A case study about the depression rate of high school students in Ho

Chi Minh City, Vietnam during the Pandemic

Nov 7, 2021 | Dang Q. Le

Abstract
The case study is aimed to recognize the prevalence of depression among high school students
in Ho Chi Minh City, Vietnam during the COVID-19 pandemic. The data used had been
conducted virtually from N = 20 Ho Chi Minh City private high school students through Google
Forms using the PHQ-9 questionnaire set for two months starting from August. The result
showed that 60% of the participants displayed some mild-to-moderate depressive symptoms.
Moreover, the article also reviews the works of other researchers around the world to come up
with a more objective conclusion. In the end, I also propose several possible causes and
solutions objectively and subjectively.

Introduction

Since the first hit of COVID-19, everything around the world has changed and lingered. In some
countries, students are mandated to study through the internet platform and more specifically, in
Ho Chi Minh City, students are faced with a prolonged virtual study session because of the
recent outbreak and the unavailability of vaccination among teenagers.

Because of the lack of social interaction, homework stress and difficulty in comprehending the
lesson through online platforms, many of my peers have confessed to being stressed and
overwhelmed, some even performing various significant depressive symptoms. According to
professor Anita Thepar, depression may increase morbidity rates in the present and the future
and augment suicide risk [2]. Moreover, she also states that the most vulnerable age to
depression is at the end of adolescence [2].

However, in Vietnam, both parents and students do not understand the fatal consequences of
depression and view it as “normal sadness”. In light of this, the study is designed to analyze the
depression status in Ho Chi Minh City and to see if its ubiquity is affected by the Pandemic,
therefore, propose possible solutions and raise awareness of Vietnamese people about this
lethal illness.
Literature Review

International

The measure of depression among high school students during the pandemic has been
addressed by different researchers and psychologists. While the average rate of teenagers
undergoing depression is approximately 20% [9], some studies suggest that this number has
increased during the COVID-19.

Figure 1 is a summary of the depression rate of schools in different countries. In 2020, the
prevalence of depressive symptoms from mild to severe among students in Shandong high
school (China) was reported to be 52.4% which is more than twice the average rate of
depression among teens. [3] Another study in Kenyan high school also informed that the
percentage of students with depression above the cutoff was around 45.9%.[4], which is also
more than double the average. Moreover, in Chinese junior highs and high schools, more than
one-fifth of students' mental health was affected.[7] More specifically, 29.7% of high school
students were depressed.[7] Last but not least, a study found that 37.5% of students in a high
school in Nghe An, Vietnam showed signs of depression.[8] Overall, during the pandemic, the
approximate rate of depression in the four schools discussed above doubled the average of
teenagers with depression. In addition, there is a correlation between the COVID-19 severity
and the rate of adolescents with depression. For instance, Kenyan and Shandong are high
schools located in the United States and China - two countries known to be affected by the
coronavirus most severely in 2020. While a high school in Nghe An, where it was damaged less
by the coronavirus, displayed a lower rate of depression among students.
Vietnam

In 2007, research on depression conducted by Dat Nguyen showed that 6.7% of Hanoi high
school students who participated in the research showed signs of depression [17]. Furthermore,
a study by Minh Nguyen in 2012 also showed a slightly similar outcome, only 6.6% of teenagers
between the age of 12 and 6 in some areas in the North of Vietnam experience depression [18].
In 2013, Mai Thi Nguyen and Hoang Minh Dang also claimed that the percentage of students in
Vietnam experiencing depression was between 0.4% to 8.3% [15]. However, in a study from
2019 to 2020, the number started to rise. The results from that research by Quynh Thi Huong
Tran showed that 38.2% of pupils in a high school in Nghe An displayed signs of depression [8].
In 2020, the number reached its peak. Manh Van Ngo stated that up to 60% of students in Thai
Binh high school were depressed. [16]

Figure 2 abstractly describes the change in the rate of depressed teenagers from 2006 to 2020.

Generally, the depression rate in Vietnam presents a relation to the epidemic situation as it
surged higher when coming closer to the COVID-19 outbreak year.
Methodology

To assess the depression status of the research subjects, the data was collected virtually
through Google Forms using the Patient Health Questionnaire-9 (PHQ-9) and analyzed by
Microsoft Excel. Participants will have to answer nine questions in multiple choices form: each
question consists of 4 answers that will be converted into a score:

● Not at all = 0
● Several days = 1
● More than half the days = 2
● Nearly everyday = 3

In the end, the score will be added up to get a total score which will be interpreted by the PHQ-9
scoring box:
 Total Score Depression Severity

1-4 Minimal depression

5-9 Mild depression

10-14 Moderate depression

15-19 Moderately severe depression

20-27 Severe depression

In addition, after finishing the PHQ-9, participants were asked to complete a short self-depict
session. In particular, the survey asked them to state 3-6 adjectives that best describe their
mood lately. The survey also gave the participants an optional box where they could describe
more thoroughly how they felt recently. Moreover, after the survey, I also emailed/messaged the
participants several followed up questions:

● Do you have any alternation in your screentime?

● What consumes most of your time on screen?
● Do you receive any mental health aid?
● How often do you expose yourself to sunlight a day?
● Do you sleep before midnight? If not, why?

The form was given to N=20 private high school students (including 8 females and 12 males
with an average age of 16.55) from August to September during the lockdown in Vietnam and
100% of survey-taking subjects are studied virtually. They were personally selected during the
pandemic under no specific condition. The analysis is divided into two parts:

● Quantitative data: I used Excel to sum the score up and compared it to the PHQ-9
scoring box. In the end, I calculated the percentage of each severity level and compared
the “Minimal” to “Mild to Severe” depression level. Also, I correlated the relationship
between gender (female and male) to the depression rate.

● Qualitative data: I manually evaluated participants' answers as Positive or Negative to

create a chart summarizing the result. The summarization should include the rate
between Positive and Negative responses and state some of the most repeated phrases
or adjectives

Finally, all the data is used to examine the rate of depression and linked to other years’ data to
conclude.
Results

PHQ-9

In total, the pervasiveness of depressive symptoms was 60% from mild to severe. In particular,
40% were mildly depressed and 20% had moderate depressive symptoms. Regarding gender,
the mean percentage of having the mild-to-moderate in females (75%) was comparatively
higher than males (50%)
Of 9 depressive symptoms, the two most common one was "having no interest/pleasure doing
things" (90%) and "having trouble focusing" (70%). The least frequent one was "wanting to die"
(15%)

Self-depict

A total of 20 participants all submitted the answer for the self-described session. After manually
classifying the data, the outcome showed that 12 statements consisted of Negative adjectives
(60%). Positive-adjective responses only took up of 40% the total answers.

The five most common adjectives mentioned are "Melancholy, stress, lonely, hopeless, fatigue.

Discussion
The study showed that the prevalence of students with mild-to-moderate depression was
significantly higher compared to those with no to minimal depressive symptoms. Of all the
answers, 90% include the "Having no interest/pleasure doing things." Respectively, some of the
students reported continually missing their friends/partners and regularly felt down, lack of
energy. Moreover, another repeated symptom is "trouble concentrating." (70%). In regards, the
report shows that some participants confessed to having trouble understanding the lesson
virtually and memorizing the information. Although no students were inscribed to be severely
depressed or above, three have thought about hurting themselves or being suicidal (15%). Two
of those selected "several days" while the other chose "nearly every day". The investigation
demonstrates there are notable twisted thinking among high school students that may end up
with fatal consequences in the future should no support be implemented. As shown in Figure 4,
the percentage of depressive symptoms among females is prominently higher than that of
males. (75% vs. 50%). More specifically, 63% of the females undergo mild depression. The
number decreases to 13% for those who show moderate depressive symptoms. On the other
hand, the ratio between males with mild depression and those moderately depressed are
equalled (25% vs. 25%). (Figure 5 & 6). Conclusively, the prevalence of depression is greater
among females but more severe among males. In the self-depict session, 60% of the responses
are negative adjectives. Melancholy, stress, hopeless and fatigue are the most repeated words.
Moreover, it was found that the negativity level of the answer is correlated with the depression
severity. Those who had no to minimal depressive rates often answered in a more neutral,
positive way, for example, "happy, excited and grateful" or "happy, feeling handsome." Likewise,
the participants with mild-to-depressive symptoms leaned more on a more pessimistic response:
"transient, melancholy, blank, solitary, underwhelmed."

Cause

As the study shows, there has been an increase in mental health problems in teenagers during
the pandemic. According to research, uncertainty, fear of getting the virus, sleep difficulties and
worries about the future may cause depression. [6] Moreover, quarantine, trauma and grief
during the COVID-19 can also enhance the risk of mental health[6][14]. Additionally, according
to my examination, the rate of grief among students is highly worrisome. Below are the four
main reasons that may be the cause of depression for students during the COVID-19.

Social media

A study has found that the risk of getting depression or anxiety is strongly correlated to social
media use [12]. Not surprisingly, during the COVID-19, lockdown and social distancing have
translated to higher overall screen time among children and adolescents for the duration of the
execution of these laws [8]. In addition, 65% of the participants have reported that they have a
markedly rise in screen time and that most of their time, they used Facebook, Instagram,
YouTube, TikTok, etc. Therefore, social media may be one of the central causes of the high
prevalence of depression. However, personally, the increase of use in social media is inevitable
since, during the lockdown, there is a very lack of personal interaction that without the help of
the online platforms, it is not possible to communicate with their friends.

Lockdown and Virtual study

Because of the recent outbreak in Ho Chi Minh City, the government promulgated lockdown in
the entire city. Accordingly, students are faced with a prolonged study session with virtual tests
and homework and a lack of interaction with friends and teachers. As a study once said,
worrying about the Pandemic, feeling left out, staying at home for too long are factors that are
associated with depression among adolescents [8]. Another study states that students who
study remotely performed worse points in well-being, emotional well-being and academic
well-being compared to those going to school. [11] Of all the factors affecting the degradation of
mental health, online learning is the most impacted reason[5]. The most recurring themes that
augment stress include Due homework (13.2%), social isolation or lack of social interaction
(8.6%) and lack support for mental well-being [5]. In Ho Chi Minh city the amount of homework
is recommended to be reduced in order to lessen stressfulness for students during online
learning, however, it seems to have little effect. The support for mental health is also lacking in
Vietnam, as 0% of the participants reported receiving help for their mental health.

Light

Deprivation of light could favour depression [19][20]. A study shows that depression and fatigue
can occur due to a deficiency of Vitamin D - caused by lack of sunlight exposure - in otherwise
healthy people [19]. This mechanism may also be relevant to SAD (Seasonal Affective Disorder)
which is mentioned in the 5th version of the Diagnostic and Statistical Manual of Mental
Disorders (DSM) as a specifier of recurrent depression or bipolar disorder, whether episodes of
major depression have a seasonal pattern [21]. Concerning the survey, 95% of the students
responded that they rarely expose themselves to the natural light as it is too hot. They said that
it is more enjoyable to be completely cold in a room with an air conditioner. Of all the causes,
lacking light is most relevant to the research subjects.
Sleep

Instead of being caused by depression, some professions in the field suggest that the lack of
sleep can be a factor causing depression. [24][26]. The amount of time on screen can cause a
decreased sleep quality, aggravated insomnia symptoms, shorten sleep duration, extended
sleep onset latency, delayed bedtime and rising time [23]. In addition, 90% of the participants
were not able to sleep before midnight and 72% of them reported to have an increase in screen
time. Although social media is necessary in these times, a bad sleep schedule can be
profoundly caused by a lack of determination and discipline.

Solution

As a person who underwent mild depression in the past, there are two personal solutions I used
to reduce the feeling of depression that have been scientifically proven.

More exposure to sunlight

As mentioned above in the Cause session, the deprivation of light is one of the most relevant
factors that affect Vietnamese students. As a study showed exposure to direct sunlight, in the
sense of outdoor exposure, was correlated with lower levels of anxiety, while exposure to
indirect sunlight, through windows, was related to lower levels of depressed mood [22].
Moreover, vitamin D also helped to lessen the severity of COVID-19 and increase the survival
rate if positive to the virus [27].

Meditation

Meditation is a simple yet great way to reduce stress instantly. According to Harvard University,
meditation is found to change certain brain regions that are specifically linked with depression
[25]. Moreover, it also helps the brain by protecting the hippocampus [25]. A study showed that
people who meditated about 30 min/day for eight weeks showed an increase in the volume of
gray matter in their hippocampus. [25] Meditation can help many people control how they react
to the stress and anxiety that often leads to depression [25].

Limitation

Firstly, the size of the study is small (N=20) so the results are not representative of the whole of
Ho Chi Minh City and may not be the same if conducted in public schools. Secondly, the study
was only carried out during the pandemic and was short of data from before the COVID-19,
therefore, is unable to conclude if there is an alternation between the two periods of time.
Thirdly, since the survey was given online to my acquaintances in school, it may create
inaccurate information due to the possible lack of seriousness in submitting the survey. Fourthly,
the subjects were not objectively selected, the outcome may change if expands the size of the
study randomly.
Conclusion

The studies have shown that during the COVID-19, the depression rate is above higher than the
approximate rate of depression among adolescents. The severity of COVID-19 of an area is
associated with its high school average depression rate. In Vietnam, the prevalence of
depressive symptoms started to soar up in 2020 and reached its peak in 2021. Respectively,
2020 and 2021 are also the two years Vietnam undergoing the COVID-19 outbreak while 2021
has the most critical bursting. The study shows an above-average presence of depression rate
among students in Ho Chi Minh City (60%). The prevalence of depression is higher among
females but more severe among males. Grief is the overall mood of 60% of the survey takers.
The possible causes of depression among high school students during lockdown are: increase
use of social media (65%), lockdown and virtual studies, light deprivation (95%), lack of sleep
(90%). The proposed solutions are: (1) increase the time exposure to light, (2) meditation.

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The PHQ-9 sample was taken from:

https://med.stanford.edu/fastlab/research/imapp/msrs/_jcr_content/main/accordion/accordion_c

ontent3/download_256324296/file.res/PHQ9%20id%20date%2008.03.pdf