Prevalence of and factors associated with depression, anxiety and stress among adolescents in Bangladesh during the COVID-19 pandemic: A population-based study

Introduction

Adolescence is a crucial phase of physical and psychological development, and adolescents are vulnerable to different mental health conditions that are often overlooked (Kieling et al., 2011). Mental health disorders in this population have been recognized as a significant public health challenge given that, according to the World Health Organization (WHO) data, 13% of adolescents worldwide suffer from psychological problems (WHO, 2021). Thus, given the disruption to their daily lives during the COVID-19 pandemic, which has resulted in severe mobility restrictions, including partial or complete lockdowns, it is not surprising that adolescents have experienced an upsurge in psychological problems (Racine et al. 2021). In adolescents already suffering from mental health conditions, sudden closure of academic institutions and extracurricular venues, unexpected bereavements, social isolation, increased screen time, and chronic stress may exacerbate the symptoms (Imran et al., 2020).

Depression, anxiety, and stress have been recognized as the three most common mental health issues among adolescents (Hicks and Heastie, 2008). Globally, depression and anxiety are ranked as the fourth and ninth leading cause of disease and disability in this age group (Reddy, 2010). However, the prevalence of depression and anxiety among adolescents is increasing around the globe (Zhang et al., 2021). In a survey conducted in 2019 in Bangladesh by Anjum et al. (2019) around 37% of participating adolescents reported being affected by depressive disorders. In another study conducted among 622 Bangladeshi adolescents, 30% and 16.4% of participants experienced depression and anxiety, respectively (Moonajilin et al., 2020). Since the COVID-19 outbreak in Bangladesh in March 2020, several preventive nationwide measures have been taken to limit the infection rate, including the closure of educational institutions, as well as episodic lockdowns and travel bans (Hossain et al., 2021). These measures have had an adverse effect on adolescents’ psychological well-being even though this age group was at the lowest risk of infection and fatal outcome.

As research on the mental health status of Bangladeshi people during the COVID-19 epidemic is limited, data pertaining specifically to adolescents is lacking (Das et al., 2021; Abir et al., 2021; Khatun et al., 2021; Islam et al., 2020). Thus, it is worth noting that through an online-based cross-sectional study involving 10,609 Bangladeshi participants conducted in 2021, Abir et al. (2021) found that 34% of the sample suffered from moderate depression during the COVID-19 pandemic, while in the same year, Das et al. (2021) found that 38% and 64% of 672 participants aged 15−65 years suffered from depression and anxiety, respectively, in Bangladesh. In another study conducted among Bangladeshi university students aged 18−29 years during the pandemic, 35.2%, 40.3%, and 37.7% prevalence of severe depression, anxiety, and stress, respectively, was noted (Islam et al., 2020). This is a marked increase compared to 2020, when Safa et al. (2021) reported 11.8% prevalence of severe anxiety among medical students, while 3.3% of the sample suffered from severe depression.

In these studies conducted in Bangladesh, different factors have been found to be associated with poor mental health during the COVID-19 pandemic, including female sex, unemployment, living without family, sharing the household with a greater number of family members, urban residence, sedentary lifestyle, greater screen time, and dissatisfaction with the system adopted for remote learning (Das et al., 2021; Islam et al., 2020). Apart from these factors, age, marital status, fear of humiliation, inability to pay attention to studies, and anxiety associated with the risk of being infected by the virus were also linked to the poor mental health status of physicians and medical students (Khatun et al., 2021; Safa et al., 2021). Therefore, the objective of this study was to determine the prevalence of depression, anxiety, and stress symptoms among adolescents during the COVID-19 pandemic in Bangladesh. Its further objective was to assess the factors potentially associated with depression, anxiety, and stress among the study participants.

Methods

Results

The study sample comprised of 2,030 adolescents aged 14−19 years, 41.4% of whom reported having experienced mental health disorders (95% CI = 39.2–43.6%), with a statistically significant female predominance (female vs. male: 66.9% vs. 33.1%, p-value < .001) and no rural−urban difference (40.1% vs. 42.7%, p-value > .05) (Table 1).

Figure 1 shows that depressive symptoms were reported by 18% of participating adolescents, while extremely severe depression was noted by 0.4% of the sample. At 16% and 14%, respectively, stress symptoms and anxiety were slightly less prevalent, and reached extremely severe levels in 1.2% and 0.3% of the cases.

Figure 1. Prevalence and severity of depression, anxiety and stress among urban and rural adolescents of Bangladesh.

Table 3 demonstrates that age (B = 0.575, p-value < .001) and female sex (B = 1.404, p-value < .001) were found to have significant relationships with depressive symptoms in the participating adolescents. Adolescents whose parents were separated, widowed, or divorced (B = 1.664, p-value < .001), who lived in urban regions (B = 1.701, p-value < .001), and who experienced food insecurity (B = 2.437, p-value < .001) showed a higher propensity for depressive symptoms compared to their counterparts. Again, Table 2 and Table 3 exhibit that positive parenting exhibited a substantial negative association with depression (B = -0.247, p-value < .001), whereas poor parental supervision had a significant positive relationship with depression (B = 0.218, p-value < .001).

Anxiety was found to be significantly associated with female sex (B = 1.881, p-value ≤ .001), age (B = 0.477, p-value < .001), urban residence (B = 0.795, p-value ≤ .001) and food insecurity (B = 1.357, p-value < .001). Positive parenting had a significant negative relation (B = -0.210, p-value <.001) whereas poor supervision had a significant positive relation (B = 0.093, p-value = .007) with anxiety (Table 3).

Stress symptoms among adolescents exhibited a significant relationship with female sex (B = 1.876, p-value ≤ .001), age (B = 0.627, p-value < .001), having separated, widowed, or divorced parents (B = 1.318, p-value = .004), urban residence (B = 2.601, p-value < .001) as well as food insecurity (B = 2.290, p-value < .001). Both positive parenting (B = -0.166, p-value = .008) and inconsistent parental discipline (B = -0.141, p-value = .002) had a significant negative link with stress (Table 3).

Discussion

The findings obtained in this study indicate 18%, 14%, and 16% prevalence of depression, anxiety, and stress symptoms, respectively, among urban and rural adolescents living in Bangladesh. These percentages exceed those yielded by the 2018−19 Bangladesh's National Mental Health Survey conducted in the pre-pandemic period (National Institute of Mental Health and WHO, 2019), suggesting that the social isolation and worries about contracting COVID-19 have exacerbated these mental health issues. However, a systematic review of the available research on the impact of COVID-19 on the adult population of Bangladesh indicated a much higher prevalence of depression and anxiety in adults (Hossain et al., 2021), likely due to methodological differences, as well as those related to sample characteristics. As no prior research has been conducted on Bangladeshi adolescents’ mental health during the pandemic, it is worth noting that, according to a recent poll in the Latin America and Caribbean region conducted by the United Nations Children's Fund (UNICEF), 27% of the respondents aged 13−29 years experienced anxiety and 15% experienced depression during the COVID-19 pandemic (UNICEF, 2021). Similarly, children and adolescents from European countries have been found to experience a wide range of psychological and behavioral problems during the early stages of the pandemic (Racine et al., 2021). Data yielded by an Australian survey involving 760 adolescents aged 12−18 indicated that about three-quarters reported mental health problems during the COVID-19 pandemic (Li et al., 2021). High prevalence of depression and anxiety was also noted among young adults aged 18−30 years living in the U.S. (Liu et al., 2020). These alarming findings point to the urgent need to provide adequate support to this population to prevent a mental health pandemic that could have devastating long-term repercussions.

In the cohort analyzed in this study, female sex emerged as a risk factor for depression, anxiety, and stress during the COVID-19 pandemic, concurring with the findings reported by other authors (Qiu et al., 2020; Wang et al., 2020; Alamri et al., 2020). While it is too early to draw any conclusions regarding the causality of this association, it is likely that fluctuations in estrogen and progesterone levels during the menstrual cycle, as well as environmental and hereditary variables, and a variety of physiological, social, and mental health factors play a role (Pigott, 2003; Tambs et al., 2012).

Although the present study focused on adolescents, there were still some age-related differences in the prevalence of depression, anxiety, and stress among urban and rural adolescents, with somewhat higher figures noted for those aged 17−19 relative to participants in the 14−16 age group. This finding is supported by a previous comparison of 14−20 vs. 21−35 age cohorts, whereby the former group was found to be more likely to suffer from psychological problems during the pandemic (Liang et al., 2020). However, other authors have noted that depressive and anxiety symptoms are more likely to be observed among older compared to younger adolescents (Xie et al., 2020; Zhou et al., 2020; Chen et al., 2020). Although the relationship between age and depression, anxiety, and stress among adolescents during the pandemic is still unclear, sociodemographic factors and parental mental health have been found to profoundly impact adolescents, and these issues are likely to be exacerbated by the pandemic (Schmidt et al., 2021).

Parental marital status was found to have an impact on the mental health of the adolescents that took part in our study, as depression and stress were less prevalent among adolescents whose parents were currently married. In their meta-analysis conducted in 2020, Wahyuningsih et al. (2020) similarly found that parental marital quality could affect the psychological wellbeing of adolescents (Shek, 2010). Available evidence further suggests that adjustment, academic, and behavioral problems, as well as depressed mood, are more likely to be experienced by adolescents whose parents are divorced or separated (Lee and McLanahan, 2015). As the pandemic also posed a risk to physical health, and even survival, it is also noteworthy that the death of one of both parents often leads to mental ill-health and related disorders among adolescents (Bergman et al., 2017). Thus, all these factors combined would likely worsen the mental health of adolescents, especially those living with only one parent.

According to our analyses, depression, anxiety, and stress symptoms were more pronounced among adolescents living in urban areas relative to those living in rural areas. These findings are contrasted by the results yielded by the study conducted in China by Zhou et al. in 2020. On the other hand, they concur with the view put forth by Menculini et al. that the urban environment, air pollution, complex social context, and other factors adversely affect the mental health of urban residents (Menculini et al., 2021). These issues are amplified during lockdowns, as urban adolescents would feel the social isolation during lockdowns more acutely than their rural counterparts (Pizarro-Ruiz and Ordóñez-Camblor, 2021).

As expected, adolescents that had experienced food insecurity throughout the pandemic period were more likely to report depression, anxiety, and stress compared to those who did not have such existential problems. Given that Bangladesh ranks 84^th out of 113 countries in the Global Food Security Index 2020, it is evident that food security plays a major role in the mental health status of its residents, and thus adolescents (Shibli, 2021). Similar observations were made by other authors in relation to developed countries, as food insecurity is on the rise across the world and contributes to mental health problems (Rahman et al., 2021; Mishra and Rampal, 2020).

In the present study, positive parenting style was also found to significantly reduce the level of depression, anxiety, and stress among Bangladeshi adolescents, concurring with the previously reported findings (Kingsbury et al., 2020). Conversely, inconsistent parenting discipline was found to be inversely related to stress, which is counterintuitive and should be examined further. Moreover, according to Tirfeneh and Srahbzu (2020), parental neglect or poor supervision strongly impacts adolescent negative affective emotions.

Conclusions

According to this cross-sectional study, a significant percentage of urban and rural adolescents in Bangladesh experienced depression, anxiety, and stress during the COVID-19 pandemic. Age, sex, food insecurity, parenting style, and place of residence emerged as significant risk factors for adolescent mental health. Given that mental health problems during adolescence increase the risk of adult mental distress, responsible authorities must take immediate action if we are to avert a mental health epidemic in the post-COVID era.