Review Articles

The International Journal of

Psychiatry in Medicine
Prevalence of 0(0) 1–18
! The Author(s) 2020
depression, anxiety and Article reuse guidelines:
sagepub.com/journals-permissions
stress in china during DOI: 10.1177/0091217420978005
journals.sagepub.com/home/ijp

COVID-19 pandemic: A
systematic review with
meta-analysis

Syeda Beenish Bareeqa1 ,

Syed Ijlal Ahmed2,
Syeda Sana Samar3, Waqas Yasin4,
Sani Zehra1, George M Monese5 and
Robert V Gouthro6

Abstract
Background: The novel coronavirus disease which is believed to have initially orig-
inated in Wuhan city of China at the end of 2019 was declared as pandemic by March
2020 by WHO. This pandemic significantly impacted the mental health of commu-
nities around the globe. This project draws data from available research to quantify
COVID-19 mental health issues and its prevalence in China during the early period
of the COVID-19 crisis. It is believed that this pooling of data will give fair estimate of
the effects of the COVID-19 pandemic on mental health.
Methods: We conducted this study in accordance with PRISMA guidelines 2009.
The protocol for this review is registered and published in PROSPERO

1
Jinnah Medical and Dental College, Karachi, Pakistan
2
Liaquat National Hospital and Medical College, Karachi, Pakistan
3
Jinnah Sindh Medical University, Karachi, Pakistan
4
Department of Psychiatry, Medical College of Wisconsin, Milwaukee, WI, USA
5
Medical College of Wisconsin, Green Bay, WI, USA
6
Department of Psychiatry, Medical College of Wisconsin, Green Bay, WI, USA
Corresponding Author:
Syeda Beenish Bareeqa, Jinnah Medical and Dental College, 22-23 Shaheed-e-Millat Road, Karachi,
Pakistan.
Email: syedabeenishbareeqa@gmail.com
2 The International Journal of Psychiatry in Medicine 0(0)

(CRD42020182893). The databases used were Pubmed, Medline, Google scholar

and Scopus. The studies were extracted according to pre-defined eligibility criteria
and risk of bias assessment was conducted. The Meta-analysis was done using
OpenMeta [analyst].
Results: Total of 62382 participants in nineteen studies fulfilled the eligibility criteria.
Stress was the most prevalent (48.1%) mental health consequence of Covid-19
pandemic, followed by depression (26.9%) and anxiety (21.8%). After performing
subgroup analysis, prevalence of depression and anxiety in both females and frontline
health care workers were high as compared to the prevalence in general Chinese
population.
Conclusion: The prevalence of depression and anxiety is moderately high whereas
pooled prevalence of stress was found to be very high in Chinese people during this
Covid-19 crisis.

Keywords
stress, anxiety, depression, pandemic, Covid-19, China, mental health, health care
worker, psychological impact

Introduction
The novel coronavirus disease which is believed to have initially originated in
Wuhan city of China at the end of 2019, was declared to be a Public Health
Emergency of International Concern in January 2020 by the World Health
Organization (WHO), and unanticipatedly became a pandemic for the world
by March 2020.1Around that time, The Lancet issued a statement to show
appreciation and solidarity towards public health workers and scientists who
were risking their lives fighting against the odds.2
While symptoms of the disease vary from an asymptomatic presentation to
severe findings including high grade fever, chills, breathing difficulty, cough,
sore throat, coryza, myalgia, nausea, vomiting, and diarrhea, the actual mode
of transmission of the virus is not completely understood. Patients with medical
comorbidities are associated with worse outcomes such as cardiac injury, respi-
ratory failure, acute respiratory distress syndrome, and death. To combat the
rapid progression of the disease the Chinese government imposed lockdown
initially in the city of Wuhan and then gradually, to other cities.3 During this
period, the significance of the desperate measures such as quarantine and self-
isolation that were imposed to halt the spread of the disease gained popularity,
but subsequently the Chinese government started noticing evolving panic, anx-
iety, and mood symptoms among their population. These psychological effects
are believed to be linked with quarantine duration, fear of infection, frustration
Bareeqa et al 3

due to boredom, inadequate supplies due to panic buying, lack of proper and
accurate information due to increased media reporting, financial loss due to
shutdown of the industrial and business sectors and the labeling of people
with the disease as “COVID-19 cases” thus creating stigma.4 The negative psy-
chosocial effects of COVID-19 are under-addressed and little data is currently
available on the mental health impact this disease, and the measures taken to
limit its spread, has on the general population or those who suffer from it.
For many, quarantine can be an unpleasant experience. Separation from
loved ones, the loss of freedom, uncertainty, and boredom can lead to anxiety,
stress, depression, and even suicide.4 Researchers have suggested the psycholog-
ical stress from situations of this magnitude may have a long-lasting effect on
one’s overall psychosocial wellbeing. Even after a decade post its outbreak in
2003, it was reported that depression, chronic fatigue and post-traumatic stress
disorders still exist in survivors of severe acute respiratory syndrome.5 Another
study, which utilizes snowball sampling strategy, focused on the general public
living in mainland China during the epidemic of COVID-19. The study suggests
females suffered a greater psychological impact of the outbreak, including
higher levels of anxiety, stress and depression.3 Another domain of the study
suggests students experience an increased psychological impact from the out-
break with higher levels of stress, anxiety, sleeplessness, frustration and
depression.6
This project draws data from available research to quantify COVID-19
mental health effects and prevalence in China during the early period of the
COVID-19 crisis. It is believed this pooling of data will help build a greater
consensus about the effects of the COVID-19 pandemic on mental health, which
may be generalizable, and provide benefit and guidance to those in other parts
of the world.

Material and methods

We’ve conducted the systematic review in accordance with the Preferred
Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guide-
lines 2009.7The protocol for this review is registered and published in
PROSPERO (CRD42020182893). It is available on: https://www.crd.york.ac.
uk/prospero/display_record.php?ID=CRD42020182893

Literature search strategy

An extensive data search was performed on PubMed, Ovid Medline, Google
Scholar and Scopus databases using MeSH and non-MeSH search terms which
includes (“Depression” OR “Anxiety” OR “Stress” OR “Major depressive dis-
order” OR “Generalized anxiety disorder” OR “Acute stress disorder” OR
“Post-traumatic stress disorder” OR “Mental Health” OR “Psychological
4 The International Journal of Psychiatry in Medicine 0(0)

impact” OR “Anxi*” OR “Depressi*”) AND (“SARS-CoV-2” OR “COVID-

19” OR “Pandemic” OR “Corona virus” OR “Coronaphobia” OR “Novel
coronavirus” OR “2019-nCoV) AND (“China” OR “Chinese” OR “Wuhan”
OR ‘’Hubei”). Two independent authors (SBB & SSS) performed this task. No
specific timeline was defined however, all research published prior to April 2020
were considered for inclusion. To expedite the identification of eligible research,
we screened the reference list of cited studies within the extracted articles.
Additionally, sources, including MedRxiv.org & SSRN were explored to look
for preprints. The screening method was as follows: initially, titles were screened
for potential relevant articles followed by detailed screening of abstracts to
confine the search. Full-texts of the articles were screened and shortlisted on
the basis of eligibility and relevance to the topic.

Eligibility criteria
Studies that met the following criteria were included in the review: (a) Studies in
which Depression or Anxiety or Stress or any combination of the above was
assessed as a primary outcome; (b) No restrictions were applied on the basis of
age, gender, study setting or type of participant; (c) Must be a cross-sectional
study/survey; (d) Only populations belonging to the region of China were
included.
Studies were excluded from this review if they met the following criteria: (a) If
depression or anxiety or stress was not assessed as a major outcome; (b) If a
study included hypothetical or unquantified results (no supportive statistical
evidence of analyzed outcome); (c) Data was presented in any language other
than English; (d) If abstracts and/or full-texts were unavailable; (e) If primary
results were presented in mean & standard deviations (SD) instead of frequen-
cies and percentages.

Data extraction
Two review authors independently (SIA & SZ) extracted data using a predefined
extraction form. Any discrepancies in extracted data, including duplicate report-
ing of studies or inclusion of irrelevant articles was resolved by collaborative
discussion with the third independent investigator (GMM). All the relevant data
about each study was entered on predefined MS-Word sheet. We extracted
information about: Study details (First author, year of publication);
Population characteristics (total number of respondents, response rate, age,
gender, country or region, types of population included in each survey); scales
(that were utilized to assess primary outcome) and addressed mental health
condition. For all quantitative variables, data was extracted in frequencies
and percentages except for age of respondents, which was presented in mean
& standard deviation.
Bareeqa et al 5

Statistical analysis
OpenMeta[Analyst] software was utilized to run meta-analysis. We’ve consid-
ered pooled prevalence with their 95% confidence intervals (95% CI) as the
measures of effect. In order to assess the heterogeneity among the studies for
primary outcome groups and subgroups, we’ve applied I2 statistic as a propor-
tionate measure of the total variance in pooled estimates. The heterogeneity was
considered low, moderate and high if the cut-off points for I2 values of 25%,
50% and 75% or more were found respectively.8 For the stability of variance,
we’ve used Freeman-Tukey Double Arcsine Transformation9 before calculating
the pooled estimates. Random-effect model was applied considering that prev-
alence of depression, anxiety and stress in different population groups would be
variable.
Subgroup analysis was conducted on gender (female), and type of population
(Front-line health care workers). Sensitivity analysis was done to evaluate
the alteration in pooled effect size. It was performed by removal of individual
studies one by one and running the meta-analysis after the removal of each
study. In this way, a cumulative analysis was carried out to test the impact
of the largest studies on the pooled effect size. To figure out the variance due
to utilization of different scales within studies, a separate scale-specific analysis
on frequently used scales (e.g. PHQ-9, SDS, GAD-7, SAS and IES-R) was
performed.

Risk of bias assessment

Two independent reviewers (SSS & SIA) conducted the process of assessing risk
of bias. Initially, relevant data and studies were extracted by two independent
investigators in accordance with The Meta-analysis Of Observational Studies in
Epidemiology standard (MOOSE)10 and Strengthening the reporting of obser-
vational studies in epidemiology (STROBE)11 22-item checklists, modified
according to Sanderson et al.12 and Fowkes and Fulton,13 to assess the meth-
odological quality of each study. Two independent authors (SBB & WY) then
evaluated risk of bias using the Modified Newcastle-Ottawa scale14 which was
cross-checked by a third independent reviewer (RVG) to resolve any discrepan-
cy between findings. Assessment was based upon following essential compo-
nents: (a) Representativeness; (b) Size of the sample; (c) Comparability; (d)
Outcome and (e) Statistical methods. Studies scoring
3 were considered to
be low risk whereas studies with scores of <3 were high risk studies. Strict
criterion were set for all the essential components to ensure appropriate quality
assessment. The details of criterion is given in supplementary document
(eMethod 1).
6 The International Journal of Psychiatry in Medicine 0(0)

Results
The initial search revealed a total of 1170 articles. Additional database and
preprints publishing sites were included in our search strategy to ensure the
most recent available data on the required topic was extracted. After extensive
scrutiny of titles, abstracts, and full texts, 19 studies were included for final
quantitative analysis. A PRISMA flow diagram detailing the study extraction
process is presented in Figure 1.

Baseline characteristics of included studies

Nineteen15–33 studies with 62382 participants were included in the analysis. As
per inclusion criteria, all studies were cross-sectional surveys reporting preva-
lence of depression or anxiety or stress or any of the preceding in combination
among Chinese population during COVID-19 pandemic. A majority of the
62382 participants were females (69.7%) with the remainder being males

Figure 1. Data extraction strategy in accordance to PRISMA flow diagram for the study.
Bareeqa et al 7

(30.3%). The median response rate for the studies was 84.7% ranging from
43.2% to 100%. Out of the 19 studies, 6 did not report the response rate. The
mean age of total participants was 36.44 (6.27) years. The most frequently
utilized scale for depression was Patient Health Questionnaire-9 item scale (in 5
studies). The Generalized Anxiety Disorder 7-item scale was used in 8 studies to
measure anxiety and the Impact of Event Scale-Revised was utilized in 3 studies
for the assessment of stress. Of the 19 studies, 15 included medical staff within
their study population.
Details about the baseline features of all studies including Author & year of
publication, total number of respondents, participation rate, distribution of age
(in mean & SD) and gender (in number & percentage), clinical scales and inves-
tigated mental health, region and the type of study population is summarized in
Table 1. After applying the Modified Newcastle-Ottawa scale (NOS) for calcu-
lating risk of bias, 5 studies were found to be high risk studies (scoring < 3 on
NOS) whereas 14 (scoring
3 on NOS) were low risk studies. Details of NOS
scoring is presented in Table 2.

Prevalence of depression
Fifteen of the 19 studies (49656 participants) assessed the prevalence of depres-
sion. Data extraction sheet of depression is given in supplementary file (eTable
1). The estimated pooled prevalence of depression in Chinese people during
COVID-19 pandemic was 26.9% (95% CI¼ 20–34.3, I2¼99.68%) as presented
in Figure 2. After performing the sensitivity analysis, we’ve found that no study
affected the pooled prevalence of depression by over 2%. The alterations in
depression prevalence obtained from influence analysis of studies ranged from
0.2%24 to 1.9%.30 When performed, a scale-specific analysis on Patient Health
Questionnaire-9 (PHQ-9) which was utilized in 5 studies, found the prevalence
of depression to be 35.5% (95% CI¼ 22.9–48.2, I2¼ 99.71%). Scale-specific
analysis on Self-rating Depression Scale (SAS) revealed that depression was
prevalent in 34.1% (95% CI¼ 30.8–37.3, I2¼ 87.71%) population.

Prevalence of anxiety
Total 17 out of 19 studies reported anxiety in Chinese people. With 57311
participants included in the analysis, the pooled prevalence of anxiety was
21.8% (95% CI¼ 16.9–27.1, I2¼ 99.52%). The detail of this analysis is shown
in Figure 3. Similar to depression, no significant alteration (>2%) was found
after performing sensitivity analysis. The changes in the estimated pooled prev-
alence of anxiety after performing influence analysis ranged from 0%31 to
1.3%.30 Details about the studies included in anxiety analysis, scales, anxiety
in frontline health care workers & females is given in supplementary data sheet
(eTable 2). The scale-specific analysis of Generalized Anxiety Disorder 7-item
Table 1. Baseline characteristics of included studies.
Total number Response Age in years Gender distribution N (%) Addressed mental Region Study
Author and year of respondent rate Mean (SD) Scales health conditions or country population
M FM

Jianming Guo et al. 11118 NR NR 2802 (25.2) 8316 (74.8) SAS -Anxiety China mainland -Medical staff
2020 SDS -Depression
Zhou Zhu et al. 5062 77.1% NR 759 (15) 4303 (85) PHQ-9 -Depression Wuhan -Medical staff
2020 GAD-7 -Anxiety
IES-R -Stress
Wenjun Cao et al. 7143 100% NR 2168 (30.35) 4975 (69.65) GAD-7 -Anxiety Changzhi -Medical students
2020
Junling Gao et al. 4827 83.2% 32.3 (10.0) 1560 (32.3) 3267 (67.7) WHO-5 -Depression China -Students
2020 GAD-7 -Anxiety -Medical staff
-General population
Yeen Huang at al. 7236 NR 35.3 (5.6) 3284 (45.4) 3952 (54.6) CES-D -Depression China -Medical Staff
2020 GAD-7 -Anxiety -Enterprise or institution
worker
-Teachers or students
-General population
Juhong Zhu et al. 165 100% 34.16 (8.06) 28 (17) 137 (83.0) SDS -Depression Gansu -Medical staff
2020 SAS -Anxiety
Wen Lu et al. 2020 2299 94.88% NR 514 (22.3) 1785 (77.6) HAMA -Anxiety Fuzhou -Medical staff
HAMD -Depression -Administrative staff
Jianbo Lai et al. 1257 68.7% NR 293 (23.3) 964 (76.7) PHQ-9 -Depression -Wuhan -Medical staff
2020 GAD-7 -Anxiety -Hubei
IES-R -Stress -Other provinces
Jie Zhang et al. 205 NR 46.9 (15.37) 90 (44) 115 (56) PHQ-9 -Depression Zhongshan -General population
2020 GAD-7 -Anxiety -COVID 19 patients
GHQ-9 -Quarantined
Yun Chen et al. 105 84.7% 32.6 (6.5) 10 (9.5) 95 (90.5) SDS -Depression Guiyang -Medical staff
2020 SAS -Anxiety
Xiaoxv Yin et al. 8151 NR 31.7 (13.69) 3514 (43.1) 4637 (56.9) PHQ-9 -Depression China mainland -General population
2020 GAD-7 -Anxiety

(continued)
Table 1. Continued.
Total number Response Age in years Gender distribution N (%) Addressed mental Region Study
Author and year of respondent rate Mean (SD) Scales health conditions or country population
M FM

Hai-Xin Bo et al. 714 97.8% 50.2 (12.9) 351 (49.1) 363 (50.9) PCL-C -Stress Wuhan - COVID 19 patients
2020
Wen-rui Zhang 2182 NR NR 781 (35.8) 1401 (64.2) PHQ-2 -Depression -Medical staff
et al. 2020 PHQ-4 -Anxiety China
GAD-2
Zhaorui Liu et al. 4679 NR 35.9 (9.0) 830 3849 (82.3) SDS -Depression China mainland -Medical staff
2020 (17.7) SAS -Anxiety
SRQ-20 -Stress
Yuhong Dai et al. 4357 94.7% 35 (8.6) 1,026 (23.5) 3331 (76.5) GHQ-12 -Stress -Wuhan -Medical staff
2020 -Hubei
-Other provinces
Wanqiu Tan et al. 673 50.87% 30.8 (7.4) 501 (74.4) 172 (25.6) DASS-21 -Depression Chongqing -Medical staff
2020 -Anxiety
-Stress
Jiang Du et al. 2020 134 43.22% 36 (8.05) 53 (39.5) 81 (60.5) BDI-II -Depression -Wuhan -Medical staff
BAI -Anxiety -Wuhan outreach
PSS -Stress
Chen-Yun Liu et al. 512 85.3% NR 79 (15.43) 433 (84.57) SAS -Anxiety -China -Medical staff
2020
Chenxi Zhang et al. 1563 80.31% NR 270 (17.3) 1293 (82.6) PHQ-9 -Depression -China -Medical staff
2020 GAD-7 -Anxiety
IES-R -Stress

NR¼Not reported; SAS¼self-rating anxiety scale; SDS¼Self-Rating Depression Scale; HCW¼ Health care worker; IES-R¼ Impact of Event Scale-Revised; PHQ-9 ¼ Patient Health
Questionnaire-9 item scale; PHQ-2 ¼ Patient Health Questionnaire-2 item scale; PHQ-4 ¼ Patient Health Questionnaire-4 item scale; GAD-7 ¼ Generalized Anxiety Disorder 7-item
scale; GAD-2 ¼ Generalized Anxiety Disorder 2-item scale; WHO-5 ¼ WHO-Five Well-Being Index; CES-D¼ The Center for Epidemiology Scale for Depression; HAMA¼ Hamilton
Anxiety Scale; HAMD¼ Hamilton Depression Scale; GHQ-9 ¼ 9- item General Health Questionnaire; PCL-C¼ Posttraumatic Stress Disorder Checklist– Civilian Version; SRQ-20¼
WHO 20-item Self-Reporting Questionnaire; DASS-21¼ Depression, Anxiety & Stress 21-item scale; PSS¼ Perceived Stress Scale; BAI¼ Beck Anxiety Inventory; BDI-II¼ Beck
Depression Inventory-II.
10 The International Journal of Psychiatry in Medicine 0(0)

Table 2. Modified Newcastle-Ottawa scale scores of each included study.

Modified Newcastle-Ottawa scale for risk of bias assessment

Representativeness Size Comparability Outcome Statistics Total

Studies (1) (2) (3) (4) (5) score

Jianming Guo et al. 2020 1 1 0 0 0 2

Zhou Zhu et al. 2020 1 1 0 1 1 5
Wenjun Cao et al. 2020 1 1 1 1 0 4
Junling Gao et al. 2020 1 1 0 1 0 4
Yeen Huang at al. 2020 1 1 0 1 1 4
Juhong Zhu et al. 2020 1 0 1 0 0 2
Wen Lu et al. 2020 1 1 1 0 1 4
Jianbo Lai et al. 2020 1 1 0 1 1 5
Jie Zhang et al. 2020 1 0 0 1 1 3
Yun Chen et al. 2020 1 0 1 0 0 2
Xiaoxv Yin et al. 2020 1 1 0 1 1 4
Hai-Xin Bo et al. 2020 1 1 1 0 0 3
Wen-rui Zhang et al. 2020 1 1 0 0 1 3
Zhaorui Liu et al. 2020 1 1 0 0 0 2
Yuhong Dai et al. 2020 1 1 1 0 1 4
Wanqiu Tan et al. 2020 1 1 0 1 0 3
Jiang Du et al. 2020 1 0 0 0 1 2
Chen-Yun Liu et al. 2020 1 1 1 1 1 5
Chenxi Zhang et al. 2020 1 1 0 1 0 3

Figure 2. Pooled prevalence of depression in China during COVID-19 pandemic.

Bareeqa et al 11

Figure 3. Pooled prevalence of anxiety in China during COVID-19 pandemic.

scale (used in 8 studies) revealed the total prevalence of anxiety to be 29.2%

(95% Ci¼ 20.1– 39.3, I2¼ 99.74%); However, the prevalence of anxiety using
Self-rating Anxiety Scale (used in 5 studies) was 16.2% (95% CI¼ 14.5–17.9,
I2¼ 73.73%).

Prevalence of stress
Of the 19 studies, only 8 surveys studied the prevalence of stress during the
pandemic. When considering all of the primary outcomes, stress was found to
be the most prevalent mental health condition in the Chinese population. The
total prevalence among the 18439 participants included in this analysis was
48.1% (95% CI¼ 28.7–67.7, I2¼ 99.86%). Sensitivity analysis of data for prev-
alence of stress revealed 6 [16, 22, 26, 28, 30, 33] studies altering the pooled
prevalence by more than 2%. The alterations in the estimated pooled prevalence
was ranging from 1.3%29 to 8.7%.26 The recalculated prevalence of stress after
removing Hai-Xin Bo et al.26 was 39.4% (95% CI¼ 22.8–57.4, I2¼99.81%). The
pooled stress prevalence by assessment method is given in Figure 4 whereas the
data extraction sheet is presented as supplementary data (eTable 3). The results
of sensitivity analysis for depression, anxiety and stress is shown in Appendix 1.
12 The International Journal of Psychiatry in Medicine 0(0)

Figure 4. Pooled prevalence of stress in China during COVID-19 pandemic.

After performing scale-specific analysis for Impact of Event Scale-Revised, the

prevalence of stress was 58.2% (95% CI¼ 26.2–90.2, I2¼99.87%).

Subgroup analysis
Our initial criteria for performance of subgroup analysis (e.g. Subgroup analysis
will be conducted only if two or more studies will be assessing a particular
variable) was quite lenient as it was anticipated there would be a lack of suffi-
cient data due to novelty of topic. However, literature extraction proved this to
not be the case. This allowed the criteria for conducting subgroup analysis to be
strengthened by raising the cutoff (subgroup analysis was conducted only if five
or more studies were assessing a particular variable).
 Frontline health care workers: We’ve considered the definition of frontline
HCW presented by Zhou M. et al. to include studies in this subgroup analysis,
which was “a worker directly involved in COVID-19 prevention and treatment
and having direct contact with confirmed or suspected cases through patient
intake, screening, inspection, testing, transport, treatment, nursing, specimen
collection, pathogen detection, pathologic examination, or pathologic anatomy
of medical and healthcare professional and technical personnel.”34 Studies that
did not provide enough information to fulfill the defined criteria concerning
included medical staff were excluded from the analysis.

Eight studies totaling 10267 participants were included for analysis of depression in
frontline HCW. The estimated prevalence of depression was 31.5% (95% CI¼
Bareeqa et al 13

20.7-43.5, I2¼ 99.30%). Similarly, 10267 total participants and the same 8 studies
were also included for assessment of anxiety in frontline HCW. The pooled prev-
alence of anxiety in frontline HCW was 23.7% (95% CI¼ 16.8-31.3, I2¼ 98.53%).
The detail about the subgroup analysis on depression and anxiety on this popula-
tion is presented as a forest plot in supplementary files (eFigure 1 and eFigure 2
respectively).

 Females: The majority share (69.7%) of participants included in this anal-

ysis was female. Six studies including 16416 participants were assessed for
depression, of which 28.5% (95% CI¼ 18.7–39.5, I2¼99.52%) were found to
be depressed. In contrast, 21391 females from 7 studies were included in the
prevalence of anxiety determination for Chinese females. The pooled prevalence
of anxiety in females was 25% (95% CI¼ 16.8–34.3, I2¼99.53%). The pooled
prevalence of depression and anxiety in Chinese females is presented as forest
plots in eFigure 3 and eFigure 4 respectively.
Subgroup analysis on stress was not performed due to insufficient data.

Discussion
Our shrinking world, where international travel is prominent, has been more
susceptible to quickly spreading viral epidemics, including the severe acute respi-
ratory syndrome (SARS-CoV), Middle-East respiratory syndrome (MERS-
CoV), Ebola35 and now this newly identified coronavirus (COVID-19), which
was declared a pandemic within the last few months. The rapid movement of a
virus across a region, not to mention the planet, has the potential to negatively
influence the economic, social, professional, and psychological well-being of
people.36 Both direct medical sequalae, and indirect effects, such as lockdowns,
isolation, stigma, and financial hardships are theorized to increase the likely
hood of developing mental health disorders and comorbidities. World-leading
experts have expressed concerns regarding the lack of high-quality data on the
psychological impact of the COVID-19 pandemic and demanded time-sensitive
efforts to fulfill the need.37 With this in mind, we have attempted to provide
timely systematic evidence on the psychological repercussions of the COVID-19
pandemic in Chinese population.
In this meta-analysis of 19 cross-sectional studies, the prevalence of depres-
sion and anxiety is moderately high (26.9% and 21.8% respectively) however the
prevalence of stress is very high (48.1%) within the population of China.
Overviewing the studies from different countries, the prevalence of depression,
anxiety and stress in India is 12.4%, 17.1% and 3.8% respectively. Whereas,
according to Chew NW. et al, 9% of people in Singapore are depressed, 14.4%
are anxious and 6.5% are stressed due to COVID-19 contagion.38 Considering
the mental health issues due to COVID-19, when compared to these other
countries, the levels seen in China were significantly higher. We recognize,
14 The International Journal of Psychiatry in Medicine 0(0)

this inference may be premature as the number of studies conducted in other

countries is few, and with China being the believed foci of the COVID-19 out-
break, it may take time to see its full impact on other parts of the globe.
Comparing the current pandemic situation with past epidemics (e.g. SARS,
MARS or Ebola) may help in better understanding the nature of stressors,
intensity of psychological burdens and coping strategies for prevailing mental
health issues. A study of SARS outbreak among unit nurses in Taiwan revealed
38.5% nurses were depressed, which was significantly higher than nurses in non-
SARS units (3.1%).39 Similarly, in our analysis, the pooled prevalence of
depression and anxiety in those personnel who were directly in contact with
or managing COVID-19 patients, was relatively high (31.5% and 23.7% respec-
tively) as compared to total estimated prevalence of depression and anxiety. In
addition, depression subgroup analysis in our study revealed 28.5% females
were depressed during the COVID-19 pandemic. In comparing our results
with the SARS outbreak in Hong Kong, a study conducted on 126 middle-
aged females during that period, consistencies are seen as they suggested
28.6% women felt depressed during SARS epidemic.40 Another notable obser-
vation after performing sensitivity analysis was that removal of study by Hai-
Xin Bo et al.26 decreased the pooled prevalence of stress by 8.7%. This partic-
ular research studied the prevalence of stress among COVID-19 infected
patients, and gives an impression that the type of population under investigation
can influence the pooled outcome.
We, as a global community can face serious consequences if timely measures
to manage mental health aren’t taken. Suicidality is one of the most fearsome
sequelae of untreated psychological illness and even early in the pandemic,
started to show itself. Thakur V and his associate have reported 7 cases of
COVID-related suicide from all over the globe, which is alarming.41
Therefore, it essential to adapt coping strategies as defined by World Health
Organization (WHO) to fight through this psychological burden.1
Since the studies included in this meta-analysis calculated only prevalence
(not incidence) of the psychological illnesses, it is important to overview the
metrics related to disease progression. In 2017, a China Global Burden
Disease (GBD) study estimated that 56.36 million people were depressed in
China, which accounted for 21.3% of the estimated global burden of the dis-
ease.42 Another factor considered while evaluating mental health in China is the
cultured behavior of Chinese individuals towards stressors. According to Parker
G. et al, when Chinese people are under stress, depression tends to be denied,
and is often shown somatically, which can lead to under-reporting.43 When
considering cultural factors and the early timeline of included studies, given
COVID has yet to fully remit at the time of our research, it is likely the numbers
reported here do not fully represent the true magnitude of COVID-19’s psycho-
logical impact on China. Our literature review clearly indicates mental health
concerns related to this outbreak has had an impact on mental health illness in
Bareeqa et al 15

the Chinese population which should not be ignored, and is in need of further
investigation.
A multidimensional approach is needed in future researches, which can study
the anticipated repercussions of Covid-19 pandemic (like suicide, violence
against health care workers, effect of isolation on elderly, damage to social,
political, economic and cultural structures).44–47 These are frustrating times
and people are channeling their stress and frustration through violence.
Recent medical literature suggests that health care workers in numerous coun-
tries (like Pakistan and Bangladesh) are facing physical and verbal assault by
Covid-19 patients and their families. Scientist needs to address this factor as well
since it can play a significant role disturbing baseline mental health of health
care workers.44,46
Our attempt to quantify the prevalence and extent of mental health concerns
present in the wake of the COVID-19 pandemic provides a starting point for
understanding the mental health impact of this disease and the governmental
response it created. The problem has been identified, and as the pandemic
unfolds further, ongoing investigation into this topic may assist in decreasing
the mental health fallout of emergencies such as these. We recognize limitations
in our analysis. Studies included in this meta-analysis are cross-sectional sur-
veys, therefore randomization was not done which can lead to highly heteroge-
neous results (due to different characteristics of people, different cut-offs of
measuring scales etc) when conducting pooled analysis. Secondly, it is not
known if the studied population had pre-existing mental health illness which
decompensated during the pandemic crisis.48 Most of the studies included in our
analysis did not measure baseline mental health status of surveyed participants.
Lastly, generalizing a data in which 15 out of 19 studies have included medical
staff within their studied population, can pose an error since the medical staff
working during the COVID-19 crisis are a high risk population themselves.

Conclusion
In conclusion, the prevalence of depression and anxiety is moderately high
whereas pooled prevalence of stress was found to be very high in Chinese
people during this Covid-19 crisis. Chronic surveillance is essential to keep
track of subtly rising mental health crises. Since the quality of related literature
to date is variable, future systematic studies like ours will be necessary to further
clarify the pandemic’s full impact, as well as provide a path to meaningful
interventions.

Author Contributions
SBB and SSS searched the data and screened the articles. SIA and SZ performed data
extraction whereas SIA and SBB conducted analysis on extracted data. SBB, SIA, SSS
and WY performed risk of bias assessment. SBB and SZ wrote the first draft with input
16 The International Journal of Psychiatry in Medicine 0(0)

from GMM and RVG. WY, SIA, SSS, GMM and RVG contributed to the design and
final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publi-
cation of this article.

ORCID iD
Syeda Beenish Bareeqa https://orcid.org/0000-0001-5579-4141

References
1. World Health Organization. Mental Health and Psychosocial Considerations
During the COVID-19 Outbreak. Geneva, Switzerland: World Health
Organization; 2020.
2. Calisher C, Carroll D, Colwell R, et al. Statement in support of the scientists, public
health professionals, and medical professionals of China combatting COVID-19.
Lancet 2020; 395: e42–e43.
3. Wang C, Pan R, Wan X, et al. Immediate psychological responses and associated
factors during the initial stage of the 2019 coronavirus disease (COVID-19)
epidemic among the general population in China. Int J Environ Res Public Health
2020; 17: 1729.
4. Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine
and how to reduce it: rapid review of the evidence. Lancet 2020; 395: 912–920.
5. Yanyu J, et al. Meditation-based interventions might be helpful for coping with the
Coronavirus disease 2019 (COVID-19), 2020.
6. Nguyen HC, Nguyen MH, Do BN, et al. People with suspected COVID-19 symp-
toms were more likely depressed and had lower health-related quality of life: the
potential benefit of health literacy. JCM 2020; 9: 965.
7. Moher D, Liberati A, Tetzlaff J, et al.; PRISMA Group. Preferred reporting items
for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med
2009; 151: 264–269.
8. Higgins JP and Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat
Med 2002; 21: 1539–1558.
9. Freeman MF and Tukey JW. Transformations related to the angular and the square
root. Ann Math Stat 1950; 21: 607–611.
10. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in
epidemiology: a proposal for reporting. JAMA 2000; 283: 2008–2012.
11. von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of obser-
vational studies in epidemiology (STROBE) statement: guidelines for reporting
observational studies. Lancet 2007; 370: 1453–1457.
Bareeqa et al 17

12. Sanderson S, Tatt ID and Higgins J. Tools for assessing quality and susceptibility to
bias in observational studies in epidemiology: a systematic review and annotated
bibliography. Int J Epidemiol 2007; 36: 666–676.
13. Fowkes F and Fulton P. Critical appraisal of published research: introductory guide-
lines. BMJ 1991; 302: 1136–1140.
14. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the
quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25:
603–605.
15. Guo J. Psychological effects of COVID-19 on hospital staff: a national cross-
sectional survey of China mainland. Available at SSRN 3550050, 2020.
16. Zhu Z, et al. COVID-19 in Wuhan: Immediate psychological impact on 5062 health
workers. medRxiv, 2020.
17. Cao W, Fang Z, Hou G, et al. The psychological impact of the COVID-19 epidemic
on college students in China. Psychiatry Res 2020; 287: 112934.
18. Gao J, Zheng P, Jia Y, et al. Mental health problems and social media exposure
during COVID-19 outbreak. PLoS One 2020; 15: e0231924.
19. Huang Y and Zhao N. Generalized anxiety disorder, depressive symptoms and sleep
quality during COVID-19 outbreak in China: a web-based cross-sectional survey.
Psychiatry Res 2020; 288: 112954.
20. Zhu J, et al. Prevalence and influencing factors of anxiety and depression symptoms in
the first-line medical staff fighting against the COVID-19 in Gansu. Available at SSRN
3550054, 2020.
21. Lu W, Wang H, Lin Y, et al. Psychological status of medical workforce during the
COVID-19 pandemic: a cross-sectional study. Psychiatry Res 2020; 288: 112936.
22. Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among
health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020; 3:
e203976–e203976.
23. Zhang J, Lu H, Zeng H, et al. The differential psychological distress of populations
affected by the COVID-19 pandemic. Brain Behav Immun 2020; 87: 49–50.
24. Chen Y, Zhou H, Zhou Y, et al. Prevalence of self-reported depression and anxiety
among pediatric medical staff members during the COVID-19 outbreak in Guiyang,
China. Psychiatry Res 2020; 288: 113005–113005.
25. Yin X, et al. The impact of the corona virus disease 2019 outbreak on Chinese residents’
mental health. Available at SSRN 3556680, 2020.
26. Bo H-X, et al. Posttraumatic stress symptoms and attitude toward crisis mental
health services among clinically stable patients with COVID-19 in China. Psychol
Med 2020; 1–7.
27. Zhang W-r, Wang K, Yin L, et al. Mental health and psychosocial problems of
medical health workers during the COVID-19 epidemic in China. Psychother
Psychosom 2020; 89: 242–249.
28. Liu Z, et al. Mental health status of doctors and nurses during COVID-19 epidemic in
China. Available at SSRN 3551329, 2020.
29. Dai Y, et al. Psychological impact of the coronavirus disease 2019 (COVID-19)
outbreak on healthcare workers in China. medRxiv, 2020.
30. Tan W, Hao F, McIntyre RS, et al. Is returning to work during the COVID-19
pandemic stressful? A study on immediate mental health status and
18 The International Journal of Psychiatry in Medicine 0(0)

psychoneuroimmunity prevention measures of Chinese workforce. Brain Behav

Immunity 2020; 87: 84–92.
31. Du J, Dong L, Wang T, et al. Psychological symptoms among frontline healthcare
workers during COVID-19 outbreak in Wuhan. Gen Hosp Psychiatry 2020;
32. Liu C-Y, et al. The prevalence and influencing factors for anxiety in medical workers
fighting COVID-19 in China: a cross-sectional survey. 2020; 148.
33. Zhang C, Yang L, Liu S, et al. Survey of insomnia and related social psychological
factors among medical staff involved in the 2019 novel coronavirus disease outbreak.
Front Psychiatry 2020; 11: 306.
34. Zhou M, et al. Knowledge, attitude and practice regarding COVID-19 among health
care workers in Henan, China. J Hosp Infect 2020; 105: 183–187.
35. Peeri NC, Shrestha N, Rahman MS, et al. The SARS, MERS and novel coronavirus
(COVID-19) epidemics, the newest and biggest global health threats: what lessons
have we learned? Int J Epidemiol 2020; 49: 717–726.
36. Pfefferbaum B and North CS. Mental health and the covid-19 pandemic. N Engl J
Med 2020; 383: 510–512.
37. Holmes EA, et al. Multidisciplinary research priorities for the COVID-19 pandemic:
a call for action for mental health science. Lancet Psychiatry, 2020; 7: 547–560.
38. Chew NWS, Lee GKH, Tan BYQ, et al. A multinational, multicentre study
on the psychological outcomes and associated physical symptoms amongst health-
care workers during COVID-19 outbreak. Brain Behav Immun 2020; 88: 559–565.
39. Su T, Lien T, Yang C, et al. Prevalence of psychiatric morbidity and
psychological adaptation of the nurses in a structured SARS caring unit during
outbreak: a prospective and periodic assessment study in Taiwan. J Psychiatr Res
2007; 41: 119–130.
40. Yu HYR, Ho SC, So KFE, et al. The psychological burden experienced by Hong
Kong midlife women during the SARS epidemic. Stress Health 2005; 21: 177–184.
41. Thakur V and Jain A. COVID 2019-suicides: a global psychological pandemic. Brain
Behav Immun 2020; 88: 952–953.
42. Ren X, Yu S, Dong W, et al. Burden of depression in China, 1990–2017: findings
from the global burden of disease study 2017. J Affect Disord 2020; 268: 95–101.
43. Parker G, Gladstone G and Chee KT. Depression in the planet’s largest ethnic
group: the Chinese. Am J Psychiatry 2001; 158: 857–864.
44. Devi S. COVID-19 exacerbates violence against health workers. Lancet 2020;
396: 658.
45. Shuja KH, et al. Letter to highlight the effects of isolation on elderly during COVID-
19 outbreak. Int J Geriatr Psychiatry 2020.
46. McKay D, Heisler M, Mishori R, et al. Attacks against health-care personnel must
stop, especially as the world fights COVID-19. Lancet 2020; 395: 1743–1745.
47. Yoosefi Lebni J, et al. How the COVID-19 pandemic effected economic, social,
political, and cultural factors: a lesson from Iran. Int J Soc Psychiatry 2020;
0020764020939984.
48. Chatterjee SS, Malathesh BC and Mukherjee A. Impact of COVID-19 pandemic on
pre-existing mental health problems. Asian J Psychiatr 2020; 51: 102071.