Depressive symptoms among Peruvian adult residents amidst a National Lockdown during the COVID-19 pandemic

The COVID-19 pandemic has substantially impacted health and well-being worldwide. Particular interest has been given to the detriments on mental health due to the disease spread, infection status, and policies to control the pandemic [1]. Although academic circles and mass media have highlighted the critical role of mental health [2], empirical data is limited, and international guidelines are based mainly on expert recommendations [3]. National health bodies, especially those in high transmission settings, require timely data to plan and implement evidence-based policies to protect mental health during the present crisis.

Severe SARS-Cov-2 infections could profoundly impact psychological well-being inducing mental conditions, including fatigue and delirium [4]. Recent evidence points out adverse neurological effects related to severe illness such as encephalopathies, inflammatory central nervous system syndromes, etc. [5]. Besides the direct biological effects of the infection on mental health, public policies, including social distancing and lockdowns, could also increase the burden of psychological reactions due to isolation, domestic violence, and the use of psychoactive substances [6, 7]. Mental health research needs to estimate the disease burden associated with the pandemic and quantify attendant mental health problems.

The Americas have become the current epicenter of the pandemic [8], mounting 31 million cases and 786,808 deaths as of December 16th [9] Forecasts suggest a sharp increase during the third quarter of 2020, affecting countries like Brazil, Chile, and Peru [10]. Countries’ responses to the pandemic in South America have included not only social distancing measures and testing but also mental health support interventions through hotlines, virtual screenings, and telemedicine [11]. Despite these laudable efforts, the effect of the pandemic and control policies on the public’s mental health and mitigation of the further spread of COVID-19 is unknown, which challenges the elaboration of national plans and evaluation of these actions.

Risk stratification is crucial to bring adequate and timely psychological support to specific populations. Early data revealed an increasing burden of psychosocial reactions in first respondents, such as emergency room (ER) and intensive care unit (ICU) health professionals [12], findings common in other crises. Nonetheless, the general population has also shown increasing stress and different psychosocial reactions during lockdowns and highly transmission contexts. For instance, in China, youth showed high rates of anxiety and depression disorder [13], while school-aged children who remained at home exhibited depressive symptoms [14].

The current scenario demands innovative research methods such as mobile or web-based tools to collect critical information rapidly during the pandemic [15]. However, awareness has been raised around the challenges of using digital tools to collect data [16, 17]. These tools can facilitate the epidemiological response from symptom screening, contact tracing, and quarantine measures.

This study aimed to identify and describe the distribution of depressive symptoms’ using a web-based questionnaire in the Peruvian population during the national lockdown due to the pandemic. Moreover, we identified associated factors and their magnitude to compare them with regional and global estimates. We report major findings by key strata of geographical location, sex, age, and previous mental health diagnosis.

The eligible sample comprised data from 57,446 respondents who were predominantly young adults (72%), female (66%), living in the capital province (53%), and completed undergraduate degrees (47%). Marginal proportions for key sociodemographic variables corresponded to the values from the Peruvian Census 2017 after raking; see Supplementary file 4.

Weighted results showed that one-quarter of the sample was unemployed, and a similar proportion reported receiving assistance from the Government during the lockdown. Nearly half of respondents had a monthly household income of less than 1860 PEN (547 USD), although 28% of the sample preferred not to respond. Differences across regions were more evident regarding education level and household income. Table 1 summarizes the key characteristics of the participants by geographical location.

Respondents with a previous mental health diagnosis were more prevalent in the Capital City (16%) and lowest in the Amazon (13%). These geographical patterns were similar for those who sought mental health care and had at least one contact with the mental health system within 2 weeks before the survey. Around half of those who sought help managed to contact the health system; however, differences persisted by region, detrimental to Amazon residents.

We found a high mental health burden during the pandemic and lockdown in Peru. Three out of ten participants reported moderate to severe depressive symptoms in the prior 2 weeks. We found substantial disparities by key social variables favoring those with higher household income, education, and employment. Besides, we showed disparities of all psychosocial symptoms by sex, age group, and region. Stratified results by previous mental health diagnosis revealed a two-fold prevalence difference in depressive symptoms among those with a prior diagnosis compared to those never diagnosed. To our knowledge, this is the first study quantifying the mental health burden associated with the COVID-19 pandemic with a considerable sample size in Latin America.

Our findings reveal an overall prevalence of depressive symptoms five times higher than the one reported previously at a national level in 2018 (34.9% vs. 6.4%, respectively) [27]. Even if we limit our results to those without a prior diagnosed mental health condition, the magnitude of moderate to severe depressive symptoms is still nearly five times higher than the national prevalence. Risk factors such as being a woman, living in the Andes, and having comorbidities increased the probability of depressive symptoms.

Contrary to previous evidence in Peru [27, 28], we found that the younger population was more prone to having depressive symptoms. However, similar results have been found in large samples in the US [29] and the UK [30] during the pandemic, where young adults showed a higher prevalence of severe psychological distress compared to older groups [29]. Another possible explanation is that the pandemic and the measures implemented affect young people and adolescents differently due to their needs, socioeconomic condition, fear, and intolerance to uncertainty [31, 32] . Differences could also be attributed to young adults’ higher participation in web surveys, in this particular case participation of those with a prior mental health problem or experiencing psychological distress.

Population-based mental health evidence during the pandemic is limited. A recent study in China, which used a web-based survey and reached around 56,000 participants, found 28% of participants had depression, seven percentage points lower than our estimate [33]. There were no other comparable studies, especially in the Americas. Few studies with large sample sizes have been reported across the world. Results from Spain during the early stage of the pandemic [34] show that a third of Spaniards reported moderate to severe psychological impact, particularly women, the young, and the unemployed. Initial results from the COLLATE project suggest increased psychological distress among those with a mood disorder compared to those without reported mental disorders [35]. A social media-based survey in Taiwan [36] found that half of the participants and some 10% reported sleep disturbances and suicidal thoughts. Similar results were obtained in a small sample of Chinese [37] and Indian [38] adults, showing mild stress but high anxiety levels. Additional studies are being implemented to assess the impact of diverse physical distancing measures [39].

Our research provides a detailed characterization of mental health and psychological symptoms using a sample of around 60,000 respondents during the community transmission phase of the pandemic and lockdown in Peru. This massive participation was possible through a key partnership between PAHO and the Ministry of Health, in a time where the Peruvian Government was communicating COVID-19 information, interventions, plans, and restrictions in their official and social media accounts. Thus, the number of people visiting these sites was abundant, which was reflected in our online questionnaire’s participation rates. Moreover, we describe associated factors among participants by a previous mental health condition, providing relevant information for mental health action plans in the COVID-19 pandemic context. For instance, this study’s preliminary results were shared with the Ministry of Health in Peru to plan its mental health response [40].

The study has some limitations that are important to consider for the correct interpretations of our findings. First, we did not include other mental health issues such as psychological distress or anxiety in this study. Unlike depression, there were not previous studies on anxiety or distress at the national level to be used as a pre-COVID reference. We believe it is very likely that these problems are also present during this pandemic and lockdown; however, quantifying these problems was beyond the scope of our study.

We used an opt-in online survey using social media as the distribution channel to collect information from respondents who had internet access and consented to participate. Internet connectivity in Peru has substantially increased in the past decade, representing 81 and 46.8% among 17–24 and 25+ years old citizens, respectively [41]. Urban areas and the Coastal region have more increased connectivity than their rural, Andean, or Amazonian counterparts. Thus, regional or national results represent those with access to internet connectivity, usually excluding the poorest and most vulnerable.

Older adults are the smallest group of social media users; thus, we expected to find a low number of respondents of this age group. Besides adjusting for lower participation in the older population using raking, we encouraged all respondents who stated there is an older adult in the household to complete the survey for themselves. We did not have information about the rurality of the residence. Rural areas are more prevalent in the Andean and Amazonian regions; however, sex-age adjusted models did not found substantial differences by geographical region. We addressed these limitations using raking weights, which optimally balanced the data to known national marginal proportions of age, sex, education, and region of residence from the latest census official data in 2017.

Lastly, due to the survey’s opt-in nature, selection bias such as volunteer bias is possible. Participants who are experiencing psychological distress or have an existing mental health condition are more likely to participate and complete the questionnaire. We addressed this issue by providing stratified results by previous mental health conditions, which uncovered a depressive symptoms prevalence of 30%, a 5-fold increase with respect to national levels reported in 2019.

An increased burden of depressive symptoms and psychosocial reactions emerged during the current pandemic and national lockdown in Peru. The mental health burden is disproportionately affecting participants with lower income and education as well as those unemployed. Peru has proven to be a dynamic country in terms of mental health reform and transitioning from a hospital-centered mental health model towards a community-based model whereby community networks are being established. As the Government is relaxing the social distancing measures and expanding its economic reactivation to phase four, with most businesses open with some restrictions, it is crucial to use local evidence to adjust public health policies and services in mental health to the renewed needs of the Peruvian people.