences, Rohtak - 124 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jgmh.jgmh_22_20

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  Abstract 


Background: The coronavirus disease 2019 (COVID-19) pandemic is a global health emergency that could potentially have a serious impact on public health, including mental health. Elderly people are more vulnerable to the stress associated with the COVID-19 outbreak, and there is a dearth of epidemiological data on this issue. Aim: We conducted a web-based survey to evaluate the mental health concerns of middle-aged and elderly populations related to the COVID-19 outbreak from Haryana, India. Materials and Methods: An online survey was conducted from April 17 to May 01, 2020 using the principles of the snowball recruiting technique. The mental health concerns of the potential study participants were evaluated using the Hindi version of Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) scales. Results: There were a total of 1006 responses, out of which 266 were excluded from the analysis. The mean age of the participant was 58.68 (standard deviation [SD] = 8.05) years, and around 36' of respondents were the elderly with an age range of 60–79 years. The mean and SD of the GAD and PHQ were 2.51 (3.69) and 2.80 (4.86), respectively. The overall prevalence of anxiety and depressive symptoms was 19.7' and 21.5', respectively, (GAD-7 and PHQ-9 cutoff score of more than 05). We found a significant association between mental health outcomes with the presence of comorbid illness and physical activeness during the lockdown period. Conclusion: The present study represents a preliminary report on the psychological impact of the novel coronavirus outbreak in the Indian middle-aged and elderly community. The findings can be preliminary evidence for conducting a larger longitudinal study to guide policy-makers for subsequent research and clinical intervention strategy for mental health concerns related to COVID-19.

Keywords: COVID-19 outbreak, elderly, India, mental health


How to cite this article:
Joseph J, Das K, Dhal S, Sehrawat T, Reshamia S, Huria G. Mental health concerns related to COVID-19 outbreak in the middle-aged and elderly population: A web-based, cross-sectional survey from Haryana, North India. J Geriatr Ment Health 2020;7:100-4

How to cite this URL:
Joseph J, Das K, Dhal S, Sehrawat T, Reshamia S, Huria G. Mental health concerns related to COVID-19 outbreak in the middle-aged and elderly population: A web-based, cross-sectional survey from Haryana, North India. J Geriatr Ment Health [serial online] 2020 [cited 2021 Jun 25];7:100-4. Available from: https://www.jgmh.org/text.asp?2020/7/2/100/307583




  Introduction Top


Coronavirus disease 2019 (COVID-19), a cluster of acute respiratory illness with unknown causes, has occurred in Wuhan, Hubei Province, China since December 2019.[1] The COVID-19 pandemic is a global health emergency that could potentially have a serious impact on public health, including mental health.[2] As previously reported, health emergencies such as epidemic can lead to detrimental and long-lasting psychosocial consequences, due to disease-related fear and anxiety, social isolation, and the overloaded information on social media and elsewhere.[3] Considering the medical health emergency associated with COVID-19 infection, the focus is more on the prevention and management related to the physical health consequences. However, it is also important to understand the myriad of psychosocial issues and negative mental health consequences of the pandemic.[4] At the individual level, epidemics are associated with a wide range of psychiatric comorbidities, including anxiety, panic, depression, and trauma-related disorders.[5]

As this pandemic has been spreading rapidly across the world, it is bringing a considerable degree of fear, worry, and concern among vulnerable groups, particularly in older adults. Report from China reflects that the case-fatality rate and the death rate in the patients over 60 years old are much higher in the national wide, which implicates aged people are more vulnerable to the COVID-19 disease.[6] The social consequences of the illness are going to be a big challenge for the elderly and geriatric mental health.[7] Available data suggest that social disconnectedness puts the older people at a greater risk of depression and anxiety.[8],[9] Elderly people are more vulnerable to the stress associated with COVID-19 outbreak, and there is an urgent need to accurately and timely assess the magnitude of mental health outcomes for the implementation of preventive and early intervention strategies for those at higher risk.[10] Due to the sudden occurrence of the disaster, there is a dearth of epidemiological data on this issue. Therefore, we conducted a web-based survey to evaluate the mental health concerns of middle-aged and elderly populations related to the COVID-19 outbreak from Haryana, India.


  Materials and Methods Top


A cross-sectional survey design was decided, and we collected the data by using free software Google Forms. Considering the limited evidence on the feasibility and acceptability of an exclusive online survey among elderly population in the state of Haryana, India, we considered all Indian citizens =50 years as eligible participants. The participants who refuse to give consent for a web-based survey and not having access to fill the google forms were excluded. Potential respondents were invited through a text message through social networking media using the principle of snowball recruiting technique. The enrolment to the study was on a first-come, first-served basis, and the participation was completely voluntary and noncommercial. The period of data collection was between April 17, 2020, and May 1, 2020. The study has been approved by the Institutional Ethics Committee at Pt. BDS UHS, Rohtak. Participants were allowed to terminate the survey at any time they desired. Participants were asked to fill the Hindi version of research questionnaires.

Besides the collection sociodemographic profile, the participants were asked to report on chronic illness, physical activeness, and living status during the current lockdown period. The presence of chronic illness was considered for those with known cases of hypertension, diabetes mellitus, or any illness of more than 6 months' duration. The regular involvement of any household work or exercise during the lockdown period was operationally labeled as “physical activeness.” The mental health concerns were evaluated using the Hindi version of Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 (GAD-7) scales available from the developer's official website https://www.phqscreeners.com/select-screener.[11]

Sample size calculation

The exact extent of the psychological impact on the COVID outbreak in the middle-aged and elderly population of India was not known. However, a previous survey using similar research scales reported the magnitude of the psychological impact of COVID outbreak in the general population from 17' to 20'.[12] Considering the rough estimate as 20' at 95' of the confidence interval and absolute precision of 5' in estimated prevalence with design effect 2, the minimum sample size required was calculated to be 492 using OpenEpi version 2.3, developed by Centers for Disease Control and Prevention Atlanta, Georgia, USA. (Source:- https://www.openepi.com/SampleSize/SSPropor.htm). Assuming a nonresponse and duplicate response rate of 15' as per previous study,[13] 73 was added to the calculated sample size. Thus, the minimum total sample size was estimated as 565. We planned to continue recruitment for approximately 2 weeks similar to the data collection period of two recent studies.[12],[13]

We used the Hindi versions of GAD-7 and PHQ-9 for the evaluation of generalized anxiety disorders and depressive symptoms associated with the COVID-19 outbreak. For both the questionnaires, each question has a set of responses, whose score ranges from minimum 0 to maximum 3. Participants have to select the most appropriate response from the options given; the score of each response is added to get the final score. The following cutoffs were used to understand the severity of anxiety (GAD-7): 0–4 minimal; 5–9 mild; 10–14 moderate; and 15–21 severe anxiety.[14] For the PHQ-9, a score of 5–9, 10–14, 15–19, and 20–27 was considered as mild, moderate, moderately severe, and severe depression, respectively.[15] The data were analyzed by using SPSS version 16.0 for Windows (SPSS, Chicago, IL). The comparisons of the categorical variables were done by the Pearson's Chi-square test (or Fisher's exact test, where the expected number of frequency in a cell is <5).


  Results Top


There were a total of 1006 responses, out of which 266 were excluded from the analysis. The exclusion was based on the following aspects: duplicate items (n = 58), respondents from outside of the Haryana (n = 46), and age range of <50 years (n = 162). The final analysis was done on the rest of the 740 respondents. The mean age of the subject was 58.68 (standard deviation [SD] = 8.05) years and around 36' of respondents were elderly with an age range of 60–79 years. Half of the participants were males (50.5'), and the majority of them were married (65.3') with an urban background (63.6') and educated up to 12th standard (63.24'). A major proportion of the participants was self-employed (80.67') and reported the presence of a chronic illness (82.6'). Most of the participants stayed within the family set up during the lockdown period (94.6'). The overall prevalence of anxiety and depressive symptoms was 19.7' and 21.5', respectively [GAD-7 and PHQ-9 cut off score of more than 5; [Table 1]].
Table 1: Characteristics of the study participants

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The generalized anxiety disorder of the COVID-19 outbreak, as measured by the GAD-7 scale, revealed a mean score of 2.51 (SD = 3.69). Around 101 (13.6') had mild anxiety (GAD-7 score of 5–9) and 34 (4.6') had moderate anxiety (GAD-7 score of 10–14) However, 11 (1.5') reported severe anxiety (GAD-7 score of >15). The mean score of PHQ-9 was 2.80 (SD = 4.86). As per the PHQ-9 scale, 94 (12.7'), 48 (6.5'), 8 (1.1'), and 9 (1.2') were reported mild, moderate, moderately severe, and severe depression, respectively. We found a significant association between mental health outcomes and the presence of comorbid illness and physical activeness during the lockdown period. However, there was no statistically significant association between any other demographic or clinical variables [Table 2].
Table 2: Depressive and anxiety symptoms during coronavirus disease 2019 outbreak period

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  Discussion Top


The index study investigated the mental health concerns associated with the COVID-19 outbreak in the middle-aged and elderly Indian population. We used the Hindi versions of GAD-7 & PHQ-9 for the evaluation of generalized anxiety disorders and depressive symptoms associated with the COVID-19 outbreak. Compared to an early report on the mental health outcomes related to COVID-19 in the Italian general population (Italian citizens = 18 years) using similar tools on 18147 respondents, we found lower rates of anxiety, depression. The Italian study reported 17.3-20.8 ' of severe depression and anxiety as per PHQ-9 & GAD-7 cut-off of =15.[12] However, we found an overall 19-21' of mild to severe level of anxiety and depression as per the GAD-7 & PHQ-9 respectively (cut off score of more than 05). A similar COVID-19 psychological impact study conducted in China reported an overall prevalence of 20.1 – 35.1' of depressive and anxiety symptoms using Center for Epidemiology Scale for Depression (CES-D) and GAD-7 (cut off score of 9) and respectively..[13] Since these findings were reported during different periods with a varying magnitude of the pandemic, it should be interpreted accordingly Overall approximately 19'–21' of the participants reported anxiety and depression as per the GAD-7 and PHQ-9 respectively. A recent nationwide online survey conducted in the Indian population with an age range from 14 to 87 years used GAD-7 and PHQ-9 as screening tools and reported 38.2' anxiety and 10.5' depression in reaction to the COVID-19 outbreak.[16] Furthermore, another Indian study measured psychological impact with the help of Impact Event–revised (IES-R) scale and reported one third of respondents (33.2') had significant psychological impact (IES-R score >24).[17] Another study conducted in China by Wang et al. reported that 53.8' of respondents suffered a psychological impact from the outbreak, ranging from moderate to severe among 1210 respondents.[18] However, a study on 7143 medical students in China found severe anxiety rates, assessed as GAD =15, to be 0.9', compared to our 1.5'.[19] This wide variation in the magnitude of psychological impact could be attributed to study setting, sample sizes, sampling criteria such as differences in assessment tools, and age limits.

We used the Hindi versions of GAD-7 and PHQ-9 for the evaluation of generalized anxiety disorders and depressive symptoms associated with the COVID-19 outbreak. An earlier study conducted in China reported that younger participants (< 35 years) were more likely to develop anxiety and depressive symptoms during the COVID-19 outbreak than older participants (= 35 years).[13] A similar online survey reported in the Indian general population reported that higher psychological impact was predicted with younger age, female gender, and comorbid physical illness.[17] However, we found an overall 19'–21' of mild-to-severe level of anxiety and depression as per the GAD-7 and PHQ-9, respectively (cutoff score of more than 05). A similar COVID-19 psychological impact study conducted in China reported an the overall prevalence of 20.1'–35.1' of depressive and anxiety symptoms using the Center for Epidemiology Scale for Depression (CES-D) and GAD-7 (cut off score of 9), respectively.[20] Since these findings were reported during different periods with a varying magnitude of the pandemic, it should be interpreted accordingly.

We found a statistically significant association between mental health outcomes and the presence of comorbid illness and physical activeness during the COVID outbreak period in this age population. A similar online survey reported in the Indian general population reported that higher psychological impact was predicted with younger age, female gender, and comorbid physical illness.[16] An earlier study conducted in China reported that younger participants (<35 years) were more likely to develop anxiety and depressive symptoms during the COVID-19 outbreak than older participants (=35 years).[19] However, our results did not reach such statistical significance of the psychological impact between middle-aged (50–60 years) and the elderly population (>60 years). An online survey conducted in the general population of West Bengal from 29 to 31 March 2020 reported a significant psychological impact (24.7') associated with the COVID-19 pandemic.[20] In an another study conducted during 22–24 March 2020 by Roy et al. also reported a higher level of anxiety in the general population of India.[21] The available literature reveals the psychological impact of COVID-19 in the Indian general population, and our findings provided data support for accurately understanding the mental health concerns of the middle-aged and elderly population during the COVID-19 outbreak.

However, there are some more limitations to be considered while evaluating the study results. First is the inherent design of the study like sampling technique being only restricted to people with internet access and having an understanding of Hindi could also limit the generalizability of the study. Second, the study was conducted during a period of lockdown, which can have its psychological impact and can be a confounder to under or over-reporting in the rate of psychological impact found in the study. Third, the study sample was recruited through a web-based survey and no measure was undertaken to identify the cognitive status of the study population. Moreover, certain factors that may influence the findings of the study such as the presence of the history of mental illness, substance use, unemployment status, stress sue to COVID-19, and attitude toward the COVID-19 were not explored.

Despite the limitations, this study provides the first cross-sectional data on the actual level of psychological impact among the Indian middle-aged and elderly community. Moreover, the Hindi questionnaire used has been validated in the Indian population earlier. Online surveys (or self-administered questionnaires) have been found as an effective way of assessing problems related to mental health, and this becomes a prudent method of conducting research in the period of lockdown.


  Conclusion Top


The study represents a preliminary report on the psychological impact of the novel coronavirus outbreak in the Indian middle-aged and elderly community. The findings can be preliminary evidence for conducting a larger longitudinal study to guide policy-makers for subsequent research and clinical intervention strategy for mental health concerns related to COVID-19.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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