Public Health of Indonesia
E-ISSN: 2477-1570 | P-ISSN: 2528-1542
Original Research Association between depression, anxiety, and stress with sleep quality in Indonesian people during the COVID-19 pandemic Teresa Mika Argo1.
Andree Kurniawan2* .
Jean Andrina Liem1.
Jeremy Octavian Sugianto1.
Rafael Jonathan Michael1.
Lisa Agatha1.
Nathania Victoria Stevina Tanuwijaya 3.
Beverley Wonsono4, and Dwi Savitri Rivami4 1Pelita Harapan University College.
Tangerang.
Banten.
Indonesia 2Internal Medicine Department.
Faculty of Medicine.
Pelita Harapan University.
Tangerang.
Banten.
Indonesia 3Udayana University.
Kampus Bukit.
Jimbaran.
Kuta Selatan.
Badung.
Bali.
Indonesia 4Faculty of Medicine.
Pelita Harapan University.
Tangerang.
Banten.
Indonesia Doi: https://dx.
org/10.
36685/phi.
Received: 20 March 2021 | Revised: 25 April 2021 | Accepted: 17 May 2021 Corresponding author:
Andree Kurniawan.
Sp.
Internal Medicine Department.
Faculty of Medicine.
Pelita Harapan University Boulevard Jendral Sudirman.
Karawaci.
Tangerang.
Banten 15811.
Indonesia Phone number: 625421030 Email: andree.
kurniawan@uph.
Copyright: A 2021 the author.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium provided the original work is properly cited.
Abstract Background: To prevent the spread of COVID-19, authorities implemented health protocols such as quarantine, large-scale social restrictions, and lockdowns.
Data on the psychological effects and sleep quality as a result of these health protocols are still limited.
Objective: This study was aimed to determine the association between depression, anxiety, and stress with sleep quality during the COVID-19 pandemic in Indonesia.
Methods: An online survey was used to do a cross-sectional study among students in Indonesia.
Sociodemographic information, including age, gender, religion, level of education, and regions, was analyzed.
Levels of depression, anxiety, and stress were measured using the DASS-21 questionnaire.
Sleep quality was determined using Pittsburgh Sleeping Quality Index (PSQI) questionnaire.
Chi-square was used to evaluate the variables for bivariate analysis and logistic regression for multivariate analysis.
Results: A total of 913 participants from across Indonesia included to this study.
Adolescent (OR=0.
367, 95%
CI=0.
, female (OR=1.
437, 95% CI=1.
, and high school students (OR= 0.
737, 95%
CI=0.
had a higher risk for having poor sleep quality.
In the multivariate analysis there were significant relationship between sleep quality with depression (Adjusted OR= 1.
887, 95% CI=1.
anxiety (Adjusted OR=1.
731, 95% CI=1.
, stress (Adjusted OR= 2.
577, 95% CI=1.
, use of sleeping medication (Adjusted OR=9.
070, 95% CI=2.
and age (Adjusted OR= 0.
414, 95% CI=
Conclusion: There was an association between depression, anxiety, stress, consumption of sleeping medication, age, and poor sleep quality during the pandemic in Indonesia.
Keywords: COVID-19.
sleep quality.
Indonesia Volume 7.
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April - June 2021 Introduction Methods Corona Virus Disease (COVID-.
is an illness that affects the respiratory system.
It will react severely to people with comorbidities, such as cardiovascular diseases, diabetes, chronic respiratory diseases (Jamie, 2020.
World Health Organization, 2020.
COVID-19 has two modes of transmission, direct and indirect.
The direct transmission includes droplets, aerosols, and body fluid which has the probability of transmitting within one-meter distance with an infected person.
Indirect transmission covers surfaces like furniture with immediate contact with an infected person or other objects used by the infected person (Karia.
Gupta.
Khandait.
Yadav, & Yadav, 2.
On March 11, 2020.
WHO has declared COVID-19 as a pandemic (Tosepu.
Effendy, & Ahmad, 2020.
World Health Organization, 2020.
Since then, 1.
528 cases have been confirmed in Indonesia (Setiati & Azwar, 2.
The Indonesian government did not take long to decide Indonesia needs to implement quarantine.
On March 13, 2020, all social activities such as school and work were instructed to be done at home, and any event with a significant number of participants was postponed (Mien.
Ananda.
Indriastuti, & Tahiruddin, 2021.
World Health Organization, 2020.
IndonesiaAos president.
Joko Widodo, also chose to implement large-scale social restrictions (PSBB) that are more flexible to prevent the disruption of the economy in several regions (Apresian, 2.
Study Design This study used a cross-sectional design.
Study Participants and Sampling This study was conducted on February 4-6, 2021.
through Instagram.
WhatsApp groups.
Line groups, and other social media platforms.
Instruments Demographic information The survey included sociodemographic data such as age, gender, religion, level of education, and residential regions.
Age was categorized into adolescence .
-24 years ol.
and adult (> 25 years The level of education was categorized into high school/diploma and respondents with a higher Residential regions were divided into Java and non-Java areas.
DASS-21
Levels of depression, anxiety, and stress were measured using the DASS-21 questionnaire.
There are five scales for each category, ranging from normal .
ot having any depression, anxiety, and stress symptom.
, mild, moderate, severe, and extremely severe.
This questionnaire measured the conditions of respondents over the past week (Psychology Foundation of Australia, 2.
analysis, the classification of depression, anxiety, and stress were grouped into two: having depression, anxiety, stress, or not.
A study examining the psychometric properties and generalizability of DASS-21 across cultures, including Indonesia, has shown that out of 18 items in DASS-21, the acceptable CronbachAos alpha value 91 with value for DASS-depression = 0.
DASS-anxiety = 0.
81 and DASS-stress = 0.
70 (Oei.
Sawang.
Goh, & Mukhtar, 2.
Another study provides evidence that the Indonesian version of DASS-21 is internally consistent and has predictive value (Onie.
Kirana.
Mustika.
Adesla, & Ibrahim.
Some studies found that quarantine and pandemics are causing an increased prevalence of psychological conditions such as depression, stress, and anxiety (Duran & Erkin, 2.
The increase of psychological turbulence is caused by being in a space for an extended period as an obligatory act, losing freedom, worrying about uncertainty, or being apart from loved ones (Javed.
Sarwer.
Soto, & Mashwani, 2.
On the other hand, another study found that there might be a correlation between psychological situations with sleep quality (Duran & Erkin, 2.
This study aimed to determine the association between depression, anxiety, and stress with sleep
quality in Indonesian people during the COVID-19
PSQI
Pittsburgh sleep quality index (PSQI) is a self-rated questionnaire that measures sleep quality over the past month.
The PSQI contains seven components that measured sleeping quality, such as sleep duration, sleep disturbance, sleep latency, sleep Volume 7.
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April - June 2021 efficiency, daytime dysfunction, subjective sleep quality, and the use of sleeping medication.
These components will give a global PSQI score, ranging from 0 to 21, that determines sleep quality.
The higher the score, the worse the quality (Zhong.
Gelaye.
Synchez, & Williams, 2.
In the analysis, sleep quality was classified into good and poor sleep The PSQI-Indonesian Version (PSQI-I) has CronbachAos alpha value of 0.
72 and ranges from 69 to 0.
72 for each item.
This study revealed that PSQI-I has adequate reliability and validity (Setyowati & Chung, 2.
Significant value was determined as a p-value less than <0.
Ethical Consideration The Ethics Committee of the Faculty of Medicine.
Pelita Harapan University, has approved the protocol for this study.
An approval letter has been issued with the number 082/K-LJK/ETIK/II/2021.
Results A total of 913 people from across Indonesia contributed to this study.
Most of the respondents are high school students .
5%) living in Java island .
9%).
There are 60.
9% females, with an average age of 18.
70 years old.
Table 1 shows the sociodemographic characteristics of respondents.
Data Analysis data were showed descriptively.
The variables were analyzed using chi-square for bivariate analysis and binary logistic regression for multivariate analysis.
Table 1 Sociodemographic characteristics of participants Percentage (%) Frequency .
Male Female High School University Islam Christian Catholic Buddha Hindu Kong Hu Cu Others Java Island Non-Java Island Age .
Gender Education Religion Region *Mean There are 43.
5% of participants depressed, 43.
are anxious, and 25.
2% are stressed during the Table 2 shows the distribution of DASS21 results among 913 respondents.
Table 2 Severity of depression, anxiety, and stress in adolescents during the pandemic Severity of Depression Frequency .
Normal .
Mild .
Moderate .
Severe .
Extremely Severe (Ou.
Volume 7.
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April - June 2021 Percentage (%) Table 2 (Cont.
Severity of Anxiety Frequency .
Frequency .
Normal .
Mild .
Moderate .
Severe .
Extremely Severe (Ou.
Severity of Stress Normal .
Mild .
Moderate .
Severe .
Extremely Severe (Ou.
More than half of respondents .
5%) have poor sleep quality during this pandemic.
Table 3 shows Percentage (%) Percentage (%) the PSQI components results and the global Table 3 Components of Pittsburgh Sleep Quality Index Variable Score Subjective Sleep Quality Very Good .
Fairly Good .
Fairly Bad .
Very Bad .
>7 Hours .
6-7 Hours .
5-6 Hours .
<5 Hours .
>85% .
75% - 84% .
65% - 74% .
<65% .
Not During the Past Month .
Less Than Once A Week .
Once or Twice A Week .
Three or More Times A Week .
Good Sleep Quality .
Poor Sleep Quality (>.
Sleep Latency Sleep Duration Sleep Efficiency Sleep Disturbance Use of Sleeping Medication Daytime Dysfunction Global PSQI Score There was a significant relationship between sleep quality and the respondent's sociodemographic such as age .
=0.
, gender .
=0.
, and education level .
=0.
Other variables such as depression, anxiety, stress, and medication also have a very significant relationship with sleep quality .
<0.
Adolescent (OR=0.
367, 95% CI=0.
Frequency .
Percentage (%) female (OR=1.
437, 95% CI=1.
, and high school students (OR= 0.
737, 95% CI=0.
have a higher risk for having poor sleep quality.
While respondents with depression are four times odds more likely to have poor sleep quality (OR=4.
092, 95% CI=3.
, people with anxiety are 3.
7 times odds more likely to have poor Volume 7.
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April - June 2021 sleep quality (OR= 3.
776, 95% CI=2.
, and people with stress are 5.
6 times odds more likely to have poor sleep quality.
The use of sleeping medication also increases the risk of having poor sleep quality by 14 times the odds than those who did not use it.
Table 4 showed the results of the full bivariate analysis.
Table 4 Bivariate analysis between sociodemographic characters of participants, depression, anxiety, stress, and sleep Variable Sleep Quality Total Good Poor .
Male Female 158 .
High School University 261 .
Age (Year.
Gender Education Region Java Island Outside Java Island 250 .
Yes 283 .
Yes 280 .
Yes 34 .
Using of Sleeping Medication 361 .
Yes 2 .
Depression Anxiety Stress Multivariate analysis using logistic regression results are shown in Table 5 Ae Table 8.
A p-value of more 05 was removed in every variable in each table with different models.
In Table 5, depression.
OR (CI 95%) p-value 367 .
<0.
<0.
<0.
<0.
anxiety, stress, use of sleeping medication have a pvalue <0.
05, while age, education, province, and gender have a p-value >0.
Table 5 Multivariate analysis between sociodemographic characters of participants, depression, anxiety, stress and sleep quality.
Model I Risk Factors Depression Anxiety Stress Use of Sleeping Medication Age Education Province Gender <0.
<0.
Adjusted OR Volume 7.
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April - June 2021
Lower
95% CI
Upper In the final model presented in Table 8 showed that there were significant relationships between sleep quality with depression (Adjusted OR= 1.
887, 95%
CI=1.
, anxiety (Adjusted OR=1.
731, 95%
CI=1.
, stress (Adjusted OR= 2.
577, 95%
CI=1.
, use of sleeping medication (Adjusted OR=9.
070, 95% CI=2.
and age (Adjusted OR= 0.
414, 95% CI= 0.
The R 2 value was 0.
210, which explains 21% of the variance in sleep quality explained by variables such as depression, anxiety, stress, consumption of sleeping medication, and age.
Table 6 Multivariate analysis between sociodemographic characters of participants, depression, anxiety, stress and sleep quality.
Model II Risk Factors Depression Anxiety Stress Use of Sleeping Medication Age Province Gender Adjusted OR <0.
<0.
95% CI
Lower Upper Table 7 Multivariate analysis between sociodemographic characters of participants, depression, anxiety, stress, and sleep quality.
Model i Risk Factors Adjusted OR 95% CI Lower Upper Depression <0.
Anxiety Stress <0.
Use of Sleeping Medication Age Gender Table 8 Multivariate analysis between sociodemographic characters of participants, depression, anxiety, stress, and sleep quality.
Model IV Risk Factors Adjusted OR 95% CI Lower Upper Depression <0.
Anxiety Stress <0.
Use of Sleeping Medication Age supports this result by saying.
AuThose who have high levels of stress, anxiety, and depression had a higher probability of having sleep problems.
Ay (Franceschini et al.
, 2.
COVID-19 pandemic restricts interaction and requires people to stay at home that can cause negative emotions such as fear, loneliness, and uneasiness.
Another factor that might be relevant to those psychological conditions is associated with quarantine and COVID-19 itself.
Discussion To our knowledge, this is the first study in 2021 to assess the association between depression, anxiety, and stress during the COVID-19 pandemics with quality of sleep in Indonesian people.
In this study, it was shown that depression, anxiety, and stress were associated with sleeping quality.
A study from Italy Volume 7.
Issue 2.
April - June 2021 such as the uncertain duration people must endure, the fear of getting infected or even spread the virus, feelings of boredom, stress, the inability to do regular activities, and so much more (Brooks et al.
, 2.
taking behaviors, and maybe contributing to It also affects peopleAos health in a longterm consequence.
Several examples that may occur to people with sleep disruption are the increased risk of having cardiovascular disease, hypertension, diabetes, weight-related issues, cancer, and if its severity has gone to the peak, sleep disruption could increase mortality rate in men (Medic.
Wille, & Hemels, 2.
Another study from Indonesia that analyses medical students also discovered how anxiety and sleep disruption are closely correlated, which increases the prevalence of irritable bowel syndrome (Fernanda & Kurniawan.
While psychological conditions affect sleeping quality, other sociodemographic factors such as age, gender, and education also take part in sleeping Another significant thing to point out is the consumption of sleeping medications or sleeping pills during the pandemics.
This study found that age 15-24 years were at more risk of having poor sleep quality.
But many international studies declared more varieties in the result that is also related to education or work status.
For instance, one study from Italy found that the lockdown has a considerable impact on students than workers (Marelli et al.
, 2.
However, a study in Spain proved how poor sleep quality increases gradually with age and may be related to menopause (Madrid-Valero.
Martynez-Selva.
Couto.
SynchezRomera, & Ordoyana, 2.
With gender, females and women suffered the most in the pandemic, conforming to a study in Canada.
This result correlates with the data shown.
This also could associate with the understanding of COVID-19 (Adella Halim et al.
, 2.
Having a role as a caregiver gives women a lot more to worry about and responsibilities to reconsider dwelling on their familyAos health, including the risk of exposure to COVID-19 (Guadagni.
Umilta, & Iaria, 2.
After knowing what poor sleep quality may do to health, we can conclude how having satisfactory sleep quality would mean having a lower risk of getting diseases in the long run.
For students, longer sleep duration and better sleep quality may affect class performance and academic category (Okano.
Kaczmarzyk.
Dave.
Gabrieli, & Grossman, 2.
Having good sleeping quality, in general, enables us to think, be more alert, vigilant, reducing stress, and also improve our mood (U.
Department of Health and Human Service, 2.
Being at home constantly, unable to meet friends or relatives like how we were used to, always being aware of personal hygiene, and consistently updating concerning COVID-19 numbers going up or down every day sure put a toll on our mental health.
Having to know ways to cope and keep track of our feelings becomes more necessary than ever.
Some healthy ways to cope and manage your emotions during this pandemic include having a personal break from the news related to COVID-19 and screen time in general.
Doing exercises, eating healthy, getting enough sleep, connect with others, or through a community may also help vent out all concerns and worries (Center for Disease Control and Prevention, 2.
Another crucial point to this study is the consumption of sleeping medications during the pandemic.
This study has shown that using sleeping medication also affects sleeping quality.
A study from Spain stated how consumption of sleeping medications resulted in a greater prevalence of sleep problems (MadridValero et al.
, 2.
Another international study also acknowledged this matter (Mandelkorn et al.
, 2.
Interestingly, both studies showed how consumption of sleeping medications is also associated with gender, females in particular.
Additionally, trying to remind ourselves of how this pandemic is temporary, trying to change perspectives, and understanding the current situation might also help relieve stress bit by bit.
Most importantly, having to seek help when necessary, sticking to treatment plans, and taking medications as told are points to be considered and noticed (Michigan Medicine Department of Psychiatry, 2.
With all this information aside, as evident as it might sound, having a good sleep quality is overriding.
Sleep disruption affects children, adolescents, and adults in short-term health consequences or psychological issues such as having a weekly headache, pain, emotional distress, performance deficits, mood disorder, poor mental health, risk- Volume 7.
Issue 2.
April - June 2021 Beverly Wonsono.
A is an Administration Director at the Faculty of Medicine.
Pelita Harapan University.
Tangerang.
Banten.
Indonesia.
Dwi Savitri Rivami.
Sc.
Ph.
D is a Medical Doctor and a Lecturer at the Faculty of Medicine.
Pelita Harapan University.
Tangerang.
Banten.
Indonesia.
Despite having to obtain data, this study had All data and results are from a crosectional method that does not have any further cause-and-effect explanations regarding the data and variables present in this research.
This study uses questionnaires distributed online and is a part of a self-report questionnaire that may not be valid because of its subjectivity.
Other factors associated with sleeping quality are still limited because this study only discusses the correlations of depression, anxiety, and stress with sleep quality.
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The International Journal of Conclusion We can conclude that depression, anxiety, stress, age, and consumption of sleeping medication were associated with sleep quality in Indonesian people during the pandemic.
Declaration of Conflicting Interest The authors declare that there is no conflict of interest, direct or indirect, in any matter regarding this study.
Funding The study did not get funding support from an external source, and there is no funding in this article.
Acknowledgment