Psychology, Health & Medicine

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Impact of the COVID-19 outbreak on mental health

status and associated factors among general
population: a cross-sectional study from Pakistan

Khezar Hayat, Muhammad Haq, Weihua Wang, Faiz Ullah Khan, Anees ur
Rehman, Muhammad Rasool, Muhtar Kadirhaz, Sumaira Omer, Usman
Rasheed & Yu Fang

To cite this article: Khezar Hayat, Muhammad Haq, Weihua Wang, Faiz Ullah Khan, Anees ur
Rehman, Muhammad Rasool, Muhtar Kadirhaz, Sumaira Omer, Usman Rasheed & Yu Fang
(2021): Impact of the COVID-19 outbreak on mental health status and associated factors among
general population: a cross-sectional study from Pakistan, Psychology, Health & Medicine, DOI:
10.1080/13548506.2021.1884274

To link to this article: https://doi.org/10.1080/13548506.2021.1884274

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PSYCHOLOGY, HEALTH & MEDICINE
https://doi.org/10.1080/13548506.2021.1884274

Impact of the COVID-19 outbreak on mental health status and

associated factors among general population: a
cross-sectional study from Pakistan
Khezar Hayat a,b,c,d, Muhammad Haqe, Weihua Wangf, Faiz Ullah Khan a,b,c,
Anees ur Rehman g, Muhammad Rasoolg, Muhtar Kadirhaza,b,c, Sumaira Omera,b,c,
Usman Rasheeda,b,c and Yu Fanga,b,c
a
Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi’an Jiaotong
University, Xi’an, China; bCenter for Drug Safety and Policy Research, Xi’an Jiaotong University, Xi’an, China;
c
Shaanxi Centre for Health Reform and Development Research, Xi’an, China; dInstitute of Pharmaceutical
Sciences, University of Veterinary and Animal Sciences, Lahore, Pakistan; eHamdard Institute of
Pharmaceutical Sciences, Hamdard University Islamabad, Pakistan; fShaanxi Provincial Center for Disease
Control and Prevention, Xi’an, China; gDepartment of Pharmacy Practice, Faculty of Pharmacy, Bahauddin
Zakariya University Multan, Pakistan

ABSTRACT ARTICLE HISTORY

The recent outbreak of coronavirus disease (COVID-19) has signifi­ Received 07 July 2020
cantly affected the mental health of people globally. This study Revised 11 January 2021
aimed to investigate the mental health status and associated fac­ Accepted 27 January 2021
tors among residents of Pakistan. An online questionnaire survey KEYWORDS
was conducted from April 3 to May 7, 2020, using convenience and COVID-19; depression;
snowball sampling techniques. Data regarding demographics, phy­ mental health; DASS-21;
sical health status and contact history during the last 2 weeks were stress; Pakistan
collected. Furthermore, the Depression, Anxiety, and Stress scales
(DASS-21) were utilized to measure the mental health of the parti­
cipants. The analyses included descriptive statistics and regression
analysis. Of the 1663 participants who completed this survey, 1598
met the inclusion criteria. The results revealed mild to moderate
depression among 390 participants (24.4%), mild to moderate anxi­
ety among 490 participants (30.7%) and mild to moderate stress
among 52 participants (3.3%). A majority of the participants rated
their health as good (n = 751, 47.0%). Moreover, students reported
significantly higher scores on depression (B = 1.29, 95% CI = 0.71–
1.88; p < 0.05), anxiety (B = 0.56, 95% CI = -0.06 to 1.18; p < 0.05) and
stress (B = 0.56, 95% CI = –0.12 to 1.23; p < 0.05). Physical symptoms,
including fever, cough and myalgia, and contact history in the last
14 days reported significant associations with depression, anxiety
and stress (p < 0.05). The mental health status of the people was
noted to be affected during the COVID-19 outbreak. Assessment of
several factors with significant associations with depression, anxiety
and stress may aid in developing psychological interventions for
vulnerable groups.

CONTACT Yu Fang yufang@mail.xjtu.edu.cn Department of Pharmacy Administration and Clinical Pharmacy,

School of Pharmacy, Xi’an Jiaotong University, No 76, Yanta West Road, Xi’an, China
© 2021 Informa UK Limited, trading as Taylor & Francis Group
2 K. HAYAT ET AL.

Introduction
The outbreak of coronavirus disease (COVID-19), which was first detected in Wuhan,
China, around the end of 2019, has now affected every continent, except for Antarctica
(Deng, 2020; Hui et al.; Zhou et al., 2020). As of June 24, 2020, eight countries, namely the
United States, the UK, Italy, France, Spain, Brazil, India and Mexico, recorded more than
10,000 deaths due to COVID-19 (Worldometer, 2020). The spread of COVID-19 not
only amplifies the rate of mortality and morbidity every minute but also threatens to
overrun the healthcare systems across the world (Bedford et al., 2020). On January 30,
2020, the World Health Organization (WHO) declared a Public Health Emergency of
International Concern and then characterized COVID-19 as a global pandemic on
March 11 due to its spread across different regions of the world (Sohrabi et al., 2020).
As of January 10, 2021, there are more than 90,220,763 confirmed cases of COVID-19
worldwide, with 1,937,209 deaths (Worldometer, 2020).
The symptoms of COVID-19 can be nonspecific, and infected patients may remain
asymptomatic. However, fever and dry cough are two well-recognized symptoms
(Huang et al., 2020; Mission, 2020; Sohrabi et al., 2020). Patients may also experience
shortness of breath, a bluish face, difficulty in walking, sudden confusion and persistent
chest pain, as reported by the US Centers for Disease Control and Prevention (CDC)
(Centers for Disease Control and Prevention, 2020). Further complications due to
COVID-19 include acute respiratory distress syndrome, severe pneumonia, sepsis
and, evidently, death. Additionally, the incubation period of COVID-19 ranges from
1 to 15 days, with an average of 5 days (World Health Organization, 2020b; Zhai et al.,
2020).
The transmission routes of COVID-19 are still being tracked (Centers for Disease
Control and Prevention, 2020); however, the CDC and WHO state that it mainly spreads
via respiratory droplets released when an infected person sneezes or coughs (Chavez
et al., 2020). It can also be spread when a person touches a contaminated surface and then
touches their mouth or nose. The transmissibility of COVID-19 makes it challenging to
block its spread across countries. While it is unclear how rapidly COVID-19 can spread,
the European Centre for Disease Prevention and Control reports that an infected person
can infect two or three healthy individuals (Centers for Disease Control and Prevention,
2020; Ye et al., 2020; Zheng, 2020).
Pakistan, with a population of more than 207 million people, shares its borders with
India, China, Iran and Afghanistan. Unfortunately, these four neighboring countries
have confirmed cases of COVID-19, with China being the epicenter, where 87,433 cases
and 4,634 deaths have been reported. Pakistan reported its first two confirmed cases on
February 26, 2020 (Agence France-Presse., 2020). As of June 24, 2020, Pakistan reported
502,416 confirmed cases of COVID-19 and 10,644 deaths (Worldometer, 2020).
Unfortunately, all provinces (Punjab, Sindh, Khyber Pakhtunkhwa and Balochistan)
and territories (Islamabad, Capital Territory, Gilgit-Baltistan, Azad Jammu and
Kashmir) of Pakistan have been badly hit by COVID-19, and the numbers are increasing
by the minute, with Sindh and Punjab provinces reporting the most significant devasta­
tion. As in other countries (Bedford et al., 2020), mitigation and containment activities
are being implemented in Pakistan to delay the surge in patients and to protect older
people and patients with multiple diseases (Hayat et al., 2020).
 PSYCHOLOGY, HEALTH & MEDICINE 3

Numerous studies have shown that outbreaks of diseases, such as COVID-19, can
have a severe impact on the psychological health of people, and they may experience fear
of contracting the disease, stigma, helplessness and fear of dying (Pierce et al., 2020;
Rajkumar, 2020). A study conducted during the recent COVID-19 pandemic found a 6-
to 7-fold increase in symptoms of depression and anxiety in adults (Feter et al., 2020).
A recently published global review found female gender, unemployment, student status
and people with chronic/psychiatric disorders as risk factors that could deteriorate the
mental health of people during COVID-19 outbreak (Xiong et al., 2020). Negative
emotions may be compounded in individuals owing to the lockdown (closure of busi­
nesses, schools, colleges and universities) (Le et al., 2020; Van Bortel et al., 2016).
Moreover, a study undertaken among Chinese and Polish respondents revealed
a positive impact of wearing face masks during COVID-19 pandemic on mental and
physical health (Wang, Chudzicka-Czupała, et al., 2020). A study on Vietnamese people
showed a significant decline in quality and quantity of working owing to fear of COVID-
19 (Dang et al., 2020). The COVID-19 outbreak could have a more severe impact on the
mental health of patients suffering from psychiatric diseases (Hao et al., 2020). Besides,
the psychological health of healthcare workers has also been affected as a result of
COVID-19 (Chew et al., 2020).
Currently, there is a lack of studies investigating the impact of the COVID-19 out­
break on the mental health status of people, since most research on COVID-19 focuses
on the epidemiology, clinical features and genomic characteristics of COVID-19. The
spread of COVID-19 across the world may cause fear among the general public; thus, the
investigation of the mental health status of the public is of great importance. There have
been no studies investigating the effect of COVID-19 on the mental health of residents of
Pakistan. Therefore, this study aimed to measure the impact of COVID-19 on the mental
health of the general population of Pakistan, which will enable the government to tailor
effective strategies to safeguard the psychological well-being of the people.

2. Methodology
Study design
This cross-sectional study was conducted from April 3 to May 7, 2020, in Punjab
province, including the capital city (Islamabad) of Pakistan. More than half of the
Pakistani people reside in Punjab. Data were collected using an online survey, as it was
challenging to conduct offline field surveys due to the COVID-19 outbreak. Seventy-six
million (36.2%) people in Pakistan have internet access, and among them, 37 million use
various social media platforms actively (Anjum, 2020).

Survey tool
A questionnaire was developed based on a literature review (Chen et al., 2020; Duan &
Zhu, 2020; McAlonan et al., 2007; Wang, Pan, et al., 2020a). Three professors of relevant
background assessed the validity of the questionnaire. A bilingual expert helped translate
the English version of the questionnaire to Urdu (native language). The backward and
forward translations were also made. The approved questionnaire (https://forms.gle/
4 K. HAYAT ET AL.

A57KpZCADdSFbx9d7) constituted four sections. The first section was based on the
demographic features of the participants. The second section included three questions on
the physical health of the participants. In the first question, participants were instructed
to report physical symptoms, including fever, chills, headache, muscular pain, cough,
breathing issues, dizziness and sore throat, experienced in the last 14 days, with “yes” or
“no” responses. The second question recorded any consultations with a doctor, hospita­
lization, isolation and testing for COVID-19 in the last 14 days, using “yes” or “no”
responses. The participants reported their physical health in the third question. The third
section assessed the contact history of the participants, including any direct or indirect
contact with a patient with suspected or confirmed COVID-19, using “yes” or “no”
responses. The last section included an assessment of the mental health of the partici­
pants using the Depression, Anxiety, and Stress Scale (DASS-21). DASS-21 constitutes 21
questions with responses ranging from “never,” “sometimes,” “often,” to “almost/
always.” Each of the three subscales of the DASS-21 includes seven questions, with
questions 3, 5, 10, 13, 16, 17 and 21 constituting the depression subscale; questions 2,
4, 7, 9, 15, 19 and 20 constituting the anxiety subscale; and questions 1, 6, 8, 11, 12, 14 and
18 constituting the stress subscale. The scores of these subscales were grouped into five
categories, namely “normal,” “mild,” “moderate,” “severe” and “extremely severe,” as
shown in Table 1. DASS was also used in previous studies conducted in China, Vietnam
and the Philippines, which investigated the psychological impact of the COVID-19
outbreak (Le et al., 2020; Tee et al., 2020; Wang, Pan, et al., 2020b) (McAlonan et al.,
2007). Additionally, the DASS-21 reported excellent validity among Pakistani samples
(Aslam & Kamal, 2019; Chishti & Rafiq, 2019).
The internal consistency of the final questionnaire was optimal with a value of
Cronbach's alpha greater than 7 (0.89).

Data collection
Due to the outbreak of COVID-19, the Government of Pakistan advised the people to
limit their face-to-face interaction to block the transmission of COVID-19. Therefore,
the participants were recruited electronically using convenience and snowball sampling
techniques. The undergraduate pharmacy students acted as data collectors who were
trained about the aims of the study. They sent a link to the questionnaire to participants
through various social media platforms, including Facebook, WhatsApp and LinkedIn.
The participants were further encouraged to disseminate the link to their fellows. The
first page of the questionnaire included information about the study’s aims, consent for
participation, confidentiality and the right to withdraw participation. Only participants
currently living in Pakistan were included in this study.

Table 1. Interpretation of DASS score (Tran TD., et al ., 2013)

Meaning Depression Anxiety Stress
Normal 0–9 0–7 0–14
Mild 10–13 8–9 15–18
Moderate 14–20 10–14 19–25
Severe 21–27 15–19 26–33
Extremely severe 28–42 20–42 34–42
 PSYCHOLOGY, HEALTH & MEDICINE 5

Data analysis
Descriptive statistics were used to calculate the numbers and percentages for demo­
graphics, physical health status and contact history. The scores on the depression, anxiety
and stress subscales of the DASS-21 were also measured and compared with demo­
graphic variables, physical symptom variables and contact history variables using multi­
ple linear regression analysis. All tests were performed using SPSS (SPSS Inc, version 18,
IBM, Chicago, IL, US), with a 0.05 level of significance.

Ethical approval
The ethics approval for this study was granted by Xi’an Jiaotong University (Ref:
Phar2020-012).

3. Results
Demographics
A total of 1663 respondents participated in this survey; however, the data of 65 were
excluded since they were currently living in countries other than Pakistan. Of 1598, most
of the respondents were from Punjab (n =1182, 74.0%), were male (n = 937, 58.6%), were
aged 20–29 years (n = 893, 55.9%), were students (n = 682, 42.7%), were single (n = 1055,
66.0%) and held a bachelor’s degree (n = 664, 41.6%). Detailed information about the
demographics is presented in Table 2.

Physical symptoms of the participants

Nearly 8% (n = 127, 7.9%) of the respondents reported a fever of 38°C that was persistent
for 1 day in the last 14 days. However, headache (n = 430, 26.9%), myalgia (n = 326,
20.4%) and cough (n = 247, 15.5%) were the most common complaints reported by the
respondents. A few respondents also reported dizziness (n = 197, 12.3%), sore throat (n =
185, 11.6%) and breathing difficulties (n = 103, 6.4%). The regression analysis revealed
significantly higher scores of depression, anxiety and stress among participants with
persistent fever, chills, cough, dizziness and breathing issues (p < 0.05).
A total of 151 (9.4%) respondents indicated that they had visited a doctor’s clinic
within the last 2 weeks. Moreover, 193 (12.1%) respondents were hospitalized, 484
(30.3%) were quarantined and 207 (13%) had recently undergone a test for COVID-19.
Of 1598, 1525 participants (95.4%) had no chronic disease. Most respondents rated their
health as either “good” (n = 751, 47.0%) or “very good” (n = 649, 40.6%). Recent
hospitalization, testing for COVID-19 and isolation were significantly associated with
depression, anxiety and stress (p < 0.05), as shown in Table 3.

Contact history of the participants

Of the 1598, 197 respondents (12.3%) had indirect contact with a patient confirmed with
COVID-19, while 106 (6.6%) reported having direct contact with a patient confirmed
with COVID-19. Only 146 (9.1%) respondents reported having contact with a patient
 6

Table 2. Association of demographic characteristics with depression, anxiety and stress (n = 1598).
K. HAYAT ET AL.

Depression Anxiety Stress

Variable Frequency (n) Percentage (%) B (95%confidence interval) p Value B (95% confidence interval) p Value B (95%confidence interval) pValue
Gender
Female 661 41.4 Reference Reference Reference Reference Reference Reference
Male 937 58.6 0.12 (–0.33 to 0.61) 0.57 0.04 (–0.40 to 0.48) 0.870 -0.01 (–0.49 to 0.46) 0.944
Age (years)
<20 273 17.1 Reference Reference Reference Reference Reference Reference
20–29 893 55.9 0.16 (–0.52 to 0.84) 0.641 0.31 (–0.32 to 0.94) 0.34 0.22 (–0.46 to 0.91) 0.522
30–39 318 19.9 –0.52 (–1.42 to 0.37) 0.250 –0.41 (–1.25 to 0.42) 0.33 –0.36 (–1.26 to 0.55) 0.44
40–49 70 4.4 –1.34 (–2.66 to 0.02) 0.046 –1.12 (–2.35 to 0.10) 0.073 –1.08 (–2.42 to 0.25) 0.112
50 or above 44 2.8 –2.34 (–3.93 to 0.76) 0.003 –1.92 (–3.39 to 0.45) 0.010 -1.66 (–3.25 to 0.05) 0.043
Marital status
Single 1055 66.0 Reference Reference Reference Reference Reference Reference
Married 505 31.6 1.95 (1.34–2.56) <0.001 1.93 (1.37–2.49) <0.001 1.81 (1.19–2.43) <0.001
Others 38 2.4 4.77 (3.23–6.31) <0.001 4.49 (3.06–5.93) <0.001 4.47 (2.91–6.03) <0.001
Education
Matric or below 211 13.2 Reference Reference Reference Reference Reference Reference
Higher secondary school 339 21.2 2.86 (2.06–3.65) <0.001 2.96 (2.22–3.70) <0.001 3.71 (2.91–4.52) <0.001
Bachelor degree 664 41.6 4.49 (3.67–5.31) <0.001 4.29 (3.53–5.06) <0.001 4.62 (3.79–5.45) <0.001
Master degree 384 24.0 2.58 (1.75–3.42) <0.001 2.58 (1.81–3.36) <0.001 3.20 (2.36–4.05) <0.001
Occupation
Employed 609 38.1 Reference Reference Reference Reference Reference Reference
Unemployed 307 19.2 0.81 (0.14–1.48) 0.017 1.28 (0.75–1.83) 0.077 1.14 (0.54–1.73) 0.106
Student 682 42.7 1.29 (0.71–1.88) <0.001 0.56 (–0.06 to 1.18) <0.001 0.56 (–0.12 to 1.23) <0.001
Table 3. Association of physical health of participants in last 2 weeks with depression, anxiety and stress n (%).
Depression Anxiety Stress
Variable Frequency (n) Percentage (%) B (95% confidence interval) p Value B (95% confidence interval) pValue B (95%confidence interval) p Value
Persistent fever (38c for at least 1 day)
Yes 127 7.9 2.02 (1.18–2.87) <0.001 1.47 (0.68–2.25) <0.001 1.69 (0.83–2.54) <0.001
No 1471 92.1 Reference Reference Reference Reference Reference Reference
Chills
Yes 148 9.3 3.06 (2.26–3.86) <0.001 2.99 (2.25–3.74) <0.001 2.72 (1.91–3.53) <0.001
No 1450 90.7 Reference Reference Reference Reference Reference Reference
Headache
Yes 430 26.9 −0.040 (–0.59 to 0.516) 0.888 0.16 (−0.35 to 0.68) 0.536 0.22 (−0.34 to 0.78) 0.439
No 1168 73.1 Reference Reference Reference Reference Reference Reference
Myalgia
Yes 326 20.4 0.79 (0.19–1.40) 0.010 0.47 (−0.09 to 1.03) 0.099 0.85 (0.24-1.47) 0.006
No 1272 79.6 Reference Reference Reference Reference Reference Reference
Cough
Yes 247 15.5 0.92 (0.28–1.56) 0.005 1.08 (0.48–1.68) <0.001 0.69 (0.036–1.34) 0.039
No 1351 84.5 Reference Reference Reference Reference Reference Reference
Breathing difficulties
Yes 103 6.4 3.28 (2.33–4.23) <0.001 3.34 (2.46–4.22) <0.001 2.90 (1.93–3.86) <0.001
No 1495 93.6 Reference Reference Reference Reference Reference Reference
Dizziness
Yes 197 12.3 1.25 (0.54–1.95) 0.001 1.28 (0.62–1.93) <0.001 1.90 (1.18-2.61) <0.001
No 1401 87.7 Reference Reference Reference Reference Reference Reference
Sore throat
Yes 185 11.6 −0.56 (-1.29–0.17) 0.134 −0.23 (−0.91 to 0.44) <0.001 −0.06 (−0.80 to 0.67) 0.862
No 1413 88.4 Reference Reference Reference Reference Reference Reference
Consultation with doctor in the clinic in the past 14 days
Yes 151 9.4 −0.12 (−0.91 to 0.66) 0.759 −0.01 (−0.74 to 0.71) 0.966 −0.16 (−0.97 to 0.63) 0.68
No 1447 90.6 Reference Reference Reference Reference Reference Reference
Recent hospitalization in the past 14 days
Yes 193 12.1 −2.24 (−3.07 to 1.41) <0.001 −1.88 (−2.66 to 1.11) <0.001 −2.18 (−3.04 to 1.33) <0.001
No 1405 87.9 Reference Reference Reference Reference Reference Reference
PSYCHOLOGY, HEALTH & MEDICINE

Recent testing for COVID-19 in the past 14 days

Yes 207 13.0 −3.05 (−3.85 to 2.25) <0.001 -2.87 (−3.61 to 2.13) <0.001 −2.63 (−3.45 to 1.81) <0.001
7

(Continued)
 8
K. HAYAT ET AL.

Table 3. (Continued).
Depression Anxiety Stress
Variable Frequency (n) Percentage (%) B (95% confidence interval) p Value B (95% confidence interval) pValue B (95%confidence interval) p Value
No 1391 87.0 Reference Reference Reference Reference Reference Reference
Recent quarantine in the past 14 days
Yes 484 30.3 −1.25 (−1.73 to 0.78) <0.001 −1.35 (−1.79 to 0.90) <0.001 −1.85 (−2.34 to 1.37) <0.001
No 1114 69.7 Reference Reference Reference Reference Reference Reference
Chronic illness
Yes 73 4.6 −0.15 (1.25 to 0.95) 0.788 −0.46 (−1.49 to 0.56) 0.374 0.23 (−0.89 to 1.36) 0.684
No 1525 95.4 Reference Reference Reference Reference Reference Reference
 PSYCHOLOGY, HEALTH & MEDICINE 9

suspected with COVID-19. All variables of contact history showed a significant associa­
tion with the subscales of the DASS-21 (p < 0.05) (Table 4).

Assessment of mental health status

Most participants (n = 1206, 75.5%) reported normal scores on the depression subscale,
with scores between 0 and 9. However, 390 participants (24.4%) reported mild to
moderate levels of depression. For the anxiety subscale, 1079 (67.5%) participants
reported normal scores, with scores between 0 and 6; however, 490 (30.7%) reported
mild to moderate anxiety and 27 (1.7%) reported severe anxiety. The results of the stress
subscale revealed normal scores for a majority of the participants (n = 1546, 96.7%) and
only 52 (3.3%) reported mild to moderate levels of stress. Age ≥50 years was significantly
associated with depression (B = −2.34, 95% confidence interval [95% CI] = −3.93 to 0.76;
p < 0.05), anxiety (B = −1.92, 95% CI = −3.39 to 0.45; p < 0.05) and stress (B = −1.66, 95%
CI = −3.25 to 0.05; p < 0.05). Students reported significantly higher scores on depression
(B = 1.29, 95% CI = 0.71–1.88; p < 0.05), anxiety (B = 0.56, 95% CI = −0.06 to 1.18; p <
0.05) and stress (B = 0.56, 95% CI = −0.12 to 1.23; p < 0.05). The highest levels of
depression (B = 4.49, 95% CI = 3.67–5.31, p < 0.05), anxiety (B = 4.29, 95% CI = 3.53–
5.06, p < 0.05) and stress (B = 4.62, 95% CI = 3.79–5.45, p < 0.05) were observed in
participants with a bachelor’s degree. The symptoms of depression were noted to be
significantly higher among unemployed participants (B = 0.81, 95% CI = 0.14–1.48; p <
0.05). Likewise, the participants who were divorced or widowed had a significant associa­
tion with depression, anxiety, and stress (Table 2).

Discussion
This is the first study to assess the mental health and associated factors among residents
of Pakistan during the COVID-19 outbreak. Our results report mild to moderate levels of
depression (n = 390, 24.4%), anxiety (n = 490, 30.7%) and stress (n = 52, 3.3%) among the
survey participants. This is in accordance with a global review which concluded a higher
prevalence of psychological disorders among the general population (Xiong et al., 2020).
Likewise, several other studies conducted in China, the Philippines and Vietnam also
reported a significant impact on the mental health of people attributed to COVID-19 (Le
et al., 2020; Tee et al., 2020; Wang, Pan, et al., 2020b).
A majority of the participants rated their health as either “good” (n = 751, 47.0%) or
“very good” (n = 649, 40.6%). Only a handful of respondents reported direct or indirect
contact with a patient confirmed or suspected with COVID-19. Moreover, only a few
respondents received medical consultation or were hospitalized in the last 2 weeks.
Similar findings were reported in a Chinese study where 68.3% of the respondents
were in good health, and ≤1% visited a doctor (Wang, Pan, et al., 2020a).
Our results reported higher levels of depression, anxiety, and stress among students.
The government of Pakistan suspended all educational activities for an indefinite period
and closed all schools, colleges, and universities. The uncertainty due to COVID-19 and
the negative influence on academic progress may have adversely affected the mental
health of students. Educational activities using online portals should be encouraged
during this epidemic. Additionally, the government should develop smartphone
 10
K. HAYAT ET AL.

Table 4. Association of contact history in the past 2 weeks with depression, anxiety and stress n (%).
Depression Anxiety Stress
Variable Frequency (n) Percentage (%) B (95%confidence interval) p Value B (95%confidence interval) p Value B (95%confidence interval) p Value
Close contact with an individual with confirmed infection with COVID-19.
Yes 106 6.6 −2.55 (−3.53 to −1.57) <0.001 −1.85 (−2.76 to 0.93) <0.001 −2.18 (−3.19 to 1.17) <0.001
No 1492 93.4 Reference Reference Reference Reference Reference Reference
Indirect contact with an individual with confirmed infection with COVID-19.
Yes 197 12.3 −4.46 (−5.17 to −3.75) <0.001 −4.54 (−5.20 to −3.88) <0.001 −4.16 (−4.88 to 3.43) <0.001
No 1401 87.7 Reference Reference Reference Reference Reference Reference
Contact with an individual with suspected COVID-19 or infected materials.
Yes 146 9.1 −1.42 (−2.28 to −0.56) 0.001 −1.37 (−2.17 to 0.57) 0.001 −1.61 (−2.49 to 0.73) <0.001
No 1452 90.9 Reference Reference Reference Reference Reference Reference
 PSYCHOLOGY, HEALTH & MEDICINE 11

applications for providing psychological interventions online, such as cognitive behavior

therapy (CBT) and psychoeducation (Li et al., 2020; Weiner et al., 2020) since smart­
phone use is higher among young people (Do et al., 2018). Thus, avoiding face-to-face
interaction and limiting the transmission of COVID-19. Moreover, a recent study also
advocated using digital CBT to help those living with insomnia (Soh et al., 2020).
Furthermore, our results revealed that divorced or widowed participants reported the
highest levels of depression, anxiety and stress. Fear of contracting COVID-19, financial
crises and social distancing could contribute to the deterioration of their mental health.
Furthermore, many studies have already highlighted poor mental health among the
widowed (Kung, 2020; Xu et al., 2019).
Additionally, unemployed participants in our study reported significant psychological
distress in terms of depression. Hundreds of millions of people have lost their jobs due to
the COVID-19 outbreak, which poses a global challenge for survival, according to the
United Nations. Nearly 30 million people in the United States and 1.76 million in Japan
have lost their jobs due to this outbreak (World Economic Forum, 2020). Previous
studies suggest a link between unemployment and the deterioration of mental health
(Konstantakopoulos et al., 2019; Achdut & Refaeli, 2020).
As per the results, participants with reports of fever, cough, myalgia, chills, dizziness,
and breathing difficulties reported higher levels of depression, anxiety, and stress.
Therefore, healthcare authorities should provide adequate resources for psychological
counseling and interventions for individuals exhibiting the above symptoms (Duan &
Zhu, 2020). The WHO has predicted a global mental health crisis as a consequence of
COVID-19. There is, thus, a need for massive investment in services for the prevention
and treatment of mental health (Chen et al., 2020; Kelland, 2020; World Health
Organization, 2020a).
This study inherits certain limitations. First, since we did not use random sampling to
recruit participants, the results may be biased. Nevertheless, we opted for convenience
and snowball sampling due to limited time and resources. Second, the small sample size
limits the scope for generalization. Third, since the study used online platforms to collect
data, the results may be biased. However, owing to lockdown in different regions of
Pakistan, it was not feasible to conduct an offline community survey. Fourth, this study
measured psychiatric symptoms using self-reported questionnaires and did not make
a clinical diagnosis. Structured clinical interview and functional neuroimaging is a gold
standard for establishing psychiatric (Ho et al., 2020; Husain et al., 2020). Despite several
limitations, our study is the first to gain insight into the mental health status of residents
of Pakistan, and the results of the study could be used as a reference for policy-making to
cope with psychological issues due to the COVID-19 outbreak. Additionally, our findings
could help develop suitable psychological interventions to limit the impact of the ongoing
COVID-19 outbreak on depression, anxiety, and stress for the public.

Conclusion
The participants of this study reported mild to moderate levels of depression, stress, and
anxiety amidst the COVID-19 outbreak. Age, education, occupation, physical symptoms,
and marital status reported a significant impact on mental health during the COVID-19
crisis. Urgent efforts by health authorities are desirable to implement psychological
12 K. HAYAT ET AL.

interventions to address mental health issues among the public.

Authors’ contribution
KH and YF were involved in the conception and design of the study. MIH, FUK, URM, FWR and
SO helped in data collection. KH, WW and MK performed the analysis and interpretation of data.
KH, AR and YF drafted the article and revised it.

Acknowledgement
We would like to thank Ms. Raesa, Ms. Fiza, Mr. Sakander hayat, Mr. Rehman, Ms. Sehrish,
Dr. Nouman ul Haq, Ms. Aqsa, Ms. Azwa Saeed and Dr. Zahida Saeed for their help in data collection.

Funding
This work was funded by the “Young Talent Support Plan”, “High Achiever Plan” of the Health
Science Center, Xi’an Jiaotong University, and the Central University Basic Research Fund
(2015qngz05).

ORCID
Khezar Hayat http://orcid.org/0000-0001-7984-1870
Faiz Ullah Khan http://orcid.org/0000-0002-1022-8688
Anees ur Rehman http://orcid.org/0000-0002-6502-8464

Declaration of Competing Interests

None

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