Fear and depression during the COVID-19 outbreak in Cameroon: a nation-wide observational study

Since its initial outbreak in China in December 2019, the coronavirus disease 2019 (COVID-19) has spread globally and caused over a million deaths [1]. Unprecedented restrictive measures were deployed by every nation to prevent or contain local epidemics. Besides the biological (and sometimes fatal) damages caused by the virus, the COVID-19 pandemic has been associated with significant psychological and social distress around the globe. Indeed, studies conducted during the COVID-19 pandemic have revealed high levels of stress, anxiety and depressive disorders among the general population [2], as well as specific populations: healthcare workers and their families [3‐5], military personnel [6], and COVID-19 survivors [7]. Available data suggests that women and younger individuals are more affected by psychosocial symptoms during the COVID-19 pandemic [8, 9]. The socio-economic consequences of the strict lockdown measures implemented in many countries further exacerbated the financial insecurities of the population with adverse effects on their psychological and social well-being, leading to suicide in some cases [10].

Cameroon, a Low-Middle income country located in the Central African sub-region, was not spared by the COVID-19 pandemic. After reporting its first case on March 6th 2020, community transmission was observed resulting in a cumulative 26,277 cases and 448 deaths as of December 31st 2020 [11]. The necessary preventive measures prescribed by the Cameroonian government [12] have disrupted daily routines and adversely impacted the nation’s socio-economic landscape given that a large proportion of the population relies on the informal sector for its livelihood. Although the mental or brain health impacts of the COVID-19 pandemic are evident in Cameroon [13], the magnitude of the problem is still poorly understood as no nation-wide study has yet been done. We therefore conducted this study to assess the level of fear and the frequency of depressive disorders in the Cameroonian population amidst the COVID-19 outbreak. We further sought to identify determinants of fear and depressive symptoms during the ongoing health crisis.

Of the 7538 responses received, 7381 were eligible for analysis (median age: 30 years, 73.3% male); Table 1. About one-fifth of the participants (n = 1454; 19.7%) resided in the conflict-stricken regions of Cameroon. Majority of participants (70.9%) had attained university level of education.

The median PHQ-9 score in our study population was 1.0 (IQR: 0–4) on a scale ranging from 0 to 21. Using the PHQ-9 cut-off value of ≥10 as positive screening for depression, the prevalence of depression was 617/7381 (8.4%). Applying the other cut-offs revealed the frequencies of no/minimal, mild, moderate, moderately severe, and severe depression to be respectively: 5669 (76.8%), 1095 (14.8%), 346 (4.7%), 178 (2.4%), and 93 (1.3%). Regarding COVID-19 fear, FCV-19S scores ranged from 7 to 35, with median 20 (IQR: 15–23) and mean 19.3 ± 6.4. Furthermore, more than half of the respondents (n = 4238; 57.4%) reported experiencing high levels of fear (i.e. FCV-19S scores ≥19). The prevalence of both depression (PHQ-9 score ≥ 10) and high level of fear (FCV-19S ≥19) were similar across genders, age groups, residential setting, being in the healthcare sector or not, and region of residence (Table 2).

FCV-19S scores correlated significantly with PHQ-9 scores (Spearman-rho = 0.28, p <  0.001). Considering only weeks with at least 100 responses, both COVID-19 fear and PHQ-9 scores seemed to increase with increasing weekly incidence of COVID-19 in Cameroon, and vice versa (Fig. 1). While the COVID-19 weekly incidence in Cameroon did not correlate significantly with the respondents’ FCV-19S scores (Spearman-rho = 0.021, p = 0.078), a weak positive correlation was found between weekly COVID-19 incidence and PHQ-9 scores (Spearman-rho = 0.033, p = 0.006). Mean weekly PHQ-9 scores did not vary significantly across the study period (range: 2.53–3.21; p = 0.101), in contrast to mean FCV-19S scores which were highest during the early weeks of the survey but decreased significantly thereafter (range: 18.34–20.31; p <  0.001). The median Likert score for worrying about other people’s health was significantly higher than that of worrying for one’s own health: 1 (IQR: 1–3) vs 1 (IQR: 1–2), p <  0.001.

Using dichotomized PHQ-9 and FCV-19S scores, we estimated the prevalence of depression and high fear for the study weeks with ≥100 responses (Table 3). We observed similar proportions of respondents with depression across the different study weeks (p = 0.195), while there were significant differences in the prevalence of high fear (p <  0.001).

The multivariate analysis revealed that having a postgraduate degree, a history of quarantine, experiencing flu-like symptoms during the past 14 days, and higher FCV-19S scores were associated with increased odds to have more severe depressive symptoms. Meanwhile, obtaining COVID-19 information from either official sources or from the social media reduced these odds (Table 4).

Our study is the first to assess fear and depression among Cameroonian adults during 6 months of the COVID-19 crisis, in a nation-wide large survey. Overall, almost one-tenth of respondents screened positive for depression and the PHQ-9 depression scores appeared to vary proportionately to the weekly incidence of COVID-19. It is worth noting that during the latter months of the study period, schools were allowed to resume cautiously and this brought about a semblance of normalcy in the daily routines of Cameroonians. These changes may have had repercussions on the overall psychosocial well-being of the study participants over time.

The prevalence of depression during the COVID-19 crisis in our study is lower compared to previous reports by researchers who also used the PHQ-9 tool with a cut-off score of ≥10 in both high-income and low- middle-income countries [17, 20‐22]. Our numbers are also lower than pre-COVID-19 depression rates in healthy Cameroonian adults, estimated at 19.8% in one study [23] but the fact that a different screening tool (Beck’s Depression Inventory) was used renders comparisons with our study difficult. It is expected that the COVID-19 pandemic would cause a rise in the burden of depression compared to baseline levels, as observed during a comparative study in American adults [24]. Of note, pre-COVID-19 depression levels were already low in Africa compared to other continents (except for Australia) [25], and the pandemic would likely exacerbate existing situations without necessarily altering the global distribution of depressive disorders. Furthermore, in resource-limited settings such as Cameroon where economic hardship is frequent, lower depression rates may also be observed because people are more focused on being financially productive amidst the crisis to keep providing for their families, even to the point of overlooking or mentally downplaying the threat of COVID-19. This notwithstanding, the most educated respondents (post-graduate level) who probably had a better understanding of the COVID-19 science and the risks associated with the pandemic were prone to more severe depressive symptoms (adjusted odds ratio of 1.5, relative to respondents with primary level education).

Regarding FCV-19S results, over half of the participants experienced high levels of fear vis-à-vis COVID-19. This is greater than the 35.7% reported in Greece [17] using a similar methodology. COVID-19 fear scores were highest at the beginning of the study period (June 2020), possibly because that period represented the first epidemic peak in Cameroon with thousands of cases confirmed on a weekly basis. No regional disparity was noted in the prevalence of depression or high fear of COVID-19. This is an intriguing finding, because we expected that persons residing in conflict-stricken regions would experience more psychological and social distress in the face of the COVID-19 outbreak. Qualitative research may be required to better understand the determinants of mental and brain health, as well as the coping mechanisms of individuals in different settings during the COVID-19 pandemic.

The frequency of depression and high fear of COVID-19 was similar among participants who were workers/students in the healthcare sector and others not involved in healthcare. A possible explanation for this observation is the reduced exposure to COVID-19 patients for health personnel in Cameroon due to a relatively lower COVID-19 burden compared to other regions of the world. Indeed, increased exposure to COVID-19 cases has been shown to fuel stress, anxiety and depression among healthcare providers [26]. Therefore, it is understandable that mental and brain disorders during the COVID-19 pandemic may be more frequent among healthcare workers in Europe, America, Asia [3, 6, 27‐29], but also in neighbouring Nigeria [30] which has more than thrice the number of COVID-19 cases in Cameroon [1]. It is worth noting that another survey previously conducted among healthcare workers in Cameroon during the COVID-19 pandemic found a prevalence of depression of 42.8% using the Hospital Anxiety and Depression scale (HADS) [31], compared to 8.5% in our study. While acknowledging the methodological differences between our study and the aforementioned survey, their findings do suggest that exposure of healthcare workers to COVID-19 patients is an important stressor in Cameroon. The authors reported that fear of contamination with the coronavirus and fear of death were modulators of depression among the health personnel [31].

Participants with a history of quarantine, or those who had recently experienced flu-like symptoms (during the past 2 weeks) were more likely to exhibit depressive symptoms. These results concur with observations made in Canada during the SARS-1 outbreak during which longer quarantine durations and a history of contact with an infected person were associated with increased psychological distress [32]. Similar observations were made in Brazil and Portugal during the COVID-19 pandemic [33]. This highlights quarantine / isolation as a risk factor for short- and possibly long-term psychosocial distress, requiring careful consideration by the health authorities [34]. We observed that during the COVID-19 outbreak in Cameroon, the respondents were more concerned about the health of their loved ones than their own health. This finding is relevant in the context of implementing public health measures such as mandatory quarantine and vaccination for COVID-19. Although adherence to preventive measures may depend more on their practicality (ease of implementation) than on the psychology of individuals [35], one could still appeal to altruism by reminding the public about the community-wide benefits of such interventions. It is clear the impact of the interventions goes beyond individual protection to shielding other community members from becoming infected. In a situation whereby even healthcare workers are against a vaccine trial in their community [36], it is important to emphasize the collective benefits of vaccination while rendering the process of COVID-19 vaccination as simple and attractive as possible in a bid to improve acceptability. Studies on attitudes and acceptability of the COVID-19 vaccine in Cameroon are needed.

Participants who resorted to various platforms (radio, television, government announcements, or social media) in search of information about COVID-19 had reduced odds of experiencing depressive symptoms. Similar findings were reported by González-Sanguino et al. in Spain, as they found a negative relationship between depression and having adequate information about the coronavirus [9]. Meanwhile, a study conducted among Chinese adults during their nationwide lockdown showed that a higher level of COVID-19 media exposure was significantly associated with higher PHQ-9 scores [37]. We surmise that the information from various media rather produced a soothing effect on Cameroonian participants by unveiling how grave the COVID-19 situation was in other countries, and providing a sense of relative safety. Indeed, the COVID-19 burden and death toll in Cameroon is considerably lower compared to the daily reports from Europe and the Americas [38]. It is expedient that the media outlets be leveraged to promptly disseminate adequate COVID-19-related information to the public, as this approach is a pillar in ensuring optimal mental and brain health during such health crises by addressing any sense of uncertainty and fear [39].

A number of limitations must be taken into account when interpreting our study findings. This was an online survey, and it is therefore impossible to verify the veracity of the provided responses. In addition, we acknowledge a sampling bias since our survey could only be filled by literate and educated individuals who had access to internet. Indeed, the web-based recruitment procedures could not achieve a representative study population. Fewer female respondents participated in the survey; this could be due to the fact that in Cameroon, it was reported that women are less likely to use the internet compared to men [40]. After the preliminary data analysis, an effort was made through the Ministry of Women’s Empowerment and the Family to encourage more women in women’s groups to participate but the percentage increase in participation was just 1.5 (from 25.2 to 26.7). Since the female gender has been associated with greater psychological distress during the COVID-19 outbreak [9], the male predominance in our study population might have led to an underestimation of the overall burden of COVID-19-related fear and depression in Cameroon. Lastly, the survey’s duration was very long, considering the rapidly evolving dynamics of COVID-19 and could lead to participant fatigue. However, this was mitigated by constituting weekly clusters during the data analysis.

Our study found that less than 10% of Cameroonian adults reported depressive symptoms amidst the COVID-19 crisis, much lower than what has been documented in other settings. Meanwhile, over half of the respondents experienced a high level of fear of COVID-19. We recommend that various media outlets should be leveraged to disseminate adequate information about COVID-19 as this will dispel fear and reduce the risk for depression. Furthermore, persons who report flu-like symptoms, the more educated individuals (postgraduates) and those who had been quarantined seem to be at increased risk for depression, and should be prioritized for interventions during the COVID-19 pandemic in Cameroon. Finally, appealing to the population’s sense of altruism may be the way forward to ensure optimal mental and brain health, as well as better acceptability of large scale COVID-19 preventive measures.