Mental disorders of students during COVID-19


Introduction

On the finish of December 2019, the COVID-19 was originated from Wuhan province, China. After a brief interval, it has unfold out globally, turning itself to be probably the most difficult catastrophe after the World Warfare II.1 Consequently, peoples’ regular life has been reported disrupting as of its devastating results. Due to this fact, on 11 March 2020, the World Well being Group declared this outbreak to be a pandemic as a consequence of its unprecedented and rampant behaviors.2,3 Nevertheless, there was 651,652 COVID-19 instances (together with 9384 deaths) recognized in Bangladesh, as of seven April 2021.

To mitigate this viral outbreak transmission in the neighborhood ranges, plenty of public well being measures corresponding to (i) imposing countrywide lockdown, (ii) shutting down instructional establishments, (iii) isolating the contaminated instances, (iv) quarantining the suspected instances, (v) confining social and group actions, and so forth., have been executed all through your complete world.4–6 These measures are expectedly efficient to suppress its transmission. As an example, 44% and 31% incident and demise charges have been recognized for the communities with quarantine measures, whereas it was 96% and 76% for the non-quarantine communities.7 Evidently, incident and demise charges lower after imposing these preventive measures. Though these measures have significance to suppress the outbreak, subsequent psychological well being impacts aren’t escaped, which evaluates psychological well being instabilities by accumulating psychological stressors like experiencing worry and panic, feeling annoyed and bored, dealing with a paucity of fundamental provides, missing genuine and dependable info, overwhelming with stigma, dropping from jobs, and dealing with monetary recession, and so forth.,8–11 and these devastating points are alleged for subsequent suicide occurrences in globally together with Bangladesh.12–17 As an example, a scientific evaluate18 reported excessive charges of psychological well being outcomes (ie, as much as 50.9% nervousness, 48.3% despair, 53.8% post-traumatic stress dysfunction, 38% psychological misery, and 81.9% stress have been discovered) among the many basic inhabitants globally, as per different literatures involved with both multi-centered cross-sectional research,19,20 or systematic critiques.6,21

Nevertheless, on Eight March 2020, the primary case of COVID-19 was confirmed in Bangladesh.22 Being a rustic of restricted sources within the healthcare setting, the authorities imposed a national lockdown to minimize its an infection.22,23 In the course of the COVID-19 pandemic, nonetheless, college students’ psychological well being turns into a priority of curiosity as all the tutorial establishments have been closed down, and their social circle, communication, and interplay processes have been additionally modified.24 Additionally, on-line education, the newly launched technique of educating could be unfavorable for the next variety of college students as of difficulties associated to understanding supplies, technical points, lack of curiosity in attending lessons, restricted entry to on-line education supplies, and so forth.24–26 Evidently, the severity of lack of willingness in on-line education led to suicide occurrences in Bangladesh. That’s, an undergraduate pupil refused to partake on-line examination, that was conflicts inside their household, in consequence, the mom and son’s suicide pact occurred.27 Thus, it’s obvious that a few of college students are dealing with the pandemic-related obstacles corresponding to social and financial disruptions, uncertainty about their future careers, loneliness, worry of dropping family members, and so forth.28,29

Contemplating the Bangladeshi college students’ vulnerabilities towards psychological stressors associated to the present COVID-19 pandemic, a number of research have been performed assessing their psychological well being. However, for generalization of the components influencing psychological well being issues of this cohort, there may be nothing however a evaluate. To the authors’ greatest of information, no try to evaluate the Bangladeshi college students’ psychological well being was made. Due to this fact, a scientific evaluate was performed herein for the first-time, contemplating the prevalence and danger components of the Bangladeshi college students’ widespread psychological problems (despair, nervousness, and stress), which is anticipated to assist take acceptable psychological well being methods within the coverage ranges.

Strategies

Search Technique

For conducting a scientific evaluate, Most popular Reporting Gadgets for Systematic Evaluations and Meta-Analyses (PRISMA) guideline30 was adhered to the current research. Thus, a scientific literature search was carried out in PubMed from 1 to April 5, 2021. Inside this time, extra searches have been carried out on the databases corresponding to Scopus, PsycINFO, International Well being, Internet of Science, CINAHL, even Google Scholar, and ResearchGate for retrieving articles and preprints that weren’t listed in PubMed. The using search technique included key phrases: (despair OR nervousness OR stress OR psychological well being OR psychological well being OR psychological impression); AND (COVID-19 OR pandemic); AND (Bangladeshi pupil).

Research Choice Standards

Initially, every publication was screened primarily based on “Titles and Summary”. Then, the full-text article was evaluated for confirming if the article to be added or not. The articles have been included on this evaluate after adhering to the inclusion standards, together with (i) being a Bangladeshi research involved about pupil cohorts, (ii) being a cross-sectional research, (iii) being performed after the pandemic initiation, (iv) using established scales/instruments for measurement, (v) reporting prevalence and/or danger components of psychological problems (despair, nervousness, stress), (vi) being revealed in a peer-reviewed journal or preprint, and (vii) being revealed within the English language.

Knowledge Eligibility

A complete of 107 articles have been retrieved from a number of databases, whereas 103 article exists after eradicating the duplicate ones. Then, “Titles and Abstracts” of every articles have been screened, the place 92 articles have been eradicated. A complete of 11 full-text articles have been assessed for eligibility. Lastly, 7 research have been survived within the course of after adhering to the inclusion standards. Full-text articles (n=4) have been excluded in the event that they have been (i) evaluate article, (ii) qualitative research (iii) mixed-method research (that’s, each qualitative or quantitative) (Determine 1).

Figure 1 PRISMA flow-chart of the present systematic review.Note: Adapted from Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336–341. doi:10.1016/j.ijsu.2010.02.007.30

Data Extraction

In Microsoft Excel, a data extraction file was created to recruit the information from the included studies. Data were extracted utilizing the following criteria (i) first author and publication year, (ii) specific group and sample size, (iii) sampling procedure, (iv) sample characteristics, (v) assessment tool, (vi) cutoff score, (vii) prevalence rate, (viii) associated risk factors, and (ix) prevalence assessment criteria.

Results

Description of the Included Studies

A total of 7 cross-sectional online survey-based studies were included in this review after adhering to the inclusion criteria.31–37 All of the studies were conducted between April and May 2020. The number of participants ranged from 425 to 15,543; whereas only 3 studies reported participant mean age. The DASS-21 and GAD-7 were the most frequently used scale for detecting the mental disorder(s) (n=3), while other scales including PHQ-9, HADS, and CESD-R-10 were also utilized. Three studies reported the prevalence rate of depression, anxiety, and stress and its associated factors while the rest of the studies reported either depression and anxiety or only anxiety (Table 1).

Table 1 Characteristics of the Included Literatures to the Present Review

The Prevalence Rate of Mental Disorders

The prevalence of depression, anxiety, and stress showed fluctuation across the included studies. All but one study considered the cutoff of point for at least the presence of mild symptoms, which seems the comparison of the prevalence rates across the included studies to be more reliable. However, details about the prevalence rate of mental disorders are discussed below.

Depression

A total of 6 studies reported the prevalence of depression, ranging from 46.92% to 82.4% among both college and university students,37 and university students,36 respectively. However, studies considering the university students found the rate to be within 72% to 82.4%,33,34,36 whereas 49.9% was reported for medical students.32 Also, a 61.9% prevalence rate of depression was identified in a study, although detail about the student status was not mentioned in that study.31

Anxiety

The prevalence of anxiety was determined in all of the included articles, ranging from 26.6% to 96.82%. Within the university students, the anxiety rate was noted to be 40% to 96.82%;33–36 where the lowest prevalence rate (40%) was detected by moderate to a severe cutoff scheme, which leads to a reasonably lower anxiety rate to that rate compared to other studies’.33 However, 65.9% of medical students reported being anxious,32 whereas it was 33.3% for both college and university students.37

Stress

The prevalence of stress was reported in three studies utilizing the same instrument (that is, DASS-21), and found its range within 28.5% to 70.1%. Khan et al37 reported the lowest stress prevalence rate among the college and university students, whereas university students were identified as dominantly stressed. The rest of the study within the students (no specific information regarding the student status was mentioned), found 57.05% of the participants to be suffering from stress.31

Risk Factors Associated with Mental Disorders

Risk factors of mental disorders are divided into four categories – (i) socio-demographic factors, (ii) behavior and health-related factors, and (iii) COVID-19 related factors, and (iv) other factors. However, details about the mental health risk factors are discussed below.

Socio-Demographic Risk Factors

Age

Two studies predicted age as a significant risk factor for psychological suffering.31,34 Sayeed et al31 found that less than or equal 22 years (vs more than 22 years) old students were at 4.49-, 4.46- and 3 times higher risk of depression, anxiety, and stress, respectively. Whereas, 18 to 24 years old students were observed to be prone to these disorders than those who had reported being aged 25 to 29 years.34

Gender

The relationship between gender and mental disorders was significant in a total of 4 studies, where all but one study found females to be at higher risk.31,32,34,35 For instance, females were at 3.44-, 3.44- and 4.54- times higher risk of depression, anxiety, and stress, respectively,31 which is similar to other studies.32,34 But, the unusual finding, that is, male students were found to be more anxious in a study compromised with a total of 15,543 university students.35

Family Monthly Income

Lower family income was significantly associated with increasing the risk of mental health disorders.31 The only study reported that students with a family income of less than or equal to 2,7000 BDT [Bangladeshi Taka (currency)] were at 2.62- and 2.56- times higher risk of suffering from depressive and anxiety symptoms, respectively, than more than 2,7000 BDT.31

Education

The levels of education were predicted as a significant risk factor for mental disorders.31 The only study depicted that students of secondary education status were at 11.03- and 11.15-fold risk of anxiety and depression, respectively, than graduate and higher ones.31

Residence

A significant mental health effect was observed by the students’ place of residence.31,34,35 A study depicted that students residing in urban areas were 3.22- and 3.22- times the high risk of depression and anxiety compared to the rural areas’ ones.31 Besides this, other studies reported people living in urban areas were more vulnerable to psychological problems.34,35

Family Size

The number of family members was found as a significant risk factor for mental health disorders. Sayeed et al reported that students who had a family size less than or equal to 4 were at 1.89- and 1.91-times high risk of anxiety and depressive symptoms than family size greater than 4.31 Adversely, another study found that having more than or equal to five family members compared to less than four family members were more prone to mental disorders.34

Number of Children in the Family

The number of children in the family was identified as a risk factor for mental health problems.31 More detailly, the study found students from these families with children under 5 years were at 2.32 times higher risk of developing depressive symptoms.31

Living with Family or Parents

Living with family or parents was also found to increase the risk of psychological suffering.36 Participants who reported currently living with their family were at 2.6- and 1.8- times higher risk of depression and anxiety, respectively,36 whereas did not live with parents increased the rate of anxiety.35

Behavior and Health-Related Risk Factors

Smoking Status

The habit of smoking was reported as a significant factor for evaluating mental health problems.34 Islam et al34 found that these students who were engaged in smoking were more prone to psychological sufferings compared to those who were not.

Physical Exercise

The role of physical exercise on mental health was found as a significant predictor.34,37 Based on two studies, students who reported not engaging in physical exercise were at higher risk of mental disorders.34,37

Internet Use Time

Internet browsing time was found as a predictive factor of psychological disorders in only a study.34 The study reported that students reporting internet browsing for 5 to 6 hours, and more than 6 hours compared to less than 2 hours were at increased risk of psychological problems.34

Satisfaction with Sleep

Having sleep difficulties could also influence the higher risk of mental health problems. A study claimed34 that students reporting dissatisfaction with their sleep experienced higher psychological sufferings compared to those who were satisfied.

COVID-19 Related Risk Factors

COVID-19 Related Perceptions

The perceptions about the negative impact of the COVID-19 pandemic were reported as the influential factors of psychological suffering. These perceptions included that (i) normal life disrupted by the COVID-19 pandemic, (ii) negatively affecting themselves by the COVID-19 pandemic, (iii) the country’s healthcare system would be overrun and people would not be able to get proper medical care, (iv) the trajectory of COVID-19 suspicion, (v) its negative impact on education like lagging academically,31,36 (vi) worrying about the effects of COVID-19.33

Fear of COVID-19 Infection

Fear of getting infected by the COVID-19 was found as a significant predictor of depression, anxiety, and stress in a couple of studies,31,32,37 whereas relatives or friends being infected with the COVID-19 had also increased the level of anxiety.35 Safa et al32 reported that students severely tensed of being contacted with the COVID-19 infected individuals were at 3.5- and 2.75-times higher risk of being anxious and depressed, respectively, than the students who had no or minimal contract. Similarly, contact with the confirmed COVID-19 cases was reported to be at 4- and 3.17-times higher risk of getting stressed and anxious, respectively.31

COVID-19 Related Symptoms

Mental health sufferings were also increased when students reported experiencing the COVID-19 related symptoms. For example, Sayeed et al31 reported that experiencing one and more symptoms, and at least one symptom increased the risk of stress by 1.60 and 3.06 times; whereas it was 3.02 and 4.96 times, respectively, for anxiety. Also, another study found having the symptoms of fever, dry cough, fatigue, sore throat, difficulty breathing as the influential factors of mental disorders.37

Other Risk Factors

Some other factors also reported increasing the risk of psychological sufferings. Such as (i) losing part-time teaching job (that is, serving as a tutor),36 (ii) reporting lack of concentration on the study,32 (iii) being agitated more easily,32 (iv) fear of getting assaulted or humiliated on the way to the hospital or home,32 (v) worsening their financial condition,35,37 (vi) being dissatisfied with academic studies,34 (vi) having an inadequate food supply,37 (viii) being more exposed to the COVID-19 news in social media and mass media,37 (ix) being more active in recreational activities (ie, watching TV series, reading storybooks, online and offline gaming, etc.), (x) engaging in household chores,37 etc.

Discussion

During the pandemic, several public health measures were already implemented in Bangladesh, which is being alleged for aggravating the risk of mental instabilities. Besides this, the online learning process, the alternative way of running educational activities after the inception of the pandemic, reportedly plays a significant role in exacerbating psychological sufferings.24–26 Online schooling turns to issues related to lack of concentration on the study, agitation, dissatisfaction with academic studies, which are reported for intensifying psychological burdens.32,34 Therefore, student cohorts are allegedly at risk of mental health sufferings because of lockdown-related issues.

The present review is the first systematic approach considering students’ mental health problems during the COVID-19 pandemic in Bangladesh, which is anticipated to be helpful for the mental health authorities. However, students are found at immense risk of psychological suffering, that is, the prevalence rate of depression, anxiety, and stress ranges from 46.92% to 82.4%, 26.6% to 96.82%, and 28.5% to 70.1%, respectively. These prevalence rates across studies may vary because of utilizing different tools, and cutoff scores of the same instrument.38 Besides this, pandemic-related issues such as COVID-19 infection rate of the participants’ area, history of the COVID-19 infection, financial difficulties, etc., may increase the probability of higher mental health suffering.32,37,39–42 These issues are not identified across the included studies, which limits the generalizability of the findings. Despite these limitations of the included studies, the estimated prevalence rates of mental disorders are supposed to be helpful in representing the cautious situation rather than reflecting as factual findings.

Based on the present findings, mental disorders’ risk factors related to basic socio-demographics included younger age, gender, lower family monthly income, lower grade education status, urban residence, family size, living with family/parents, and having children in the family. Also, behavior and health-related mental health risk factors included being smokers, lack of physical exercise, reporting more internet use time, and dissatisfaction with sleeping status. The COVID-19 pandemic related negative perceptions and social stressors, COVID-19 related symptoms, fear of COVID-19 infection, fear of getting assaulted or humiliated on the way to hospital or home acted as the triggers to escalate mental sufferings. Study found that COVID-19 patients were at higher risk of psychological suffering than psychiatric patients and healthy control individuals.43 Finally, other risk factors included losing the part-time teaching job, lacking concentration on the study, agitation, fear of getting assaulted or humiliated on the way to hospital or home, financial problems, having dissatisfaction with academic studies, having an inadequate food supply, being more exposed to COVID-19 related news, engaging with more recreational activities (ie, watching TV series, reading storybooks, online and offline gaming, etc.), performing more household chores, etc.

Being a resource limited country, Bangladesh has lack of capability to combat the current awful situation.22,44 Therefore, involving medical students in the health sector might be effective to fight against the COVID-19 pandemic in both hospital settings and community levels.45 Focus on mental wellbeing activities during the pandemic is not possibly started actioning to the country as expected. But, it has become urgent for the health authorities to initiate appropriate measures concerning the psychological sufferings of this cohort, where the present review might have some potential implications. First of all, based on the present findings (eg, mental health problem risk factors), special attention should be provided to the risky individuals considering their vulnerability towards serious psychological disorders. Also, the mental health or educational institutes’ authorities are suggested to arrange frequent webinars on mental health wellbeing to motivate and facilitate students taking care of their mental health problems. These webinars should also be concerned with the de-stigmatization of mental health issues. Besides, the government should provide beneficial funds considering the financial conditions of the respective students’ families, which might be able to reduce the student’s mental sufferings if they are needy. An individual effort like avoiding smoking, taking part in regular physical exercise (at least daily 30 minutes running, cycling, gym, and so on), browsing less internet, and sleeping adequately might decrease the psychological impacts on students. In addition, the most evidence-based treatment is cognitive behavior therapy (CBT), especially internet-based CBT that can be helpful for mental health interventions during the pandemic.46,47 Finally, the authority should command on the media/news channel not to spread misinformation, because social media exposure also triggered the mental state of the students.

Conclusions

Psychological sufferings of the Bangladeshi students during the pandemic are reported reasonably high. The present review provides an initial overview of depression, anxiety and stress prevalence rates and associated risk factors among Bangladeshi students during the COVID-19 pandemic. Thus, this systematic approach might be a strength for the policymakers of the country to take necessary steps considering the findings reported herein.

Ethics Statements

Being review on secondary data, ethical approval was not applicable for this study. Besides, there was no conflict of interest in relation to present work as informed consent was inapplicable.

Acknowledgments

The authors would like to acknowledge that their affiliation, the CHINTA Research Bangladesh, was formerly known as the Undergraduate Research Organization.

Funding

The present study did not get any financial support.

Disclosure

The authors of the paper do not have any conflict of interest. The authors involved in this research communication do not have any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work.

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