Determinants of Mental Health Status in Indonesian Pre-elderly and Elderly with Comorbidities during COVID-19
Introduction: The pre-elderly and elderly populations with comorbidities are among the vulnerable groups to having mental health issues during COVID-19. This study aimed to examine the mental health status of this population in Indonesia and analyze the associated factors. Methods: This cross-sectional study enrolled 105 pre-elderly and older adults residing in Java Island, Indonesia, in September–October 2021. Mental health status was measured using the Depression, Anxiety, and Stress Scale-21 (DASS-21). Sociodemographic factors, hospital visits, and medication during the pandemic were also asked. Comparison of DASS-21 scores across these factors was analyzed with the Mann-Whitney U test. Results: More than half of the respondents were within a normal range of DASS scores. About 14% of respondents reported depression, and 17% reported stress symptoms, while about 41% were experiencing anxiety. There were gender differences in anxiety and stress scores and education differences in depression. DASS-21 scores were also varied by marital status (p < .05). No significant between-group differences in mental health status according to routine hospital visits and medication during the COVID-19 pandemic. Conclusion: Comorbidities are a risk factor for mental health problems in the pre-elderly and elderly. Women, low economic level, and unmarried individuals were among the vulnerable groups to develop mental health issues during the COVID-19 outbreak.
Introductions
The COVID-19 outbreak has had an impactful effect on all aspects of individuals’ lives, particularly their mental health, due to the fear associated with the pandemic[1]. COVID-19 produced an increasing mortality rate of around 2–3% for adults, and this was even higher in the elderly[2]. However, mental health issues became underappreciated amidst the rapid spread of the coronavirus[3]. Epidemiological data studies in China reported moderate to severe depression, anxiety, and stress in the first stage of the outbreak[4]. The elderly's physical and emotional health is impacted by the COVID-19 pandemic. According to a Hong Kong cohort study of senior citizens with at least two chronic illnesses, there has been a noticeable rise in loneliness, anxiety, and sleeplessness since the COVID-19 outbreak[5]. A similar finding was made in a San Francisco study, where loneliness was reported by over 50% of the elderly and was linked to anxiety and sadness[6]. Research conducted in Germany during the beginning of the pandemic also found a correlation between senior loneliness and depressive symptoms[7]. Additionally, the results of research conducted in Iran during the COVID-19 pandemic demonstrated a reciprocal relationship between the mental health conditions of the elderly and sociodemographic factors, including age, gender, marital status, educational attainment, employment status, economic status, and living situation[8].
Policies like "lockdown" and "stay at home" have curtailed social connections, which has led to an increase in psychiatric problems[9]. The regulation of “physical distance” from the elderly may result in a lack of social engagement for this population. The elderly also cannot obtain routine treatment as previously because of limited access to health care, and an abundance of knowledge about the pandemic (infodemic) can make them feel more stressed and anxious[10]. People naturally started to worry about getting the sickness and the accompanying fear of death, witnessing unimaginably surmounting death cases[11]. Positive psychological traits are essential for reducing the harmful consequences of dread in these unfavorable circumstances because they lower the psychological weight of ongoing discomfort[12]. Research revealed that a considerably higher level of fear of COVID-19 was indicated by those who had previously been hospitalized for their comorbidity, which can result in mental health issues[13].
A coronavirus infection and its associated morbidity and mortality were more common in the elderly due to their advanced biological age and high prevalence of comorbidities[14]. Comorbidities have been found to be a contributing factor to anxiety in studies conducted on general populations[15]. Older persons with comorbidities are substantially more vulnerable than other populations due to diminished cognitive function, poor physiological function and physical fitness, and inadequate immunological function. Older adults have lower cognitive function, which makes them more prone to worry, which leads to psychological instability[16]. Medical conditions like hypertension, diabetes, and chronic obstructive pulmonary disease are major risk factors for the elderly during the pandemic, which threatens their endurance due to mental health problems[14]. Telemedicine may be a solution to the problems caused by the interaction limitation for providing health services. However, the elderly have less knowledge of using technology, which creates a gap in the usage of health services. Elderly people with comorbidities cannot be adequately monitored for hospital visits and treatment during a pandemic, which can exacerbate the illness caused by this limitation[17].
A study on the mental health conditions of the elderly with comorbidities is urgently needed, especially in Indonesia. This study aimed to determine the mental health of the pre-elderly and elderly with comorbidities in Indonesia using the Depression, Anxiety, and Stress Scale-21 (DASS-21). It was hypothesized that mental status in the pre-elderly and elderly with comorbidities was associated with sociodemographic factors, hospital visits, and medication during the COVID-19 pandemic.
Methods
This study has received ethical approval from the Faculty of Medicine, Universitas Airlangga (No. 167/EC/KEPK/FKUA/2021). This cross-sectional study was performed during the end of the second wave of COVID-19 in Indonesia (September 4thto October 10th, 2021). Pre-elderly and elderly people (≥45 years old) who could read and understand Indonesian from Java Island, Indonesia participated in this study. All participants were completely aware. Those respondents who were experiencing an acute illness, had a positive confirmed COVID-19 test, were in self-quarantine, had a serious mental disease, or had cognitive impairment were excluded. Respondents to an online survey regarding mental health among the elderly were mostly made aware of it through a public webinar. They could either finish and submit the survey on their own or with help from close family.
Using an online survey platform (www.surveyplanet.com) that prevented multiple submissions, the questionnaire was created and distributed in compliance with the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines. The first page of the consent form contained information concerning respondents' voluntary involvement, the anonymization of published data, and a brief, plain-language description of the study.
The questionnaire comprised three sections: 1) questions on the comorbidities of respondents and data about sociodemographic factors, including age, gender, marital status, education level, and economic status; 2) measurement of mental health status using DASS-21; and 3) questions on hospitals visit and medication during the pandemic.
DASS-21 instrument
The Indonesian version of the DASS-21 instrument had already been tested for validity and reliability previously. It is a self-report tool designed by Lovibond to
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