|Year : 2022 | Volume
| Issue : 3 | Page : 211-216
Impact of COVID-19 on Mental Health of Aged Population in India: An Online, Cross-sectional Survey
Rachna Bhargava1, Preethy Kathiresan2, Yatan Pal Singh Balhara1, Megha Sharma3, Peter Phiri4, Shanaya Rathod5
1 Department of Psychiatry and National Drug Dependence Treatment Centre, AIIMS, New Delhi, India
2 Department of Psychiatry, AIIMS, Jodhpur, Rajasthan, India
3 Department of Psychology, IGNOU, New Delhi, India
4 Department of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, SO17 1BJ, UK
5 Department of Research and Development, Southern Health NHS Foundation Trust, Southampton, United Kingdom
|Date of Submission||28-Aug-2022|
|Date of Decision||11-Sep-2022|
|Date of Acceptance||11-Sep-2022|
|Date of Web Publication||21-Dec-2022|
Dr. Rachna Bhargava
Department of Psychiatry and National Drug Dependence Treatment Centre, AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: The COVID-19 pandemic impacted the lives of millions of people around the world. The stress due to the increased risk of morbidity and mortality among the elderly along with the lockdown measures can impact the mental health of older aged adults. Hence, the current study aimed to assess the mental health impact of COVID-19 pandemic on older adults in India. Methods: The current study was part of an online, cross-sectional survey conducted in eight countries. For the current study, participants were included if they were Indians, were at least 55 years of age, had Internet access, were residing in India, and were willing to participate in the study. A semi-structured questionnaire to assess the sociodemographic data and worries related to the COVID-19 pandemic, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Impact of Events Scale-Revised were applied. Results: A total of 181 older adults participated. The most common worries were the impact of COVID on society (65.2%) and on friends and family (50.8%). About 14.9%, 2.8%, and 14.9% of participants were screened positive for depression, probable posttraumatic stress disorder, and anxiety based on PHQ-9, IES-R, and GAD-7, respectively. There was a significant association of both depression and anxiety with preexisting mental illness, worry about transmitting COVID to others, ability to care for others, impact of COVID-19 on one's own health, finances, and society. Conclusions: Higher levels of altruism and “psychological jointedness” in the Indian family could have led to this unique finding that older adults were more worried about the impact of pandemic on others, than self.
Keywords: COVID-19, mental health, older adults
|How to cite this article:|
Bhargava R, Kathiresan P, Balhara YP, Sharma M, Phiri P, Rathod S. Impact of COVID-19 on Mental Health of Aged Population in India: An Online, Cross-sectional Survey. World Soc Psychiatry 2022;4:211-6
|How to cite this URL:|
Bhargava R, Kathiresan P, Balhara YP, Sharma M, Phiri P, Rathod S. Impact of COVID-19 on Mental Health of Aged Population in India: An Online, Cross-sectional Survey. World Soc Psychiatry [serial online] 2022 [cited 2023 Feb 1];4:211-6. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/3/211/364582
| Introduction|| |
The COVID-19 pandemic led to a huge negative impact in the various domains – physical, psychological, financial, social, and occupational – in the lives of millions of people around the world. Older adults were found to be more vulnerable with mortality rates as well as morbidity due to COVID-19 being higher among older adults compared to younger adults. Even though telemedicine services expanded during the COVID-19 pandemic, older adults usually found it difficult to access the same., This increase in vulnerability to COVID-19 and increased risk of loneliness coupled with difficulty in accessing health services can increase the risk of mental illness among the elderly. Interestingly, multiple studies conducted during the pandemic from high-income countries such as the USA and Spain showed that the prevalence of mental illness and psychological distress was less among older adults compared to other age groups. However, studies from upper-middle income country like Thailand and lower-middle income countries have shown that there is a high prevalence of psychological distress among older adults, following COVID-19 pandemic.,
Indian culture is unique in that in India, family system is more cohesive and families live in a joint or nuclear family system. Caregiving of the elderly in families is traditionally considered a responsibility of the younger family members. Studies have shown changes in the family structure over time with dissolution of the joint family system., Family support can help in providing good emotional support as well as support for the other resources needed during the lockdown associated with COVID-19 pandemic. This unique situation in Indian context leads to the query of what could have been the impact of COVID-19 and associated lockdown on the mental health of older adults in India.
However, very few studies have attempted to examine the impact of COVID-19 on the mental health of older adults in India. A study conducted by HelpAge India found that nearly half of the older adults were worried about their own future, and nearly one-half also worried about their family members, domestic help, and others getting infected. While this study was a multicentric study, no standard tools were used to assess the prevalence of mental illness in the elderly population. Another study conducted by Das et al. among 92 elderly adults from Chandigarh found the prevalence of anxiety and depression to be 8.7% and 15.2%, respectively. However, this study focused only on the elderly population from one city in India.
The current study, thus, aimed to assess the mental health impact of COVID-19 on older adults in India. The primary objectives of the current study were to assess the worries related to COVID-19, and the prevalence of depression-, anxiety-, and stress-related disorders during the COVID-19 pandemic. The secondary objective of the current study was to find the association between the sociodemographic variables, the clinical variables, namely the presence of preexisting mental illness, worries related to the COVID-19 pandemic, and perceived social support with the presence of depression and anxiety. Older adults in the current study were defined as age ≥55 years. An operational definition was followed as the exact age of the participant was not known. The study being part of the large survey for adult population, the age was enquired in a categorical form.
| Methods|| |
The current study was part of an online web-based cross-sectional study carried out among adults in eight countries. The methodology has been described in previous publications., This study was conducted during the first wave of COVID-19 pandemic, when the fear and apprehension of acquiring novel coronavirus infection among older adults were perceived as life-threatening. Due to the COVID-related restrictions prevalent during that time, the study was conducted as an online, cross-sectional study. The link for the study questionnaire was sent through social media apps like WhatsApp using snowballing technique. In India, the survey was conducted between July 2020 and September 2020 after obtaining ethical clearance at the Institutional Ethics Committee at India Site. All participants who wanted to contact the investigators for any help related to mental health were provided contact details of the investigators.
The sample for the present study was drawn from the respondents who had participated in the first wave of the survey and fulfilled the following inclusion criteria: older adults (defined as age ≥55 years for the current study), who had access to the Internet, residing in India, who were able to understand the questions, and who were willing to participate in the study.
A semi-structured questionnaire specially developed for the study was used to assess the sociodemographic data and worries related to the COVID. The Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder-7 (GAD-7), and the Impact of Events Scale were applied to screen for depression-, anxiety-, and stress-related disorders, respectively, while the Multidimensional Scale of Perceived Social Support (MSPSS) was used to assess the perceived social support. PHQ-9 Scale is a self-administered tool for screening for depression and its severity. The scale has a sensitivity and sensitivity of 88% and 88%, respectively, has a good internal reliability with Cronbach's alpha of 0.89, and has excellent test–retest reliability. GAD-7 Scale is a seven-item screening tool used for screening anxiety disorder and its severity. The scale has a sensitivity and specificity of 89% and 82%, respectively, has excellent internal consistency with Cronbach's alpha score of 0.92, and has good test–retest reliability (intraclass correlation of 0.83)., The Impact of Events Scale-Revised is a 22-item screening tool used to assess the current subjective distress for a specific traumatic event. The scale has high internal consistency with Cronbach's alpha of 0.96. The correlation between IES-R and posttraumatic stress disorder (PTSD) checklist was high (0.84). MSPSS is a 12-item scale used to measure the perceptions of social support from friends, family, and significant others. The scale has good internal reliability with Cronbach's alpha score of 0.88, and the test–retest reliability was 0.85.
Statistical Package for Social Sciences Statistics for Windows, Version 20.0 (IBM Corporation; Armonk, New York, USA; Released 2011) was used for statistical analysis. Categorical data were summarized using frequencies and percentages. PHQ-9, GAD-7, and Impact of Events Scale were categorized into different severity levels. Chi-square test/Fisher's exact test was applied, as appropriate, to find if there was any significant association between the various clinical and sociodemographic variables with the presence/screen positive of depression on PHQ-9 and the presence/screen positive of anxiety on the GAD-7 Scale. P <0.05 was considered statistically significant for all the tests.
| Results|| |
A total of 181 older adults from India participated in the study. Around 51.4% (n = 91) of the sample were female. Majority of them (78.5%, n = 142) belonged to Hindu religion. More than half of the sample were educated up to postgraduation or more (57.4%, n = 104), while 55 participants (30.4%) had completed graduation. 88.9% (n = 161) of the sample stayed in their own home or their parent's home. Around half of the participants (n = 93, 51.4%) were employed at the time of survey, and among those employed, around half (n = 48, 51.6%) reported working from home at the time of survey.
Presence of preexisting mental illness
Eleven (6.1%) participants reported the presence of preexisting mental illness, with 5 (2.8%) participants reporting depression, 5 (2.8%) participants reporting anxiety disorder, and 3 (1.7%) participants reporting other mental illness before the start of the COVID-19 pandemic.
Mental health impact during COVID-19 pandemic
The most common worry during COVID-19 pandemic was the worry related to the impact of COVID on society (65.2%) and on friends and family (50.8%), followed by worry about getting COVID to self or transmitting the infection to others [Table 1]. Worry about the impact of COVID on employment or one's own mental health was found to be relatively less.
Depression-, anxiety-, and stress-related disorders during COVID-19 pandemic
Screening with the PHQ-9 Scale found that 14.9% of the participants (n = 27) were screened positive for depression. Of those who were screened positive, majority (n = 16) had mild depressive symptoms only. Similarly, screening with the GAD-7 Scale showed that 14.9% (n = 27) were screened positive for anxiety disorder. Of these, majority (n = 23) had mild anxiety symptoms and none had severe symptoms. The Impact of Events Scale showed that 2.8% of the participants had a probable diagnosis of PTSD [Table 2].
|Table 2: Depression-, anxiety-, and stress-related disorders during COVID-19 pandemic|
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Association of clinical and sociodemographic variables with depression and anxiety
There was no statistically significant association between the presence of depression based on the PHQ-9 Scale and the presence of anxiety based on the GAD-7 Scale with the sociodemographic variables, namely gender, education, religion, living arrangement, and employment status. Association analysis for PTSD based on the Impact of Events Scale was not done due to very low prevalence.
[Table 3] shows that the variables that were found to be statistically associated with both depression and anxiety were the presence of any preexisting mental illness, the presence of worry about transmitting COVID infection to others, the presence of worry about ability to care for others, the presence of worry about impact of COVID-19 on one's own physical and mental health and finances, and the presence of worry about the impact of COVID on society. History of domestic violence ever was significantly associated with the presence of depression, while worry about impact on employment was significantly associated with anxiety. There was also a significant association between perceived total social support and support from significant others and friends with depression, but not with anxiety.
|Table 3: Association of clinical variables with the presence of depression based on the Patient Health Questionnaire-9 and the presence of anxiety based on the Generalized Anxiety Disorder Scale-7|
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| Discussion|| |
There is a dearth of data-based evidence regarding the impact of COVID-19 pandemic on the mental health of older adults. The current study highlights the concerns and the psychological impact among older adults in a community setting during the first wave. The worry related to the impact of COVID on one's own long-term physical or mental health was comparatively less; however, nearly half of the older adults felt worried about COVID impacting the society, friends, and family. Furthermore, the presence of depressive symptoms and anxiety symptoms was significantly associated with these worries and not with the worry about getting COVID to self. The prevalence of PTSD based on the Impact of Events Scale was found to be very less which is similar to other studies among older adults during the COVID-19 pandemic.
Studies have found that aging leads to change in altruism with older adults showing higher altruism than younger adults. In India, even though the National Family Health Survey-5 shows a higher prevalence of nuclear families compared to nonnuclear families in India, some families stay close to each other in different households but in the same community. Furthermore, the strong ties of the extended families have been observed even when relatives could not actually stay in close proximity with the relative maintaining strong bonds and provide each other with good emotional as well as economic support. These strong family bonds coupled with feelings of altruism in the elderly could have led to the finding of mental illness symptoms being more prominent among those older adults who had more worries related to others.
The prevalence of depression in our study was similar to another study from Chandigarh, India, conducted among 98 older adults which showed a prevalence of depression and anxiety to be 15.2% and 8.7%, respectively. However, a study conducted around the same time in June 2020 using the PHQ-4 Scale in the United States found the prevalence of depressive disorder and anxiety disorder to be very less, i.e., 5.8% and 6.2%, respectively, among the elderly population above 65 years of age. This emphasizes the role of diverse cultural context in understanding the dynamics of distress among older adults. In India, studies have shown that anticipation of negative outcomes, especially the fear of a family member or close friend falling ill and dying from the virus, was associated with increased risk of having depressive or anxiety symptoms. In this study too, the presence of better perceived social support was associated with significantly higher prevalence of depression than those with low social support. The presence of social support may have induced the fear of transmitting COVID to significant others, which could have led to the higher prevalence of depression among patients with higher social support. Furthermore, the association analysis showed a significant association of worry about transmitting COVID to others, worry about risk of COVID impacting one's ability to care for others, with depression and anxiety. Since most of the elderly Indians live with their adult children, the risk of depression and anxiety in India could have been higher compared to the USA.
A survey carried out among lower- and middle-income countries found that nearly 74% of older people were anxious all or most of the time, while 68% were depressed, with the rates being higher in women than for men. Another survey by the same organization along with another organization called as GRAVIS had also conducted a rapid needs assessment survey among 88 older adults in Rajasthan in August 2020, when they found that nearly 40% of the older adults reported being depressed most of the time and 76% reported feeling anxious most of the time, which was higher than the current study. This survey involved only participants who were already beneficiaries of GRAVIS. Another online survey from Kerala in India found nearly 40% of the elderly population to be having anxiety which was again, very much higher compared to our study. The wide variations in prevalence rates in different states highlight differences across states and need to have a larger sample from various states and strata. Another reason could have been the fact that most of these studies on older adults or the elderly had focused on individuals above 60 years of age., However, in our study, we had taken those who were 55 years of age or above.
One of the strengths of the study is that it is one among the very few studies from India that have focused on the mental health of older adults during COVID-19 pandemic. As it was done during the pandemic, it captures the actual mental health status of older adults during that time.
There were certain limitations in our study. At the outset, the universal definition of the elderly could not be followed due to lack of exact age of participants. Hence, this mixed group did not symbolize totally retired group. In addition, our study was based on a web-based survey. It restricted to those elderly adults who were able to access the Internet and understood technology. Furthermore, most of our participants were staying in their own home and had completed postgraduation, and were employed, which shows that most of the participants must have belonged to higher socioeconomic status, and had better financial independency and hence the study cannot be generalized to the whole of the elderly population in India. The current study used screening tools such as PHQ-9, GAD-7, and IES-R only to assess the presence of depression, anxiety, and PTSD. The use of diagnostic interviews or diagnostic tools could have provided more accurate diagnosis among the participants but would have been time-consuming and difficult for the participants to fill it online.
The current study provides valuable insights into the mental health of the elderly during the first wave of COVID-19 pandemic. Although the fear and anxiety for COVID have reduced, the study throws light on the “existing jointedness” within the family system. Although the literature documents disintegration in joint family system because of jobs and other issues, the psychological jointedness-the concern for family was apparent at the time of traumatizing situation. Although the sample is small and restricts generalizability, it suggests the need for exploring socioemotional dynamics in the Indian family matrix where the mental health issues appear to be significantly related to bonding in the latter half of the life span.
| Conclusions|| |
Around 14.9% of older adults were screened positive for depression and 14.9% for anxiety, respectively. The presence of depression and anxiety was significantly more among older adults who had higher social support, those who reported worries about transmitting COVID to others, and those who reported worries about the impact of COVID on others. Although the findings need to be replicated and at this stage generalizability cannot be made, the findings indicated that psychological connectedness among the family members in the Indian culture coupled with a higher degree of altruism among older adults could have been responsible for anxiety. The findings have clinical implications in terms of psychological management. In order to deal with distress among the elderly, one needs to take into cognizance regarding their concerns about family. An important implication from management perspective is that the findings also suggest the significance of culture-specific factors in treatment. Further studies are needed to confirm or refute whether altruism can act as a risk factor for depression or anxiety among older adults. Furthermore, studies on whether culturally sensitive treatment for mental illness is more effective for older adults in Indian population.
The authors would like to acknowledge the help of Elizabeth Graves, Ashlea Brooks, Saseendran Pallikadavath, and Pranay Rathod in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]