This social media survey has generated evidence related to the impact of COVID-19 on psychological wellbeing of people in Nepal. There are limited academic studies which have studied the impact of COVD-19 pandemic on the mental health and psychological wellbeing of people . To the best of our knowledge, this study is the first large scale survey of psychological distress in the Nepalese population following the COVID-19 outbreak. Due to the way the survey was constructed, all participants completed all items, which was a further strength of the study.
The study suggests that half of the respondents suffered from at least one symptom of psychological distress whereas 32% suffered from two or more symptoms of psychological distress such as restlessness, fearfulness, anxiety and worry, and sadness in the past 2 weeks preceding the survey date. The findings further suggest that respondents having lower family income, residing in rented room, and participants from province 2 were more likely to suffer from both single and multiple symptoms of psychological distress. On the other hand, health workers, those currently involved in regular service, and the respondents from the Bagmati province (excluding capital city) were less likely to suffer from either single or multiple symptoms of psychological distress.
The outbreak of COVID-19 has raised concerns about the potential for a widespread increase in mental health issues [20,21,22]. People could experience fear of death, fear of getting oneself or their family infected, anxiety, anger, depressive symptoms, and other mental health concerns during this pandemic outbreak . COVID-19 pandemic outbreak could have negative impact on psychological and mental health of people, for instance psychological distress, mental health issues, grief, shame, helplessness, hopelessness, posttraumatic symptoms, substance abuse, panic attacks, stress, anxiety, depression, loneliness, ambivalence, fear, anger, stigma and worry towards socioeconomic status . Similar findings have been replicated in our study. Our study has also revealed increased prevalence of psychological distress such as restlessness, fearfulness, anxiety and worry, and sadness among the participants following COVID-19 outbreak. The prevalence of symptoms of psychological distress seem to have increased following COVID-19 outbreak and lockdown when compared to data available from existing literature prior to the epidemic. A nation-wide cross sectional study conducted among Nepalese adults between 18–65 years showed the age- and gender-adjusted prevalence of anxiety, depression and co-morbid anxiety and depression as 16.1, 4.2 and 5.9% respectively . However, the data is comparable to other humanitarian settings as major earthquake of 2015. A representative cluster sample survey conducted by TPO Nepal four months post-earthquake in three affected districts demonstrated elevated rates for depression (34.3%) and anxiety (33.8%) which were higher than prior epidemiologic surveys conducted using similar measures .
Our study has demonstrated that the prevalence of psychological distress is higher among households with low income and those residing in rented room/house. Poverty and low socioeconomic status are identified factors associated with poor mental health and increased psychological distress . A systematic review of the epidemiological literature on common mental disorders and poverty in low-and middle-income countries found that of the 115 studies reviewed, over 70% reported positive associations between a variety of poverty measures and common mental disorders . The finding of our survey is consistent with the findings from systematic review.
Similarly, the prevalence of psychological distress has been higher among female than male. This is consistent with the finding from previous studies. Epidemiological surveys have consistently documented significantly higher rates of internalizing disorders as anxiety and mood disorders among women than men [28,29,30,31]. Our study focused on symptoms of psychological distress characteristic of internalizing disorders as restlessness, fearfulness, anxiety and worry, and sadness. Thus, our finding on greater prevalence of psychological distress is similar to the findings from the epidemiological surveys on gender differences on internalizing disorders.
Our study has demonstrated lower prevalence of psychological distress amongst the health workers and those having service as an occupation. Service category includes banking, education, communication, engineering and construction works, etc. Similarly, health workers include Auxiliary Health Workers (AHWs), Health Assistants (HAs), Auxiliary Nurse Midwives (ANMs), Staff Nurses (SNs) and medical doctors. Poor quality employment, such as employment with no or short-term contracts, and jobs with low reward and control at work, have significant harmful impacts on mental health . Conversely, job security and a sense of control at work are protective of good mental health [33, 34]. Health workers and respondents enrolled in service have relatively better job securities and sense of control than other occupations as labour including students who are dependent. This might have contributed to lower prevalence of psychological distress among health workers and individuals enrolled in service. Contrastingly, studies from China on mental health impacts of COVID-19 on health professionals demonstrated increasing psychological problems including anxiety, depression and stress with increase in the number of diagnosed cases and deaths from the disease [3, 4]. This might be due to the fact that Nepal is at the beginning of epidemic with limited number of cases diagnosed with COVID-19 and health system being far less overwhelmed than China where thousands of cases had been detected positive.
Additionally, our study has demonstrated higher prevalence of psychological distress in respondents from Province 2. A study entitled "Provincial Comparison of Development Status in Nepal: An Analysis of Human Development Trend for 1996 to 2026" demonstrated that the province had lower HDI, lowest literacy rate, lower per capita income and lowest increment in HDI between 1996 to 2011 . Education and HDI are significant social determinants of mental health. Similarly, gender disparities, poor women empowerment, gender discrimination and limited access of women to income generating activities are other associated factors contributing to poor socioeconomic status. Since these social determinants are adverse in Province 2, it is pertinent that respondents from this province reported having higher prevalence of psychological distress over past 2 weeks of the study period. Province 2 lies adjacent to border of India and has a high influx of migrant workers and Indian citizens to Nepal for various purposes . This puts the province into ongoing risk of COVID-19 transmission. Additionally, the status of quarantine and isolation centres in the province are not satisfactory. A number of newspaper articles and reports from the province reflect lack of access to basic health and sanitation facilities; lack of personal protective gears; poor security and lack of hygienic food in the quarantine and isolation centres. Similarly, the health facilities and health indicators in the province are already in a poor state . All these factors might have accounted for increase in odds of distress in respondents from Province 2.
The study has several limitations. First, the survey was done online and included people using social media within the network of investigators. Thus, the survey might not represent a larger population outside the social network of investigators and not using social media. Secondly, the study did not use standardized tool for anxiety and depression and has used only four constructs of psychological distress. This might not give accurate measures for anxiety and depression. The study might also have missed many other symptoms of psychological distress which the respondents could have manifested. Third, since this was a cross-sectional study, analyzing the causal relationship was not possible. Fourth, some of the possible predictors such as caste/ethnicity and education were not included in the survey questionnaire and thus their interpretation could not be done. Fifth, the study did not assess level of functioning and correlate with the presence of one or more symptoms of psychological distress in respondents. Therefore, it could not specify whether the psychological distress had resulted in impairment of socio-occupational functioning. Sixth, the investigators had no control over the respondents attending the survey more than once. This might have resulted in repetitive participation in the survey and duplication of data. Seventh, since the study did not define the focus population for the survey and the online link was recirculated in chain, the interpretation of results might be quiet tricky. Additionally, between the group differences was not hypothesized prior and could not be analyzed.
A major adverse consequence of the COVID-19 pandemic is likely to be increased social isolation and loneliness  which are strongly associated with anxiety, depression, self-harm, and suicide attempts across the lifespan [39, 40]. The number of diagnosed COVID-19 cases has been increasing; the duration of nationwide lockdown is extending and economic crisis is growing. This seems to put an additional turmoil into mental health and psychological wellbeing of Nepalese population. There is likely to be a surge in the number of newly diagnosed mental disorders and the deterioration of those with existing difficulties in the aftermath of COVID-19 . So, the current crisis demands creating an operational framework of mental health and psychosocial response (MHPSS) and delivering integrated MHPSS services to address these consequences.