Sociodemographic Factors of Depression During the COVID-19 Pandemic in Malaysia: the COVID-19 Mental Health International Study

Abstract

Objectives: To determine the prevalence of depression and the sociodemographic factors associated with depression in Malaysia during the COVID-19 pandemic.

Methods: This study is part of the COVID-19 Mental Health International Study to collect data on the impact of the pandemic on mental health through an online survey. 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. The presence of distress and depression was assessed using the English or Malay version of the Center for Epidemiologic Studies Depression Scale.

Results: 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%). Participants had higher odds of having depression when living with two people (adjusted odds ratio [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).

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. Urgent intervention for those at risk of depression is recommended.

Key words: COVID-19; Depression; Malaysia; Sociodemographic factors

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, [greater than]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 [greater than or equal to]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 [greater than]23/24 and the algorithm score was [greater than or equal to]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 [lesser than] 0.001) or four people (AOR = 3.135, p [lesser than] 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 [lesser than] 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 [lesser than] 0.001) or rural area (AOR = 3.467, p [lesser than] 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 [greater than]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 [lesser than]20 000 inhabitants) or villages had [greater than]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.

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