Prevalence of depression, anxiety and stress symptoms and their association with quality of sleep and loneliness in the general population during the COVID-19 pandemic in India

The impact of mental health due to coronavirus infection caused by SARS -2 COVID -19 is severe. The spread of the virus has been reported not only in India but also in many countries worldwide. The lockdown amid the recent COVID-19 widespread has brought about a change in the way of life in most people. The self-isolation and social distancing measures may result in individuals becoming more anxious, angry, stressed, disturbed and depressed. The aim of our study is to assess the prevalence of depression, anxiety and stress and their association with quality of sleep and loneliness in the general population during the Covid 19 pandemic. The study design was a crosssectional study, and information and data were collected through an online questionnaire using Google forms. A total of 726 participants had completed the online questionnaire from which socio-demographic details, Depression, Anxiety & Stress (DASS 21), Insomnia (ISI) and Loneliness (UCLA) were assessed. The overall prevalence rate of depression, anxiety, stress, insomnia and loneliness was 27%, 24.9%, 12.1, 16.9% and 8.8%, respectively. Age, education, occupation and living status had a strong association with depression. Concerning anxiety, age, marital status, living status and past history of medical illnesswere positively correlated. Stress had a strong associationwith education. Insomnia was signi icantly associated with depression, anxiety, stress and loneliness. Anxiety, stress and insomnia had a strong association with loneliness. This study shows that the psychological impact of the COVID-19 pandemic in the general population is very high. Since loneliness and insomnia have been shown to be associated with psychological symptoms, screening for and addressing them can help in reducing the psychological impact of COVID-19.


INTRODUCTION
The novel coronavirus SARS 2 (COVID-19) created a pandemic situation, wherein initially, a small number of atypical cases of pneumonia were reported in December 2019, and the causative virus CoV-2 were similar with SARS-CoV from the 2003 SARS outbreak. On February 12, 2020, the World Health Organization of icially named the disease caused by the novel coronavirus as coronavirus disease 2019 . On March 11, 2020, the WHO announced the outbreak as a worldwide pandemic which has created a lot of threat to human lives both physically and mentally.
India is the second most populated nation in the world, with a population of 1.3 billion individuals spread over different states having vast inancial, social and health imbalances, which posed an extraordinary challenge in this period of the COVID-19 pandemic. India reported its irst case on January 30, 2020 (Reid, 2020). The common symptoms include fever, cough, and myalgia, with diarrhoea, with or without the subsequent development of dyspnea and transmission of Covid 19 infections occurred through infected secretions, droplets and direct contact. To reduce the spread of COVID-19, the Indian Government announced a complete lockdown for 21 days from March 25, 2020. The lockdown was further extended, and many other restrictions were put in place to curtail disease spread. Many aspects of this disease prevention, including social distancing, decreased means of travel, closure of workplace and educational institutions, resulting in individuals being separated from family, friends, colleagues or co-students. These have the potential to cause loneliness, anxiety, and depression. Many previous studies during outbreaks or epidemics have reported a high prevalence of psychiatric symptoms in the general population (Sim and Chua, 2004;Tzeng et al., 2020). Even during the current pandemic, a few studies have reported the psychological impact of COVID-19 among the general population (Wei et al., 2020;Pan et al., 2020) and among healthcare workers Rossi et al., 2020;Santarone et al., 2020).
Some studies have attempted to analyse the correlates of psychological symptoms like depression and anxiety during the COVID-19 pandemic. In a study by Smith et al., it was concluded that female sex, student status, chronic physical illness, and low socioeconomic status were altogether related to a signi icant psychological impact and higher levels of stress, anxiety, and loneliness (Smith et al., 2020). Extensive utilisation of social media by youth and grown-ups between 18 and 35 years of age is connected with a raised tendency to create decreased interaction and disturbance of day to day activities. The COVID-19 situation and the lockdown also resulted in altered work pattern and the closure of educational institutions. In such a case, people are also likely to have varying sleep pattern. A few studies have looked for the quality of sleep and the prevalence of insomnia during the COVID-19 pandemic (Deng et al., 2020;Gupta et al., 2020;Sinha et al., 2020). They have reported a high prevalence of sleep problems in the general population during the COVID-19 pandemic. Many factors were attributed to the increase in sleep problems, includ-ing increased screen time, altered work timings, altered working habits like working from home and closure of workplaces and educational institutions. Hence we conducted this study to ind the prevalence of depression, anxiety and stress symptoms and their association with loneliness and insomnia in the general population during the COVID-19 pandemic.

Study design and procedure
In this study, the design was a cross-sectional epidemiological study. We collected data through an online survey questionnaire, mainly targeting the general population in India. The survey was conducted by distributing forms through Google link to known friends and passing it on to their groups through snowball sampling technique within India. The study was done after getting approval from the ethical committee of the institution. The responses were collected for 3 months, from April to June 2020. Out of 740 participants, 726 had completed their forms; hence inal sample size in this study was 726. All participants aged between 18 to 65years of age were included after obtaining informed consent. They were instructed to withdraw at any time if they felt any discomfort and we have informed the purpose of the study to all participants through the same form.

Measures
Socio-demographic measures included age, sex, address, education, occupation, marital status, family status, living status, student status, past history of medical illness and past history of psychiatric illness.

DASS-21
Psychological status was measured using the scale -DASS 21. The DASS-21 is a 21-item validated tool that has been extensively used to measure psychiatric symptoms of depression, anxiety and stress (Ng et al., 2007). DASS-21 has also been used to assess the psychological impact of COVID-19 in previous studies (Odriozola-González et al., 2020). It contains 3 scales, each containing 7 items which are further divided into subscales having the same content. The scale contains 4 options, namely 0,1,2,3. 0 meant that "it did not apply to me at all", whereas 3 meant "applied to me very much or most of the time ". Based on which option suited them over the past week, the participant had to choose one of the four options. The sum of the scores was calculated separately for depression, stress and anxiety and then multiplied by 2 to determine the inal score. For depression, a score of 0-9 was considered normal, 10-13 mild, 14-20 moderate, 21-27 severe and 28+ was extremely severe. For anxiety, a score of 0-7 was taken to be normal,8-9 mild,10-14 moderate,15-19 severe, and 20+ was extremely severe. For stress, a score of 0-14 was considered normal,15-18 mild,19-25 moderate,26-33 severe and 34+ extremely severe. In line with previous studies, we took only moderate and above scoring to represent each of the evaluated symptoms of depression, anxiety and stress (Santamaría et al., 2020;Tee et al., 2020). Mild scoring was ignored and was not taken to represent depression, anxiety or stress symptoms.

Insomnia Severity Index
The quality of sleep was assessed using the Insomnia severity index scale. The Insomnia Severity Index (ISI) is a brief instrument that is designed to assess the severity of insomnia. It is used as a metric of treatment response in clinical research. Its psychometric properties and its validity has been previously established (Gagnon et al., 2013;Veqar and Hussain, 2017).
In the scale, 7 questions are asked, which are related to: dif iculty falling asleep, dif iculty staying asleep, problem waking up too early, satisfaction with sleep pattern, distress about sleep, noticeability of sleep problems by others and interference of sleep dif iculties with daytime functioning. A 5-point Likert scale is used to rate each item (e.g., 0 = no problem; 4 = very severe problem), yielding a total score ranging from 0 to 28. The total score is interpreted as follows Categories,

UCLA Loneliness Scale
For loneliness measurement, the UCLA loneliness scale was used. The validity and reliability of the scale and its application in the Indian context has been established in previous studies (Russell, 1996;Shettar et al., 2017). It is a 20-item scale designed to measure one's subjective feelings of loneliness as well as feelings of social isolation. Participants rate each item as either O ("I often feel this way"), S ("I sometimes feel this way"), R ("I rarely feel this way"), N ("I never feel this way"). Scoring: Make all O's =3, all S's =2, all R's =1, and all N's =0.

Statistical analysis
Data was analysed using SPSS statistics, and we ran descriptive analysis and frequency distribution for all information. The association between variables was measured using the Chi-square test. P value < 0.05 was considered as signi icant value.

Socio-demographic variables and their association with depression
Pearson's chi-square test was used to determine the socio-demographic variables with depression, anxiety, stress, insomnia and loneliness. Younger age group, school going, being unemployed and living alone were associated with more prevalence of depression (Table 3).

Socio-demographic variables and their association with anxiety
Younger age, being unmarried, living alone and a past history of medical illness had a strong association with more prevalence of anxiety (Table 4)

Socio-demographic details and their association with stress
In contrast to depression and anxiety, stress had a strong signi icant association only with education with more stress found in school-going children (Table 5)

Association of insomnia with Depression, Anxiety and Stress
Insomnia had a statistically signi icant association with depression, anxiety, stress and loneliness (Table 6)

Association of Loneliness with Depression, Anxiety, Stress and Insmonia
Anxiety, stress and insomnia had a statistically sig-ni icant association with loneliness. But there was no signi icant association between depression and loneliness (Table 7) DISCUSSION This study was conducted in the Indian adult population during the lockdown period due to the Covid-19 pandemic. The main aim of this study was to determine the prevalence of depression, anxiety and stress and their association with insomnia and loneliness among the study population.

Prevalence of Depression, Anxiety and Stress during the pandemic
Our study showed a high prevalence of depression, anxiety and stress among the general popu-lation during the COVID-19 pandemic. To account for various factors and in line with previous studies, we omitted milder forms of depression, anxiety and stress and took only moderate and above severity to represent the presence of a psychological symptom. Despite that, we found a high prevalence of depression, anxiety and stress. Our study showed that 27%, 24.9% 12.1 % were depressed, anxious and stressed, respectively. Increased prevalence of psychiatric symptoms has been observed during previous epidemics. Taylor et al., in H1N1 SARS outbreak in Australia reported 34% high psychological distress compared to levels of around 12% in the general Australian population (Taylor et al., 2008). A study on the Middle East respiratory syndrome (MERS) epidemic by Jeong and colleagues (2016) reported that 7.6% of 1,656 patients in Korea had anxiety symptoms, and 16.6% of them were distressed (Jeong et al., 2016). Studies done during the COVID-19 pandemic have also reported a high prevalence of psychiatric morbidity in the general population. In a study by Wang and associates, out of the 1211 members, 53.8% evaluated the mental effect of the outbreak as direct or serious; 28.8% reported moderate to severe anxiety symptoms; 16.5% showed moderate to severe depressive symptoms; 8.1% reported moderate to severe stress levels . Another study in India showed similar results using DASS 21, where 28.8% reported moderate to severe anxiety symptoms; 16.5% showed moderate to severe depressive symptoms; 8.1% reported moderate to severe stress levels (Verma and Mishra, 2020). A study conducted in China appeared that those who are at the greatest chance for mental health impact are youths, health care professionals, and individuals who spend a part of their time around patients in the pandemics (Huang and Zhao, 2020). Some previous research found that the prevalence of overall stress was between 8.1% to over 81.9%. (Mazza et al., 2020;Wang et al., 2020)

Sleep and Loneliness
In our study, the prevalence of overall insomnia was 16.9%, in that sub-threshold was 8.4%, 6.7% of participants had moderate insomnia, and 1.8% study group had a severe form of insomnia. In a study by Gupta et al., it was found that compared to the pre lockdown period, there was a shift to a later bedtime and waking time, with a reduction in nighttime sleep and an increase in daytime napping (Gupta et al., 2020). In the study, 23.4% reported that sleep quality had worsened. In 8.4%, it had improved, and in others, it had remained similar to the pre lockdown state. In a study, Voitsidis et al. reported that sleep problems were detected in 37.6% of the par-ticipants (Voitsidis et al., 2020). He also concluded that sleep deprivation inside the Greek people was a function of loneliness, instability, depression, and COVID 19 related stresses with a genuine commitment from two components which were depression and uncertainty. Other components that were said to impact sleep patterns were screen time, which increased after lockdown. Longer time on screen is related to shorter sleep and lesser quality of sleep.

Association with Socio-Demographics
In this study population, younger age group, school going, being unemployed and living alone were associated with more prevalence of depression. This result was similar to previous research, which showed that people less than 40 years old displayed more psychological impact during the pandemic (Huang and Zhao, 2020). The study by Smith et al. had also reported younger age group were associated with higher levels of poor mental health (Smith et al., 2020). Age, marital status, living status and past history of medical illness had a strong association with anxiety. Stress was associated only with education. In a study by Özdin et al., it was found that individuals with previous psychiatric illness, individuals living in urban areas and those with an accompanying chronic disease have more psychological distress (Özdin and Özdin, 2020).

Association of psychological symptoms with Insomnia and Loneliness
In our study, we found that all the psychological symptoms, including depression, anxiety and stress, had a strong positive association with insomnia. This association can re lect either a causative role of insomnia producing psychological symptoms, or insomnia can also be an easily observable symptom of the psychological impact of COVID-19. Though we cannot establish causation, we can say that evaluation or screening for insomnia would help to identify those with psychiatric disturbances. Also, people may be more forthcoming answering questions related to insomnia as a screening tool rather than answering a screening questionnaire related to psychological symptoms because of the associated stigma. Our study found a positive association between loneliness and the psychological symptoms of anxiety and stress, but there was no statistically signi icant association between loneliness and depression. This was in contrast to a previous study that showed that loneliness was the leading risk factor for depression (Palgi et al., 2020).

Strengths
This study offers information on the mental health issues of the Indian population during the ongoing COVID-19 pandemic lockdown. The data suggest that there is an increased prevalence of anxiety and depressive symptoms and psychological distress in the Indian population related to the continuing pandemic.

Limitations
There are a few limitations to this study that should be considered. The study is of cross-sectional design, which has its own set of constraints. Also, selection bias is possible in this study, as an online survey was used to collect the information. Thus the section of the population without access to internet facility has not been included in this study. Therefore the inferences cannot be extrapolated to the entire population.

CONCLUSION
In conclusion, our study revealed a high prevalence of psychological symptoms of depression, anxiety and stress in the general population during the COVID-19 pandemic. Also, a high prevalence of insomnia and loneliness was observed. Younger age, being unmarried, school going, being unemployed and living alone were some of the factors associated with more psychological symptoms. Psychological symptoms were also associated with loneliness and insomnia. This study brings out the signi icant psychological impact of COVID-19 into the light. Developing screening methods with a focus on the established associations in this study can help for early detection and management of psychological symptoms.