Depression is a major mental health problem that primarily disrupts mood and the ability to experience pleasure. This mood disruption is coupled with associated physical, emotional and cognitive symptoms, and behavioral changes. Our study showed that during the MCO for COVID-19 pandemic, approximately one-third of Malaysians were mild-to-severely depressed. Factors that increased Malaysians’ likelihood of being depressed were: being in younger age group, having no partner, living in the red zone during the MCO, having income categorized as B40, and having avoidant coping strategies. Religious coping and having a partner were associated with less depression during the MCO. Depression was associated with a significantly worse quality of life across all domains.
The proportion of respondents with mild-to-severe depression in our study was 28.2%, which was higher than the prevalence of depression during COVID-19 in other countries. Specifically, when compared with depression levels during the COVID-19 pandemic, a study in China reported the prevalence of depression in the general population to be 20.1% [11]. One possible explanation why our study’s prevalence of depression was higher was because it involved people who were in lockdown and affected by the MCO directly. In comparison, the study done by Huang and Zhao et al. was a general survey among the Chinese population that might not be directly affected by the lockdown in Hubei. In addition, our study was done some time after the MCO was implemented, and possibly, the concern and effect of the MCO towards normal daily life were more pronounced. If the survey was done during the initial phase of the MCO, the prevalence of depression might have been lower. Therefore, it will be useful for future studies conducted to assess the effect of the MCO over time on the depression level. The prevalence of depression in our study was more similar to the prevalence of depression during the SARS epidemic in Taiwan and Canada. Past studies analyzing the prevalence of depression during SARS in Taiwan showed a similar prevalence of depression (27.5%) [21]. A study conducted on the effects of quarantine during the SARS outbreak in Toronto also revealed a similar prevalence of depression (31.2%) [22]. The depression symptoms may persist even beyond the duration of this pandemic. Studies during the SARS outbreak found that quarantining was predictive of a high level of depressive episodes, even 3 years after the outbreak [23]. Although the prevalence of depression during this pandemic in Malaysia was similar to that in other countries, the prevalence of depression was higher than in the general population, which ranged from 6.7 to 14.4% [24]. These findings of higher mental health problems during the current pandemic are consistent with studies that have shown that public health emergencies could cause mental health problems [25, 26].
Our study found that being younger was associated with a higher risk of depressive symptoms. Other COVID-19 studies supported our findings. A nationwide survey in China during the COVID-19 crisis showed that young adults were more vulnerable to depression [27]. Previous studies conducted during the SARS outbreak also revealed younger people to be more at risk of depression [22, 23]. This might be explained by the young people’s increasing use of social media to obtain information. However, this behavior could be counterproductive, as such information could trigger stress. This was supported by a recent study that demonstrated that frequent social media exposure during the COVID-19 pandemic was associated with mental health problems [28]. Our study also showed that Malaysians who belonged to a lower economic class (B40) were more significantly associated with depression. This finding was consistent with studies conducted during the SARS outbreak, which showed that people with an annual household income of less than $40,000 had increased depressive symptoms [22]. Those from the lower socioeconomic class were more likely to work part-time, odd hourly rates, and did not have access to paid vacation and sick days [29]. Therefore, the restriction of movement due to MCO, resulting in the closure of many economic trades causing job insecurity, could harm psychological well-being [30, 31]. Meaningful social relationships are fundamental to a healthy human life [32]. The presence of healthy supportive relationships can have a positive impact on long-term health outcomes. Studies have shown that the emotional support provided by meaningful relationships enhances psychological well-being [33], while loneliness is a risk factor for depression [34]. Social isolation due to the MCO may make these effects more apparent. However, it is unknown whether loneliness was a cause of depressive symptoms in Malaysians. Therefore, future studies will be needed to assess the effect of the COVID-19 lockdown on loneliness. Our study showed that living in the red-zone area with many confirmed COVID-19 cases was associated with depression, and this finding was supported by another study conducted in China, which showed that living in areas with COVID-19 patients increases psychological stress such as anxiety and anger. The closer they were to confirmed cases, the more the risk of being infected, which caused more psychological distress [35]. Traditionally, disaster models have described a bull’s eye effect, which assumes that the psychological effects of a disaster are narrowed and geographically circumscribed near the area of disaster [36]. A study done during the SARS outbreak showed that the respondents in epidemic area were less anxious than those in non-epidemic area [37]. Recent studies have also shown that instead of only the geographical location, the appraisal of risk may be more helpful to explain observations on how disaster affects the psychological well-being [36]. It is likely that the geographical effect of the pandemic cannot be simply explained by one theory only, and future research will be needed to ascertain how the geographical distance to the epicentre of the COVID-19 pandemic predicts depression and other psychological distress [38].
Our study demonstrated that avoidant coping strategies predicted more depression, corroborating studies in adolescents that have shown the association between avoidant coping strategies with depression and anxiety [39]. Another study of pregnant minority women showed a correlation between avoidant coping and depression in pregnancy [40]. Although avoidant coping may reduce distress in the short-term, in the long run, approach coping strategies are associated with a more positive outcome if the stressor is chronic [7]. This is because avoidance coping may forestall more effective ways of coping or involve harmful behaviors such as substance abuse [7].
There are two types of religious coping, positive and negative. Positive religious coping means developing a positive relationship with God, and involve meditation, prayer, and reflecting on God’s to help in distressing times. Negative religious coping is, when one believes the affliction is a punishment from God, or blames God for the mishaps. The literature suggests that positive religious coping is related to positive psychological adjustment to stress, while negative religious coping was related to negative psychological adjustment to stress [41]. As our study found that religious coping reduced depression level, it is possible that Malaysians adopted positive religious coping during this pandemic. The slowing of the daily pace and having more time at home during the MCO may have enabled Malaysians to meditate, pray, or connect more with God. Previous research has shown that being more self-aware, having a sense of faith and empowerment, and living with meaning and hope improves well-being [42]. This positive religious coping strategy may help Malaysians to cope with the stress and uncertainties of the pandemic and, as a result, ameliorate symptoms of depression. In our study, the approach to coping strategies was not significantly associated with depressive symptoms. Strategies such as problem-solving, positive reappraisal, and active acceptance involve taking steps to ameliorate the negative effects of stressors. Even in isolation, individuals can partake in many activities that spark positive emotions, such as hobbies or learning a language. These behavioral activation activities are diverting and can spark positive emotions, which would hopefully build resilience [43]. Therefore, finding ways to engage with life during traumatic events can improve general psychological well-being [44].
Our study demonstrated that depression affects quality of life in all domains. This finding was consistent with a previous study, which showed that depressive symptoms were associated with impaired quality of life [45]. Patients with depressive symptoms had poorer functioning than patients with no depressive symptoms [45]. The psychosocial disability due to depressive symptoms was also seen to be affected by the severity of the symptoms. During more symptomatic periods, the disability was worse than during remission [46, 47]. The effect of depression on the quality of life during the pandemic was also shown by a study, which revealed that individuals who were quarantined or indirectly exposed to SARS experienced depressive symptoms due to the economic downturn and poor social support [48].
Our study has several strengths and limitations. It not only examined depression but also the coping strategies used by Malaysians during the MCO and the impact of the depression on the quality of life. Also, our study was ones among the few studies that looked at the effect of the MCO on the psychological health of the general population instead of focusing only on the psychological health of healthcare workers. The limitations were: first, due to the nature of the MCO implementation, coupled with the risk of contagion, our study was conducted using an online questionnaire. Thus, the non-IT literate population might have been excluded, especially those living in rural areas or with a poor educational background. In addition, the participants of this study were mostly young individuals, predominantly female and excluded individuals with chronic medical and psychiatric illness, which possibly could make the findings of this study biased. Furthermore, as the study was conducted in English and Malay, it excluded those not literate in these two languages. The non-random sampling method predisposed to a selection bias and might not represent the Malaysian population. Also, due to the cross-sectional method, no causality could be established between coping, depression, and quality of life. Some of the Brief-COPE dimensions needed to interpret with caution due to the low internal consistency. Our study found that religious coping lessened depression, but it was not certain whether it was positive or negative religious coping that protected individuals from depression. Therefore, future studies will be needed to attain a better picture of Malaysians’ ability to cope.