This study assessed the levels of depression, anxiety and stress among the general population in Ecuador during social isolation due to the COVID-19 outbreak. Our results showed that the most common mental health issue was anxiety, with 30.7% of the respondents reporting moderate to very severe anxiety levels, followed by depression (17.7%) and stress (14.2%). Similar findings were reported by a Chinese study in which the most common mental health issue was also moderate to severe anxiety (28.8%), followed by depression (16.5%) and stress (8.1%) [18]. In contrast, a Spanish study revealed that the most prevalent issue was depression (29.6%), rather than anxiety (25.3%) or stress (22.4%) [19]. This analysis contributes to our understanding of the behavior of the Ecuadorian population in comparison with that of their communities [14, 20,21,22].
Our study determined that women have significantly higher levels of depression, anxiety, and stress than males, which tends to be a common finding in most studies around the world [10, 18, 19, 23]. Restrictive measures regarding schools and daycare centers may significantly increase the burden on women at home, leading to fatigue and a reduction in their work performance [11, 19, 24]. On the other hand, an increase in domestic violence against women during quarantine due to the pandemic and a higher risk of losing their job and income could be the reasons for our findings [24,25,26,27,28].
Verma and Mishra reported that male sex is associated with reduced odds of stress; however, their findings also suggest that being male is associated with greater odds of depression and anxiety [29]. In contrast, our study determined that being male is associated with reduced odds of having severe levels of depression, anxiety, and stress. Studies in Latin America have shown that men have significantly lower levels of depression, stress and anxiety than women [14, 15, 20].
A recent systematic review and meta-analysis stated that younger adults (21–40 years) constituted the most severely affected population [18, 21], with a high risk of mental health issues during the COVID-19 pandemic [8, 19, 20, 23, 30]. In fact, we found inverse correlations between age and the levels of depression, anxiety, and stress. The reason may be that younger individuals tend to be more concerned about future consequences and the negative impact of the pandemic on the global economy and job availability [18, 21]. Similarly, young people have greater and more continuous access to worrisome and/or inaccurate information due to their use of social media, which can affect their mental health [10, 25, 26, 31, 32]. Additionally, young people tend to be students, for whom uncertainty and the lack of academic progression are sources of significant distress [18]. In our study, students had significantly higher levels of depression, anxiety, and stress, which is a common finding of other studies [18, 19, 23].
The relationship status of the respondents seemed to influence the severity of mental health issues. We found that married people tended to have significantly lower levels of depression, anxiety, and stress than single people, as reported in other studies [19, 23, 33]. The number of children also appeared to have an effect on the psychological impact of social isolation. Our study showed inverse correlations between the number of children and the levels of depression, anxiety and stress. The more children an individual had, the lower the level of mental distress. Similarly, other studies have also found that having a child was associated with lower levels on each subscale of the DASS-21 [9, 34,35,36]. Interestingly, the number of cohabitants was not correlated with the levels of depression, anxiety, and depression, unlike the Spanish population, where a household with 2 people was likely to experience a reduced psychological impact [19].
A more favorable perception of health was associated with a reduced psychological impact [9, 19]. Similarly, we found that a higher perception of overall health was negatively correlated with the levels of depression, anxiety, and stress. Having a variety of symptoms compatible with COVID-19 was associated with a significant increase in the odds of more severe levels of anxiety, as reported in previous studies [11, 18, 19]. However, having a positive COVID-19 diagnosis was not associated with more anxiety in our population. This finding seems paradoxical because research has shown that COVID-19 patients experience significant psychological distress [37]. A possible reason may be that most of these patients were not hospitalized; therefore, they were probably experiencing a mild case of COVID-19. A recent Ecuadorian study assessed depression and anxiety in patients with confirmed or suspected COVID-19 diagnoses using the Generalized Anxiety Disorder 7-item (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) questionnaires. Those findings suggested that the severity of depressive symptoms was significantly greater in the group with confirmed COVID-19, although there was no effect on the severity of anxiety symptoms. One of the major limitations of that study was that the researchers could not determine if the presence of psychological symptoms was the result of being under surveillance or the disease itself. Therefore, the researchers recognized the need for a study focusing on the general population [38].
On the other hand, having a relative diagnosed with COVID-19 was associated with more severe levels of depression and anxiety. This result is similar to some findings from China, where people were more worried about their relatives contracting COVID-19 but were less distressed when they themselves were infected, remaining optimistic that they would survive the disease [18]. Based on these findings, we believed that subjective perceptions (e.g., overall health, mental health, and COVID-19 compatible symptoms) were more strongly correlated with a negative psychological impact than more objective measurements, such as a confirmed COVID-19 diagnosis. A possible explanation is that isolated people perceived themselves as being more vulnerable than they actually were [19].
Furthermore, our research suggested that the COVID-19 pandemic, along with social isolation measures, has definitely affected the mental health of the general population in our country. Hopefully, some interventions can be initiated to improve the mental health of Ecuadorians during the pandemic. The first step should be to raise awareness of the current mental health issues due to the COVID-19 pandemic to provide information and guidelines to help identify individuals in need of appropriate help.
Online psychological assistance and telephone counseling should be provided to address this issue [39]. In addition, cognitive behavioral therapy (CBT) does not always require the assistance of a mental health professional [18], which makes this a cost-effective intervention. Our study identified high-risk groups, such as females, students, young adults, unmarried people, and individuals with COVID-19 symptoms, who were found to be more vulnerable to greater psychological impact. Based on this, we recommend that educational institutions and workplaces arrange psychological tests to determine the mental health status of their students and workers, especially females, thereby identifying who is in need of further psychological support.
One of the main strengths of this study was that it included a relatively large sample. However, with regard to the interpretation of our findings, there are several limitations worth mentioning. First, we adopted the snowball sampling method due to limitations with regard to time and resources. This prevented our study population from being randomly selected and led to an oversampling of participants from a particular region (Guayas/Guayaquil). Additionally, young individuals accounted for a significant proportion of our sample, which may be due to the use of social media as the primary broadcast channel for the survey. Furthermore, our results could be different in other Latin American countries, limiting the generalizability of our results. Another major limitation was that the levels of depression, anxiety, and stress were self-reported by the respondents. Finally, due to the large number of asymptomatic patients and the lack of widespread COVID-19 testing in the early stages of the pandemic, it is possible that a considerable number of the respondents had been infected with SARS-CoV-2 but were unaware of that fact at the time of the survey. Nevertheless, our findings provide valuable information about mental health in a Latin American country during the social isolation period of the current COVID-19 pandemic.
