What We Already Know

• Ongoing COVID-19 pandemic and its control measures have adverse psychological consequences.

• There is a limited literature related to mental health status of general public in India facing the pandemic till date, more so among slum dwellers.

What This Article Adds

• This article describes the prevalence of depression and anxiety and assesses the knowledge and concerns regarding coronavirus disease 2019 (COVID-19) among residents of an urban slum in North India.

• Level of awareness and precautionary measures followed by the residents of urban slum.

Introduction

Since the first few cases of coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), were identified in China in December 2019, the pandemic is rapidly spreading worldwide. A high attack rate and majority of the cases being of mild symptoms along with globalization have facilitated this process.1 The accelerating mortality trend in various age groups and absence of vaccine or structured treatment choices have added to the global panic.

Humans cannot live alone and need a social life for existence or survival. Self-isolation and quarantine measures in this growing COVID-19 pandemic have disrupted our usual activities and livelihoods leading to loneliness, anxiety, depression, insomnia, substance use disorders, and suicidal behavior.2 Social stigma has arisen and the cases are being targeted as they are considered the source for escalation of the outbreaks. Epidemics of such large scale are almost always accompanied by spectrum of mental disorders.3 In addition, among individuals with history of mental illness, all these conditions can exacerbate.4

As of March 25, 2020, globally there were 414,179 cases and 18,440 deaths and reported case fatality rates varied from 1% to more than 7%.5 6 India reported its first case of COVID-19 on January 30th, 2020 and had a total of 220,114 active cases with 17,400 deaths as on July 1st, 2020.7 The social distancing measures and stringent lockdown policies have affected the mental health of many nations, including India.8 9 As research into COVID-19 continues, many myths are also prevalent in the general population regarding the prevention and management of this contagious disease. Interestingly the pandemic has highlighted another aspect in India in this era of social media—infodemic! Individuals are getting overloaded with rumors, misinformation, and near-constant stream of news reports which are not authentic and verified, fueling the already existent depression and anxiety. The World Health Organization has also conveyed its apprehension regarding this and has furnished skilled directions to public queries in coping with fear, stigma, and discrimination during COVID-19.10

Globally there are records of the psychological impact of COVID-19 pandemic on the general public, patients, medical staff, children, and older adults.11 12 13 Preliminary evidence suggests that symptoms of anxiety and depression range from 16 to 28% and self-reported stress is around 8% during COVID-19 pandemic throughout the world.14 However, there is a lacunae in literature related to mental health status of general public in India facing the pandemic till date, more so among the unorganized sector. More than 90% of Indian workforce and about 50% of the national product are accounted for by the unorganized sectors.15 Extra efforts should be made to ensure connections and social support to people who are typically marginalized and isolated, including the immigrants, homeless persons, and those residing in slum areas. Hence, we aimed to estimate the prevalence of depression and anxiety and assess the knowledge, concerns, and practice regarding COVID-19 during the peak of the pandemic among the residents of an urban slum in Chandigarh, India.

Methods

Results

The mean (SD) age of the 200 participants was 33 (13) years with majority being females (83%, n = 166). The median (IQR) family income per month was $137 (113–205) and of the total, 81% (n = 162) had formal education and 93% (n = 185) lived in joint families. Majority of them did not suffer from any chronic illness and did not have any kind of addiction (Table 1).

The prevalence of depression and anxiety were 3.5% (95% CI: 0.95–6.05) and 2.5% (95% CI: 0.34–4.66), respectively. Of the total, eight (4%) had either depression or anxiety and four (2%) had both. Less than half of the study participants have responded affirmatively that COVID-19 spreads through droplet (46%, n = 92) and direct contact (45%, n = 90).

Of total, 82% (n = 163) had confidence in the ability of their treating physician in recognizing COVID-19 and one in three (31%, n = 61) thought that they were likely to get infected with SARS-CoV-2 during this pandemic. Half of the participants believed that too much unnecessary worry was being made concerning the present pandemic (Table 2). Nevertheless, three out of every four persons were wearing masks regardless of symptoms (74%, n = 148) and washed hands after coughing, sneezing, or rubbing the nose (75%, n = 150).

Discussion

In a community-based setting in North India; we found that depression and anxiety were 3.5 and 2.5%, respectively. Majority followed precautionary measures even though half of them viewed that excessive apprehension existed regarding COVID-19 pandemic.

The prevalence of depression and anxiety among our study participants is slightly higher than the national average given by National Mental Health Survey.23 Still, studies from other places have reported higher burden of mental health illness during the pandemic.24 25 26 A study from North India had reported higher burden of mental health illness during the pandemic.27 This study was done among migrant workers who were directly hit by the pandemic as they lost their livelihood and homes resulting in higher level of depression and anxiety. Another reason for lower prevalence can be due to the robust choice of instrument and differences in response with online surveys and real-life settings. PHD being located within 30 minutes walking distance from each house along with satisfaction with the health information made available to them has been a determining factor. Moreover, majority of the study participants were living in joint families and loneliness has significant positive correlation with severity of depression, anxiety, and somatic symptoms.28 Our results also showed a higher percentage of depression than anxiety and this is comparable with other studies in the slum population of India.29 30 This can be explained by the fact that depression is more common among the females, and our study population comprised majorly of females.31 Anxiety coexists with, and commonly precedes depression.32 Hence it is also possible to have missed these acute anxiety cases immediately after the countrywide lockdown was announced.

In a study conducted in China, the overall correct rate of knowledge about the mode of transmission of COVID-19 was 90%.33 In the present study less than half of the participants were aware regarding this. The difference in the knowledge could be attributed to the contrasting level of education in the two settings as in the other study majority (65%) of the participants hold bachelor’s degree and above and a significant difference was found between education and level of knowledge. Also, there is difference in the assessment tool and scoring systems. So, it is not possible to accurately compare the knowledge levels across these studies. Majority of the participants were also satisfied with the information provided to them through mass media. This might be the reason that in our study a considerable number of participants followed the correct practices to prevent the disease. So, the public belief toward the government policies is very much required to contain the spread of this pandemic.

Nearly half of the people think that unnecessary rhetoric has been generated regarding the COVID-19 pandemic. During the time of crisis people tend to search for essential information. Lack of availability of accurate facts can increase anxiety among the common people.34

Most of the people have been adhering to the recommendations given by the government of India and have a good faith in health system which can be used as an opportunity to organize community efforts in fighting this pandemic. To cope with this critical situation, it is necessary to strengthen the awareness programs targeting the mental health issues of these people. The government should provide crisis-based psychological services to the needy through mass media, maintaining the norms of physical distancing—which is difficult to be exercised in slum areas.

Even though the socio-economic characteristics of the study population are comparable to other urban slums in India, this study is limited to a particular stratum of society, so it cannot be generalized to the whole population.35 Thus, more such studies are warranted to see the mental health status of the general population. In addition, selection bias (as females were a considerable fraction in our study group) and social desirability bias (as psychiatric disorders are still a taboo in Indian context) cannot be ruled out in this study.

Conclusion

The prevalence of depression (3.5%) and anxiety (2.5%) is low during the peak of the pandemic among urban slum residents in North India. Majority of the participants followed precautionary measures and half of the them believed that unnecessary worry has been created regarding COVID-19.