key: cord-0903538-kmr3pq8p authors: Abir, D. T.; Kalimullah, D. N. A.; Uchechukwu, D. L. O.; Nur -A Yazdani, D. M.; Husain, T.; Goson, P. C.; Basak, P.; Rahman, M. A.; Al Mamun, D. A.; Permarupan, D. P. Y.; Khan, M. Y. H.; Milton, D. A. H.; Agho, D. K. title: Prevalence and Factors associated with Mental health impact of COVID-19 Pandemic in Bangladesh: A survey-based cross-sectional study date: 2021-01-06 journal: nan DOI: 10.1101/2021.01.05.21249216 sha: d8942bb812ed1555918a266b20507b4c814e66f1 doc_id: 903538 cord_uid: kmr3pq8p Abstract Background: Feelings of isolation, insecurity, and instability triggered by COVID 19 could have a long-term impact on the mental health status of individuals. This study examined the prevalence and factors associated with the mental health symptoms of anxiety, depression, and stress during the COVID 19 pandemic in Bangladesh. Methods: From 1st to 30th April 2020, we used a validated self-administered questionnaire to conduct a cross sectional study on 10,609 participants through an online survey platform. We assessed mental health status using the Depression, Anxiety, and Stress Scale (DASS-21). The total depression, anxiety, and stress subscale scores were divided into normal, mild, moderate, severe, and multinomial logistic regression was used to examine associated factors. Results: The prevalence of depressive symptoms was 15%, 34%, and 15% for mild, moderate, and severe depressive symptoms, respectively. The prevalence of anxiety symptoms was 59% for severe anxiety symptoms, 14% for moderate anxiety symptoms, and 14% for mild anxiety symptoms while, the prevalence for stress levels were 16% for severe stress level, 22% for moderate stress level and 13% for mild stress level. Multivariate analyses revealed that the most consistent factors associated with mild, moderate, and severe of the three mental health subscales (depression, anxiety, and stress) were respondents who lived in Dhaka and Rangpur division, females, those who self quarantined in the previous 7 days before the survey and those respondents who experienced chills, breathing difficulty, dizziness, and sore throat. Conclusion: Our results showed that about 64%, 87%, and 61% experienced depressive symptoms, anxiety symptoms, and levels of stress, respectively. In Bangladesh, there is a need for better mental health support for females especially those that lived in Dhaka and Rangpur division and experienced chills, breathing difficulty, dizziness, and sore throat during COVID 19 and other future pandemics. As the global population tries to make sense of the transformations including personal adjustments to lifestyle brought about by the COVID-19 pandemic, residents of low to middle-income countries (LMIC) including Bangladesh face greater challenges due to the fragile health systems [1, 2] , the dense population of Bangladesh and the fact that the country houses a million stateless Rohingya refugees in sprawling refugee camps that are conducive to the spread of epidemics. Bangladesh also has significant migrant populations living in Italy, a COVID-affected country [1] . Whilst the mortality rates in Bangladesh have remained low, due to the timing of the infection, the early transmission of the virus, and the response to the pandemic by authorities, the low socio-economic status of the country and the existing health inequalities usually lead to worse effects [3] . Science has played a significant role in improving people's understanding of the virus, finding effective ways of containment through timely sequencing of the virus and rapid sharing of the data [4] , and most recently the development of different vaccines. Unraveling the genetic sequence of the SARS-COV-2 virus about 4 weeks after the outbreak of the SARS-COV-2 virus [5] , which was shorter compared to the Spanish flu, took almost seven decades for the scientist to unravel the genetic sequence of the disease [6] , is crucial to the development of a diagnostic test and potential treatment [7, 8] . 5 | Prevalence and Factors associated with Mental health impact of COVID-19 Pandemic in Bangladesh: A survey based cross sectional study high mortality rate, closure of businesses, and strict containment measures by national governments also added to the hidden and unhidden mental health burden of the pandemic [10, 11] . However, no one has been able to report comprehensively the mental health impact of the pandemic in most Low and Middle Income Countries (LMIC). Despite the delay in COVID 19 cases in Bangladesh (the first case reported 18 th March 2020), the country's global supply chain of International fashion brands and human resource exports suffered a huge set-back with devastating psychosocial consequences emanating from the International and local economic impacts [12] . The rapid spread of the infection and the business climate in Bangladesh, caused fear, worry, and stress as restrictions were put in place by the government. Post-traumatic stress symptoms as well as delayed grief and the sense of loss after multiple deaths and loss of jobs and avenue to socialize have been reported in previous studies [13] . Studies have reported that the COVID-19 pandemic has significant negative impacts on the mental health of college students, with female students reporting higher levels of perceived stress and inability to focus on their academic work [14] . Similarly, couples undergoing Assisted Reproductive Treatment showed the severe psychological impact of the pandemic particularly among women who were more emotionally distressed, anxious, and depressed than their men counterparts. This is because Assisted Reproductive Treatment was stopped in many centers due to rising concern on the impact of COVID-19 on pregnancy [15] . Coupled with these, are the uncertainties about effective treatment, availability of effective vaccine as well as whether life could return to normal. All these could negatively affect the mental health of the populace and by extension, the productivity of the country that depends largely on international trading, which has so far been decimated by the pandemic. Health care delivery in Bangladesh has major challenges including weak governance and over-centralized framework, the fact that over 58% of all the 7 | Prevalence and Factors associated with Mental health impact of COVID-19 Pandemic in Bangladesh: A survey based cross sectional study The respondents had to be resident in Bangladesh and able to provide online informed consent. To be eligible for participation, participants had to be 18 years and over, and should be able to provide online consent. The covariates, which are shown in Table 1 , were classified into four parts: demographic, household factors, compliance with health measures, and health-related factors. The first part gathered demographic information of the participants, including gender, age, living area (division), level of education, marital status, and working status. The second part was the household factors, which asked about living arrangements, the number living together, and the third part included COVID-19 factors, which asked whether the participants have been tested for COVID-19. The fourth part evaluated the compliance to WHO recommended precautionary measures, which included avoiding crowded gatherings, handshaking and use of public transport, wear of facemask when going out, advocate other people about the health risk of the infection. The fifth part evaluated the history of health-related symptoms (if the respondents had experienced any of the following symptoms: fever, pain, headache, chills persistent, dizziness, and breathing difficulties, a couple of weeks before data collection). The information about these five parts is listed in Supplementary Table 1. The Depression, Anxiety and Stress Scale -21 Items (DASS-21) is a set of three self-report scales designed to measure the emotional states of depression, anxiety, and stress and were calculated based on a previous study [18] . Responses to each item were rated from 0 to 3, where "never" (score '0') to 'almost always" (score '3'). Item 3, 5, 10, 13, 16, 17, and 21 (see supplementary table 1) were classified as the depression subscale, and the total depression subscale score was multiplied by 2 to calculate the final score and divided into normal (0-9), mild depression (10-13), moderate depression (14) (15) (16) (17) (18) (19) (20) , severe depression (21+). The All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in Cronbach's alpha coefficients measuring internal consistency among the depression subscale score ranged from 0.75 to 0.77, indicating a satisfactory level of reliability. The items 2, 4, 7, 9, 15, 19, and 20 (see supplementary table 1) formed the anxiety subscale, and the total anxiety subscale score was multiplied by 2 to calculate the final score and divided into normal (0-7), mild anxiety (8) (9) , moderate anxiety (10) (11) (12) (13) (14) , severe anxiety (15+) [18] . The Cronbach's alpha coefficient for anxiety subscale scores ranged from 0.65 to 0.77, indicating acceptable internal consistency. Items 1, 6, 8, 11, 12, 14 , and 18 (see supplementary table 1) were classified as the stress subscale. The total stress subscale score was multiplied by 2 to calculate the final score and was divided into normal (0-14), mild stress (15) (16) (17) (18) , moderate stress (19) (20) (21) (22) (23) (24) (25) , severe stress (26+), and extremely severe stress (35) (36) (37) (38) (39) (40) (41) (42) [18] . The Cronbach's alpha coefficient of stress subscale scores ranged from 0.78 to 0.81, indicating an acceptable level of internal consistency. Descriptive statistics using frequency tabulations were used to present the sample characteristics. The prevalence and 95% confidence intervals of symptoms of depression, anxiety, and levels of stress were calculated for normal, mild, moderate, and severe. The association was further tested by odds ratios (OR) using univariate multinomial logistic regression, and multiple multinomial logistic regression analyses were performed to identify significant factors associated with symptoms of depression, anxiety, and levels of stress. In the multiple multinomial logistic regression analyses, four-stage modeling was employed. In the first stage, the demographic factors were entered into the first stage model. We conducted a manually executed elimination method to determine factors associated with symptoms of depression, anxiety, and levels of stress at (p <0.05). The significant factors in the first stage were added to the household factors in the second stage model; this was then All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. 9 | Prevalence and Factors associated with Mental health impact of COVID-19 Pandemic in Bangladesh: A survey based cross sectional study followed by the elimination procedure. We used a similar statistical approach for compliance with public health and Health condition actors in the third and fourth stages, respectively. Associations were presented as unadjusted OR (95% CI) for all explanatory variables and then adjusted OR (95% CI) for the variables retained in the final step. All statistical analyses were conducted using STATA/MP Version.14.1 (Stata Corp, College Station, TX, USA). We conducted spatial distribution for mental health which consisted of depression, anxiety, and stress subscales. A series of maps were prepared using ArcGIS Desktop 10.8 [19] . The average level of depression, anxiety, and stress for the first-level administrative unit of Bangladesh (division) was calculated based on the identification of factors through map comparisons and regression analysis for mild, moderate, and severe levels. In the maps, the adjusted odds ratios (AOR) for each level was categorized into five quantiles and were presented using graduated colour symbols. From the 10,900 participants, data for 10,660 respondents (aged 18 years and over) deriving out of all 8 divisions in Bangladesh were included in the analysis. 5238 participants (49.1%) were males and mostly aged between 18-37years (8466, 79.4%). Of the total number of respondents, 6233 (58.5%) had a university degree or higher, and 5332 (50.3%) were perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in Of the total number of respondents, the majority enforced protective measures in their homes to protect their families (9705, 91.5%), had quarantine experience, 8454 (79.7%) but more than two-third (~78% each) did not comply with the public health measures of avoiding public transport, handshaking, large gatherings, wear of facemask when going out, which were put in place to contain the spread of the disease. More than two-thirds of the participants had at least one symptom of COVID-19 a couple of weeks before data collection, especially persistent fever and cough (9727, 91.7%) and difficulty breathing (9207, 86.8%). Additional demographic and epidemic-related characteristics are presented in Table 1 . The prevalence of symptoms for the 3 mental health conditions among the total sample is shown in Figures 1 (a-c) Figure 1 . The results of the unadjusted analysis of demographic and COVID-19 related variables are presented in the supplementary Tables 1-3, for depression, anxiety, and stress, respectively. Table 2 presents the multivariate analysis of factors associated with depression in this cohort. In the multivariable analysis, being married, having lower than a postgraduate degree, living All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. ; https://doi.org/10.1101/2021.01.05.21249216 doi: medRxiv preprint 11 | Prevalence and Factors associated with Mental health impact of COVID-19 Pandemic in Bangladesh: A survey based cross sectional study alone or living in shared accommodation, living in the Sylhet, Dhaka, Chittagong, Rajshahi, and, Rangpur divisions, having experienced any COVID-19 related health symptom couple of weeks before data collection, were found to be associated with symptoms of depression at all levels. Figure 2 presents the adjusted odds ratios for depression symptoms among the respondents by region. The map in Figure 2 , indicates that significantly high odds of depression occurred in all 8 regions of Bangladesh with the highest odds of severe depression reported in Rangpur, Sylhet and Chittagong reported (darkest brown colour). Individuals who were tested for COVID-19 also had remarkably higher levels of mild-severe symptoms of depression compared to those that had not been tested. In addition, female participants, those who were divorced or separated, residents of Barisal or Mymensing divisions, and those who traveled by public transport displayed a higher risk of moderate-severe symptoms of depression. Additional details on the factors associated with depression are presented in Table 2 . Individuals with confirmed COVID-19 had at least a 50 percent higher risk of moderate-severe depression symptoms compared to those who were not tested for the disease. Table 3 presents the multivariate analysis of factors associated with anxiety among the participants. Their distribution by region is shown in Figure 3 , revealing that the odds for feeling severely anxious increased by more than 3 folds among respondents from four of the eight regions (see Figure 3 for details). From the Table, females, those who were divorced or widowed, those who lived in shared accommodation during the lockdown, individuals who experienced self-quarantine, and those who experienced fever and cough a couple of weeks before data collection, were more likely to experience mild-severe symptoms of anxiety, while older participants experienced a lower risk of depression at all levels. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. ; and Rangpur [adjusted OR, 5.86, 95%CI, 3.64-9.42] had a higher risk of severe symptoms of depression (see Figure 4 ) as well as those who lived alone [adjusted OR, 1.70, 95%CI, 1.35-2.16] during the lockdown. Those with confirmed or suspected cases of COVID-19 were more about two times more likely to experience severe symptoms of depression compared to those who were not tested. Other symptoms of COVID-19 were also significantly associated with some degree of depression in this study. The factors associated with stress in the multivariate analysis are shown in Table 4 . Females, those living outside of Khulna division, participants with lower than postgraduate education, older people (>27years), participants who were married, those who lived alone, and participants who had experienced self-quarantine and any of the health symptoms in this study (except for fever) were more likely to experience symptoms of stress at all levels. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. ; perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. ; Adjusted odd ratios (aOR); 95% confidence intervals (CI) perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. ; Figure 3 Spatial distribution of anxiety during COVID-19 in Bangladesh by division All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. ; This cross-sectional survey assessed the prevalence and associated factors of mental health symptoms related to the COVID-19 pandemic in Bangladesh using an online survey. The study found a high prevalence of mental health symptoms during the pandemic, particularly feeling anxious and depressed while about half of the respondents experienced stress. Respondents who reported these mental health symptoms during the pandemic were more likely to be females, married, have lower education, faced by various factors related to accommodation and living arrangements, and those who experienced COVID-19 related health symptoms. In addition, respondents who were tested for COVID-19, those who traveled via public transport, and people who practiced self-quarantine self-reported a higher prevalence of depression, anxiety, and stress in this study. The prevalence of mental health symptoms found in this study was higher than previous studies conducted elsewhere during the COVID-19 pandemic including those from the United Kingdom [20] and Iran [21] where two in five respondents reported some form of depression. Similarly, studies in Asia have shown that people experienced substantial psychological problems during the pandemic [22, 23] . The authors attributed factors such as the recommended self-quarantine and isolation measures, employment uncertainty, and the rapid spread of COVID-19 related misinformation [24] . A similar high prevalence of depression and anxiety was reported among those with chronic medical problems in Ethiopia during the COVID-19 pandemic [25] , and in Australia, a high prevalence of psychological distress was reported during the highly infectious equine influenza in 2007 [26] . The higher prevalence of mental health symptoms found in this study compared to previous studies may be due to the difference in the study population between studies as well as the socio-cultural differences and the methods used in assessing the mental health symptoms. All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. ; Previous epidemiological studies found that women had a higher risk of depression [27] than men and were more vulnerable to stress and post-traumatic stress disorder [28] . These findings were corroborated in recent studies where the prevalence of anxiety, depression, and stress during the COVID-19 pandemic was significantly higher among women than men [29, 30, 31] . Compared with the previous studies the present study used a larger sample size to confirm that women in Bangladesh experienced significantly higher mental health symptoms than men and this could be due to the higher representation of women in various industries like retail, manufacturing, healthcare, and service industries, affected by the current pandemic. These findings are also in agreement with the suggestion that, with the uneven effects in the employment sector, women were more likely to experience psychological and mental health problems when faced with depression, anxiety, and stress [32] . Older people had a higher risk of COVID-19 infection and mortality [33] ., however, the results of existing studies found higher levels of anxiety, depression, and stress among the younger population particularly those aged 21-40years [11, 34] . In the present study, age had a significant effect on the participants' report of mental health symptoms of depression, anxiety, and stress. This may be attributed to the fact that people in this age group are more concerned over the future consequences and economic challenges caused by the pandemic, as they are the key actors working force in society and are, therefore, mostly affected by fear of joblessness and business closures [35] . Some researchers have argued that greater anxiety among young people may be related to their greater access to information through social media, which can also cause severe stress [22, 36] . It has also been suggested that people become stressed and feel anxious when the information from public health experts are unreliable or was delivered incorrectly and as such could create confusion regarding the practice of self-quarantine or other public health measures put in place to control the spread of a pandemic [37] . All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in This study found a significant association between level of education and the mental health symptoms during the pandemic which was consistent with a study from China that was conducted at the initial stage of the COVID-19 outbreak [38] . In that study, those with no formal education were more likely to report depression during the epidemic. Other studies have also reported significant associations between the lower level of education, and anxiety and depression levels [20, 25] . In contrast to these studies, we found that during the COVID-19 pandemic, respondents in Bangladesh who had a higher level of education reported higher levels of anxiety, depression, and stress [31, 39] . It was because 59.75% of respondents of our study had the university level of education in comparison to respondents of the previous studies. Even some recent studies also revealed similar findings as our study did [40] Similar to the findings of this study, some authors in China [38, 41] reported higher levels of anxiety among participants who had at least one family member, relative, or friend with COVID-19. Also, those who were separated or widowed/divorced were more likely to experience depression during the pandemic than other respondents which was consistent with a previous study in the USA [42] during the pandemic. Before the pandemic, a study in Pakistan revealed that among the older population, those who lived in a nuclear family system were more likely to report depression compared to those who lived in a joint family system [43] . During the early outbreak of COVID-19 in Bangladesh, people who had potentially come into contact with the infection were asked to isolate themselves at home or in a dedicated quarantine facility [1] . The findings of negative psychological effects of these measures in this study have consisted with other studies which found that lockdown and self-quarantine during the pandemic like SARS, MARS, and COVID-19 had higher levels of post-traumatic stress symptoms, confusion, and anger [29, 36] . In our study, more than two-thirds of those who practiced self-quarantine reported mental health issues. Due to the self-quarantine All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. ; measures and fear related to the spread of COVID-19, other persistent mental health disorders like anxiety, emotional disruption, and exhaustion, depression, anger, irritability, insomnia, and stress can be developed among the population [44] . Moreover, the longer the quarantine or self-isolation, the more detrimental these outcomes can become [45] . This study had some limitations. First, it was limited in scope. Many of the participants (50%) were from the capital city of Dhaka division, limiting the generalization of our findings to rural regions. Second, the study was carried out during the COVID-19 lockdown period and lacked longitudinal follow-up. The analysis of the periodic state of individuals may not reflect the psychological state, which changes with time and with the alterations in one's surrounding environment. Because of the increasingly arduous situation and the fear of the second wave, the mental health symptoms of residents could become more severe. Thus, the long-term psychological implications of this population are worth further investigation. Third, due to ethical requirements on anonymity and confidentiality, we were not allowed to collect contact details and personal information from the respondents. As a result, we could not conduct a prospective study that would provide a concrete finding to support the need for a focused public health initiative. Fourth, the study was not able to distinguish between preexisting mental health symptoms and new symptoms. Fifth, there was an oversampling of a particular network of peers (e.g., students), which may lead to selection bias. However, a large percentage of respondents who were within 40 years old consisted of students. They were exposed to higher mental health symptoms due to the temporary shutdown of educational institutions, disbandment of social gatherings, and the pressure from having to attend classes online [46] . Sixth, the self-reported levels of psychological impact, anxiety, depression, and stress may not always align with assessment by mental health professionals. Despite these limitations, this study has several strengths. Further, then providing insight on the actual existing pandemic situation, this study sheds added light on the impact of COVID-All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. ; https://doi.org/10.1101/2021.01.05.21249216 doi: medRxiv preprint 35 | Prevalence and Factors associated with Mental health impact of COVID-19 Pandemic in Bangladesh: A survey based cross sectional study 19 on the mental health conditions of the educated people in Bangladesh who are the potential future workforce as well. In this survey study conducted in Bangladesh, respondents reported high rates of symptoms of depression, anxiety, and distress while non-compliance with public health measures increased the risk of mental health outcomes. Protecting the Bangladesh population is an important component of public health measures for addressing the COVID-19 epidemic. Special interventions to promote mental wellbeing in Bangladesh communities exposed to COVID-19 need to be immediately implemented, with women, married people, the less educated people, and those that were tested for COVID-19 requiring particular attention. To further close the gap in the relationship and improve the mental health wellbeing of the Bangladeshi people, alternative ways of communication such as the use of internet video calls [47] should be promoted during similar situations. Factors associated with the perception of risk and knowledge of contracting the SARS-Cov-2 among adults in Bangladesh: Analysis of online surveys The COVID-19 pandemic: Effects on low-and middle-income countries | Prevalence and Factors associated with Mental health impact of COVID-19 Pandemic in Bangladesh: A survey based cross sectional study Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR SARS-CoV-2 vaccines in development Complete genome sequencing of influenza A viruses within swine farrow-to-wean farms reveals the emergence, persistence, and subsidence of diverse viral genotypes The human Coronavirus disease COVID-19: Its origin, characteristics, and insights into potential drugs and its mechanisms The genetic sequence, origin, and diagnosis of SARS-CoV Weekly operational update on COVID-19 -30 The fear of COVID-19 scale: Development and initial validation How have COVID-19 isolation policies affected young people's mental health? -evidence from Chinese college students Coronavirus and impact on the Bangladesh economy: Assessing the damage Factors associated with Mental health impact of COVID-19 Pandemic in Bangladesh: A survey based cross sectional study 13 The impact of the COVID-19 epidemic on mental health of undergraduate students in New Jersey, cross-sectional study Influence of COVID-19 pandemic on the psychological status of infertile couples Pathways to care of patients with mental health problems in Bangladesh The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19: longitudinal analyses of 36 Factors associated with Mental health impact of COVID-19 Pandemic in Bangladesh: A survey based cross sectional study 22 The effects of social support on sleep quality of medical staff treating patients with Coronavirus disease in China Impact of COVID-19 pandemic on mental health in the general population: A systematic review Depression, anxiety and associated factors among chronic medical patients amid COVID-19 pandemic in Factors influencing psychological distress during a disease epidemic: data from Australia's first outbreak of equine influenza Prevalence of depression in the community from 30 countries between 1994 and 2014 Risk factors for post-injury mental health problems: Review: Post-injury mental health problems Psychological impact and predisposing factors of the Coronavirus disease 2019 (COVID-19) pandemic on general public in China Mental health outcomes of the CoViD-19 pandemic All rights reserved. No reuse allowed without permission. perpetuity the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted January 6, 2021. ; 39 | Prevalence and Factors associated with Mental health impact of COVID-19 Pandemic in Bangladesh: A survey based cross sectional study 31 Sex differences in depression: Insights from clinical and preclinical studies Covid-19: death rate is 0. 66% and increases with age, study estimates Anxiety and depression in the Republic of Ireland during the COVID-19 pandemic Epidemic of COVID-19 in China and associated Psychological Problems The psychological impact of quarantine and how to reduce it: rapid review of the evidence The experience of quarantine for individuals affected by SARS in Toronto Immediate psychological responses and associated factors during the initial stage of the 2019 Coronavirus disease (COVID-19) epidemic among the general population in China Impact of the COVID-19 pandemic on mental health and quality of life among local residents in Liaoning Province, China: A cross-sectional study Loneliness in the UK during the COVID-19 pandemic: Cross-sectional results from the COVID-19 Psychological Wellbeing Study Challenges and burden of the Coronavirus 2019 (COVID-19) pandemic for child and adolescent mental health: a narrative review to highlight clinical and research needs in the acute phase and the long return to normality Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic Depression in the elderly: does family system play a role? A cross-sectional study The psychological impact of COVID-19 on the mental health in the general population Loneliness, common mental disorders and suicidal behavior: Findings from a general population survey An online survey of factors associated with self-perceived stress during the initial stage of the COVID-19 outbreak in Nepal Impact of COVID-19 on public mental health and the buffering effect of a sense of coherence All rights reserved. No reuse allowed without permission. perpetuity preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted Have you enforced protective measures inside your home to protect yourself and your family from COVID 19? No 2Are you currently in Self-Quarantine since past seven days? No 2 Avoid public transportation 1Avoid shaking hands 2Wearing face mask 3Avoid large gatherings 4Advocating people about the health risk related to COVID- 19 5 All of the above 6None of the above 7What is your household size?