East Asian Arch Psychiatry 2022;32:82-8 | https://doi.org/10.12809/eaap2204

ORIGINAL ARTICLE

Salmi Razali, Department of Psychiatry, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia. Institute of Pathology, Laboratory and Forensic Medicine (I-PPerForM), Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
Dina Tukhvatullina, Center for Global Public Health, Institute of Population Health Sciences, Queen Mary University of London, London, United Kingdom 
Nurul Azreen Hashim, Department of Psychiatry, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
Nor Jannah Nasution Raduan, Department of Psychiatry, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
Saw Jo Anne, Department of Psychiatry, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
Zaliha Ismail, Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia
Mikaella E Patsali, 3rd Department of Psychiatry, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
Daria Smirnova, Department of Psychiatry, Narcology, Psychotherapy and Clinical Psychology, Samara State Medical University, Samara, Russian Federation. International Centre for Education and Research in Neuropsychiatry, Samara State Medical University, Samara, Russia Konstantinos N Fountoulakis, 3rd Department of Psychiatry, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece. International Centre for Education and Research in Neuropsychiatry, Samara State Medical University, Samara, Russia

Address for correspondence: Salmi Razali, Consultant Psychiatrist & Associate Professor in Psychiatry, Women and Perinatal Mental Health, Department of Psychiatry, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Selangor, Malaysia.
Email: drsalmi@uitm.edu.my

Submitted: 13 January 2022; Accepted: 29 August 2022

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Introduction

During the COVID-19 pandemic, the daily increase of cases and death rates, the fear of infection, isolation, and illness, the public pressure, the bereavement, and the lack of reliable information predispose to psychological disturbances.^1-3

In addition, mental health can be affected by fake news, lack of knowledge on protective measures, and healthcare system crises.^4,5 Psychological wellbeing is impacted by the uncertainty, rapidly changing government policies, unstable political situation, loss of employment, and financial strain.⁶ In China, at the beginning of the COVID-19 outbreak, >50% and about 33% of participants had moderate-to-severe immediate psychological response and anxiety, respectively.⁷ In the US, 13.6% of Americans had severe psychological distress in April 2020, compared with 3.9% in 2018.⁸ In an Australian community, mental health was more impacted by financial distress and impairments in social functioning than by the fear of exposure risk to COVID-19 or contact with the ill.⁹

In Malaysia during the pandemic, the healthcare system and workers were seriously affected.¹⁰ Provisional hospitals and collaboration with private hospitals were set up, and additional laboratories were assigned to enhance public services to manage COVID-19–related health conditions.¹¹ However, the number of mental healthcare professionals remains low, with a ratio of one psychiatrist per 100 000 people, and only 15 clinical psychologists were employed in the public sector in 2018.¹²

According to the National Health and Morbidity Survey, the percentage of mental health problems has increased from 10.7% in 1996 to 29.2% in 2016, and the prevalence of depression and anxiety among adults in Malaysia was 2.2% and 10.4%, respectively.^13,14 The prevalence of mental health problems differs between urban and rural areas^15,16 and between different sociodemographics such as ethnicity, sex, education, and marital status.¹⁷

This study aims to determine the prevalence of depression and the sociodemographic factors associated with depression in Malaysia during the COVID-19 pandemic.

Methodology

This study was approved by the ethics committee of Universiti Teknologi MARA (reference: REC/06/2020 (MR/109)). This study is part of the COVID-19 Mental Health International (COMET-G) study initiated by the Aristotle University of Thessaloniki and the Mental Health Sector of the Scientific Research Institute of the Pan- Hellenic Medical Association, Greece. It is a cross-sectional online survey using convenient sampling.¹⁸ In Malaysia, the survey was disseminated using the Google Forms through Facebook and Twitter between 1 July 2020 (average of 6 cases per week) and 6 October 2020 (average of 338 cases per week) during the COVID-19 pandemic.

People who were aged ≥18 years, able to read Malay or English, had access to the internet, and consented to participate were asked to complete a pro forma questionnaire to collect their sociodemographic data (sex, age, marital status, residential area, educational status, employment, healthcare workers status, living condition [number of people living together, number of children, and whether living with a vulnerable family member], and chronic medical disease).

The presence of distress and depression was assessed using the English or Malay version of the Center for Epidemiologic Studies Depression Scale (CESD).^19,20 Participants were considered as having major depression when both the CESD score was >23/24 and the algorithm score was ≥9.03.²¹ Others were considered to have no depression who were either normal or had distress/dysphoria (with only one criterion fulfilled). Emotional changes (joy and melancholy) were also assessed.

Statistical analyses were performed using SPSS (Windows version 26; IBM Corp, Armonk [NY], US). Chi-squared tests were used for comparison of frequencies of categorical variables. Bonferroni correction was used of pairwise comparisons.²² Depression status was dichotomised (yes/no). Binary logistic regression was used to determine the associated factors for depression, with adjusted odds ratio (AOR) and 95% confidence intervals presented.

Results

A total of 963 participants (578 women, 311 men, and 74 undisclosed) were included (Table 1). Their mean age was 40.1 years; 68.7% were aged 22 to 45 years. 75.2% had tertiary education or above. 53.7% were from cities. 95.1% were living with someone; 30.9% had no children; and 32.3% were living with someone vulnerable. 84.8% did not work in the health sector. 81.3% had no chronic medical illness.

The mean CESD score was 20.98 ± 10.53 (range, 0-56). Of 963 participants, 451 (46.8%) had depression and 512 (53.2%) had no depression who were either normal (n = 169, 17.5%) or had distress (n = 343, 35.6%). The mean subscale score was 3.42 ± 2.14 for positive affect, 3.49 ± 2.96 for irritability and disturbed social aspects, and 12.73 ± 9.82 for depressed and somatic complaint. 205 (21.2%) participants reported that their feeling of joy or sadness worsened, compared with that before the pandemic.

In univariate analysis, depression was associated with sex, age, marital status, education level, employment status, healthcare worker status, residential area, number of people living together, number of children, whether living with someone vulnerable, and chronic medical illness (Table 1).

In binary logistic regression, depression was associated with number of people living together, number of children, residential area, employment status, and chronic medical illness (Table 2). Participants had higher odds of having depression when living with two people (AOR = 3.896, p = 0.001), three people (AOR = 2.622, p < 0.001) or four people (AOR = 3.135, p < 0.001). Participants with three children had higher odds of having depression (AOR = 2.084, p = 0.008), whereas having only one child was a protective factor for depression (AOR = 0.481, p = 0.01). Participants had higher odds of having depression when self-employed (AOR = 3.825, p = 0.003), retired (AOR = 4.526, p = 0.001), being housekeeper (AOR = 7.478, p = 0.004), not working by choice (AOR = 5.511, p < 0.001), or unemployed (AOR = 3.883, p = 0.009). Participants had higher odds of depression when living in a small town (AOR = 3.193, p < 0.001) or rural area (AOR = 3.467, p < 0.001). Participants with no chronic medical illness had lower odds of having depression (AOR = 0.589, p = 0.008).

Discussion

In Malaysia, COVID-19 infection was first reported in January 2020, and the lockdown was imposed on 18 March 2020. In an online survey on depression from April to May 2020, the prevalence of mild-to-severe depression (measured using the Depression Anxiety Stress Scale–21) was 28.2%.²³ Two months later, in the present study, the prevalence was 46.8%, which is higher than that reported in other collaborating countries in the COMET-G study.²⁴ From August to September 2020, as the pandemic and lockdown continued, the prevalence increased to 59.2%.²⁵ During the third wave of the pandemic (January to April 2021), of 1554 respondents, the prevalence of mild-to-severe depression (measured with Patient Health Questionnaires) further increased to 87.7%.²⁶ There is an urgent call for the authority to implement policies to address mental health problems for future pandemic.

Risk factors for depression during the pandemic have been reported to be financial burden, poor accessibility of healthcare as a result of lockdown, and deteriorating physical condition owing to disease complications.^12,25

In the present study, employment status was a risk factor for depression during the pandemic. Those with unstable income (unemployed, self-employed, not working by choice, retired) had three to seven times higher odds of having depression than those working in the public sector. Economic burden plays an important role in mental health status.²⁷ Movement restriction and lockdown severely affect most aspects of economic activities.^28,29 Financial difficulties affect mental health and well-being during the pandemic.^30,31 In Ireland, the loss of income secondary to the COVID-19 pandemic is associated with significant mental health problems.³² Therefore, government should implement financial and mental health interventions targeting those affected people.

In the present study, the number of households (reflected by the number of children and the number of people living together) was a risk factor for depression during the pandemic. Participants who were living with two, three, or four people, and those with three children had higher odds of having depression. In Cyprus, those who are living with >3 people had higher anxiety and depression than those who are living with only one person.³³ Increased time spent in direct contact with family and children who work and study from home during the lockdown may change the family dynamic and trigger stress leading to depression.^34,35

Nonetheless, living with only one child had a protective effect from having depression. This suggests that the parent- infant interaction may reduce the feeling of loneliness. Living with others reduces loneliness resulted from lockdowns.^36,37 In contrast, in Greece, family relationships and fewer conflicts may yield higher depression, as close relationships induce fear of other family members being infected and died from COVID-19.¹⁸

In the present study, the residence area was a risk factor for depression during the pandemic. Those living in small towns (with <20 000 inhabitants) or villages had >3 times higher odds of having depression than those living in cities. Those living in small towns and villages (such as farmers or fishermen) experience economic hardship, lack of social support, and isolation, which already existed before the pandemic.^38,39 In 30 provinces of China, depression levels are high among residents of small towns,⁴⁰ whereas in India, rural residents are more prone to mental illness because of the difficulty in obtaining social support.⁴¹

In the present study, those without chronic medical disease had lower odds of having depression. Chronic medical disease increases the morbidity and mortality secondary to COVID-19. Knowing this fact may induce fear, worry, and anxiety and lead to depression.^1,25

The present study has several limitations. The cross- sectional design cannot determine the causal relationship; longitudinal prospective cohort studies are recommended. Online survey social media may only capture data from those who are internet savvy and better educated. There may be selection bias because of convenient sampling, as 75.2% of participants have tertiary education or higher. Thus, generalisation of our findings to the general population in Malaysia may not be appropriate. Confounders such as previous mental health problems and other factors for depression (including adverse life events, substance misuse, and presence of other mental illnesses) were not investigated.

Conclusion

In Malaysia during the COVID-19 pandemic, people who are living with two, three, or four people, having three children, living in a small town or rural areas, and having unstable income have higher odds of having depression. Living with one child and not having chronic medical diseases are protective factors for depression. Given the higher prevalence of depression during the pandemic, urgent intervention for those at risk of depression is recommended. Early detection and treatment for depression as well as financial support and allowances during the pandemic should focus on people with many children, living in rural and small-town areas, and with financial difficulties.

Contributors

All authors designed the study, acquired the data, analysed the data, drafted the manuscript, and critically revised the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

All authors have disclosed no conflicts of interest.

Funding/support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

All data generated or analysed during the present study are available from the corresponding author on reasonable request.

Ethics approval

This study was approved by the ethics committee of Universiti Teknologi MARA (reference: REC/06/2020 (MR/109)).

Acknowledgments

The co-investigators from Malaysia would like to thank the leading investigators from the Aristotle University of Thessaloniki and the Mental Health Sector of the Scientific Research Institute of the Pan-Hellenic Medical Association, Greece for the opportunity to collaborate in this study.

References

1. Guo G, Ye L, Pan K, et al. New insights of emerging SARS-CoV-2: epidemiology, etiology, clinical features, clinical treatment, and prevention. Front Cell Dev Biol 2020;8:410. ^Crossref
2. Kulig B, Erdelyi-Hamza B, Elek LP, et al. Effects of COVID-19 on psychological well-being, lifestyle and attitudes towards the origins of the pandemic in psychiatric patients and mentally healthy subjects: first Hungarian descriptive results from a large international online study [in Hungarian]. Neuropsychopharmacol Hung 2020;22:154-65.
3. Šuriņa S, Martinsone K, Perepjolkina V, et al. Factors related to COVID-19 preventive behaviors: a structural equation model. Front Psychol 2021;12:676521. ^Crossref
4. Chaturvedi SK. Covid-19, coronavirus and mental health rehabilitation at times of crisis. J Psychosoc Rehabil Ment Health 2020;7:1-2. ^Crossref
5. Hick JL, Biddinger PD. Novel coronavirus and old lessons: preparing the health system for the pandemic. N Engl J Med 2020;382:e55. ^Crossref
6. Blumenthal D, Fowler EJ, Abrams M, Collins SR. Covid-19: Implications for the health care system. N Engl J Med 2020;383:1483-8. ^Crossref
7. Wang C, Pan R, Wan X, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020;17:1729. ^Crossref
8. McGinty EE, Presskreischer R, Han H, Barry CL. Psychological distress and loneliness reported by US adults in 2018 and April 2020. JAMA 2020;324:93-4. ^Crossref
9. Dawel A, Shou Y, Smithson M, et al. The effect of COVID-19 on mental health and wellbeing in a representative sample of Australian adults. Front Psychiatry 2020;11:579985. ^Crossref
10. Razali S, Abdullah MN, Rahman NA, Azhar NA, Yaacob SS. Psychological distress of health care workers in the main admitting hospital and its related health care facilities in Malaysia during the COVID-19 pandemic. Asia Pac J Public Health 2021;33:667-9. ^Crossref
11. Shah AUM, Safri SNA, Thevadas R, et al. COVID-19 outbreak in Malaysia: actions taken by the Malaysian government. Int J Infect Dis 2020;97:108-16. ^Crossref
12. Chua SN. The economic cost of mental disorders in Malaysia. Lancet Psychiatry 2020;7:e23. ^Crossref
13. National Institutes of Health, Ministry of Health Malaysia. National Health and Morbidity Survey 2019. Technical Report. Volume 1. NCDs: Non-communicable diseases: risk factors and other health problems. Available from: https://iku.moh.gov.my/images/IKU/ Document/REPORT/NHMS2019/Report_NHMS2019-NCD_v2.pdf.
14. Institute for Public Health, Ministry of Health Malaysia. National Health and Morbidity Survey 2019. Available from: http://www.iku. gov.my/nhms-2019.
15. Ibrahim N, Din NC, Ahmad M, et al. Relationships between social support and depression, and quality of life of the elderly in a rural community in Malaysia. Asia Pac Psychiatry 2013;5 Suppl 1:59-66. ^Crossref
16. Tan KL, Yadav H. Depression among the urban poor in Peninsular Malaysia: a community based cross-sectional study. J Health Psychol 2013;18:121-7. ^Crossref
17. Khan TM, Sulaiman SAS, Hassali MA. The causes of depression? A survey among Malaysians about perception for causes of depression. Asian J Pharm Clin Res 2008;2:6-9.
18. Fountoulakis KN, Apostolidou MK, Atsiova MB, et al. Self-reported changes in anxiety, depression and suicidality during the COVID-19 lockdown in Greece. J Affect Disord 2021;279:624-9. ^Crossref
19. Fountoulakis KN, Iacovides A, Kleanthous S, et al. Reliability, validity and psychometric properties of the Greek translation of the Center for Epidemiological Studies-Depression (CES-D) Scale. BMC Psychiatry 2001;1:3. ^Crossref
20. Ghazali SR, Elklit A, Balang RV, Sultan MA, Yoke YC. Determining the cut-off score for a Malay language version of the Centre for Epidemiologic Studies Depression Scale (CESD). ASEAN J Psychiatry 2014;15:146-52. ^Crossref
21. Fountoulakis KN, Karakatsoulis G, Abraham S, et al. Results of the COVID-19 mental health international for the general population (COMET-G) study. Eur Neuropsychopharmacol 2022;54:21-40. ^Crossref
22. MacDonald PL, Gardner RC. Type I error rate comparisons of post hoc procedures for I × J chi-square tables. Educ Psychol Meas 2000;60:735-54. ^Crossref
23. Yee A, Hodori NM, Tung YZ, et al. Depression level and coping responses toward the movement control order and its impact on quality of life in the Malaysian community during the COVID-19 pandemic: a web-based cross-sectional study. Ann Gen Psychiatry 2021;20:31. ^Crossref
24. Fountoulakis KN, Karakatsoulis GN, Abraham S, et al. The effect of different degrees of lockdown and self-identified gender on anxiety, depression and suicidality during the COVID-19 pandemic: data from the international COMET-G study. Psychiatry Res 2022;315:114702. ^Crossref
25. Wong LP, Alias H, Fuzi AA, et al. Escalating progression of mental health disorders during the COVID-19 pandemic: evidence from a nationwide survey. PLoS One 2021;16:e0248916. ^Crossref
26. Marzo RR, Vinay V, Bahari R, et al. Depression and anxiety in Malaysian population during third wave of the COVID-19 pandemic. Clin Epidemiol Glob Health 2021;12:100868. ^Crossref
27. Kämpfen F, Kohler IV, Ciancio A, Bruine de Bruin W, Maurer J, Kohler HP. Predictors of mental health during the Covid-19 pandemic in the US: role of economic concerns, health worries and social distancing. PLoS One 2020;15:e0241895. ^Crossref
28. Foo LP, Chin MY, Tan KL, Phuah KT. The impact of COVID-19 on tourism industry in Malaysia. Curr Issues Tour 2021;24:2735-9. ^Crossref
29. Hasanat MW, Hoque A, Shikha FA, Anwar M, Hamid ABA, Tat HH. The impact of coronavirus (COVID-19) on e-business in Malaysia. Asian J Multidiscip Stud 2020;3:85-90.
30. Lenzen M, Li M, Malik A, et al. Global socio-economic losses and environmental gains from the Coronavirus pandemic. PLoS One 2020;15:e0235654. ^Crossref
31. Osterrieder A, Cuman G, Pan-Ngum W, et al. Economic and social impacts of COVID-19 and public health measures: results from an anonymous online survey in Thailand, Malaysia, the UK, Italy and Slovenia. BMJ Open 2021;11:e046863. ^Crossref
32. Hyland P, Shevlin M, McBride O, et al. Anxiety and depression in the Republic of Ireland during the COVID-19 pandemic. Acta Psychiatr Scand 2020;142:249-56. ^Crossref
33. Solomou I, Constantinidou F. Prevalence and predictors of anxiety and depression symptoms during the COVID-19 pandemic and compliance with precautionary measures: age and sex matter. Int J Environ Res Public Health 2020;17:4924. ^Crossref
34. Evandrou M, Falkingham J, Qin M, Vlachantoni A. Changing living arrangements and stress during Covid-19 lockdown: evidence from four birth cohorts in the UK. SSM Popul Health 2021;13:100761. ^Crossref
35. Zainal Badri SK, Wan Mohd Yunus WMA. The relationship between academic vs. family/personal role conflict and Malaysian students’ psychological wellbeing during COVID-19 lockdown. J Further High Educ 2022;46:76-88. ^Crossref
36. Fancourt D, Steptoe A, Bu F. Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study. Lancet Psychiatry 2021;8:141-9. ^Crossref
37. McQuaid RJ, Cox SML, Ogunlana A, Jaworska N. The burden of loneliness: implications of the social determinants of health during COVID-19. Psychiatry Res 2021;296:113648. ^Crossref
38. Kua EH. Culture and mental health care in Asia-Pacific rural communities. In: Chaturvedi S, editor. Mental Health and Illness in the Rural World. Mental Health and Illness Worldwide. Singapore: Springer; 2020:285-96. ^Crossref
39. Yee WS, Lin LP. Anxiety and depressive symptoms among communities in the east coast of peninsular Malaysia: a rural exploration. Malays J Psychiatry 2011;20:59-71.
40. Zhong B, Jiang Z, Xie W, Qin X. Association of social media use with mental health conditions of nonpatients during the COVID-19 outbreak: insights from a national survey study. J Med Internet Res 2020;22:e23696. ^Crossref
41. Raj S, Ghosh D, Singh T, Verma S, Arya Y. Theoretical mapping of suicidal risk factors during the COVID-19 pandemic: a mini-review. Front Psychiatry 2021;11:589614. ^Crossref