Today marks the first day of Phase 4 of the Movement Control Order (MCO), which was first implemented by the Malaysian government on 18 March 2020. The mental health fallout from not being able to leave home (except for essential needs) or enjoy recreational activities outside of one’s residence has begun to show. Since the MCO began, Mercy Malaysia / Ministry of Health’s Psychological First Aid hotline  has received thousands of messages and calls. Support groups like Befrienders have also seen a sharp increase in calls, with two-thirds of them being MCO-related.

Mental well-being has a significant impact on the economy: a recent study by RELATE showed that in 2018, mental health issues among employees were estimated to cost RM14bn, or 1% of GDP. Given this and increased mental well-being concerns surrounding the MCO, The Centre conducted a study to investigate how MCO-related drastic changes, enforced in times of a health crisis, impacted the mental well-being of Malaysians. We focus on living conditions – reported in this article – and financial well-being (to be published in Part 2).

About the Study

The study was conducted via an online survey which was distributed using a snowball sampling method between 5 April to 10 April 2020. With the help of a consultant psychiatrist, the DASS-21 questionnaire was chosen to measure mental well-being.

The DASS-21 questionnaire is used to measure the emotional states of depression, anxiety and stress. It is important to note that the questionnaire does not diagnose depression, anxiety or stress as a medical condition.

The DASS-21 questionnaire measures an individual’s emotional well-being over three different areas: depression, anxiety and stress. For depression, it looks at general dissatisfaction, hopelessness, and lack of interest. For anxiety, it looks at situational physical reactions, and the general anxiety experience. For stress, it assesses difficulty relaxing, agitation, impatience and over-reactiveness.

While the DASS-21 evaluations can be used by non-psychologists for research such as this study, clinical decisions made on the scores can only be made by experienced clinicians alongside extensive clinical examination.

By using the questionnaire, we are able to look at mental well-being based on the individuals’ self-assessment of their mental state, rather than extrapolating an individual’s mental well-being using external proxies. The scores from the DASS-21 questionnaire responses for each emotional state can be classified into various levels of severity ranging from normal, mild, moderate, severe to extremely severe (see Table 1).

Table 1: DASS-21 Scale

We collected 1103 responses, of which 19 were rejected due to duplication and irregular responses, leaving us with a sample of 1084. As with most surveys, under or over reporting can occur. These have been reviewed and outliers were identified and omitted where necessary.

Given that a snowball sampling method was used, our responses do not represent a nationally stratified sample. 57% of our respondents identified as living in urban areas, with 76% coming from Selangor and Kuala Lumpur. 66% of the respondents were female, 81% were Malay/Bumiputera and 42% were between the age of 25-34. We advise readers to interpret the results with these limitations in mind.

This study is divided into two parts. This article, Part 1, covers mental well-being and living conditions. Part 2, which will be published next week, will cover financial concerns during the MCO and how it relates to mental well-being.

Mental Well-Being during the MCO

IMPORTANT NOTE: As previously emphasised, this study is not diagnostic – we are not diagnosing respondents with depression, anxiety or stress as a medical condition. The responses of the DASS-21 questionnaire measures the intensity of general feelings of depression, anxiety or stress as reported by the respondents. Any diagnosis of mental health or mental illness needs to be done by a qualified professional.

Figure 1 summarises our findings on mental well-being. Our survey revealed that Malaysians are reporting high levels of negative emotions during the MCO. 48% and 45% of respondents self-reported experiencing varying levels of anxiety and depression, with 34% reporting varying levels of stress. Of these, 22% of respondents self-reported severe and extremely severe anxiety, with 20% and 15% experiencing similarly alarming levels of depression and stress.

Unfortunately, we were unable to locate national level ‘normal time’ baseline proportions to compare these proportions to. However, the absence of the baseline does not invalidate the seriousness of the extent to which Malaysians are experiencing negative emotions during the MCO.

Figure 1: Under a half experiencing negative emotions

Demographic Differences

Gender

Figures 2a-2c show the gender differences in reported levels of depression, anxiety and stress. Women reported experiencing significantly more negative emotions compared to men. The difference between women and men is more observable for stress and anxiety, where 38% and 48% of women respectively reported experiencing these two negative emotions, compared to 25% and 38% respectively for men.

Notably, a higher proportion of women in the sample exhibited severe or extremely severe signs of depression, anxiety and stress (21%, 26% and 18% respectively) compared to men (14%, 15% and 10% respectively).

Figure 2a: Differences in Reported Depression Levels by Gender

Figure 2b: Differences in Reported Anxiety Levels by Gender

Figure 2c: Differences in Reported Stress Levels by Gender

Age

In Figures 3a-3c, we observed that over 60% of those aged 18-24 and 25-34 reported signs of depression, and approximately 50% of the same age groups reported signs of anxiety and stress. In comparison, only between 14% to 39% of the older age groups (35-44, 45-54 and 55 and above) reported similar signs.

In terms of levels of severity, respondents from the 18-24 and 25-34 age groups reported up to two to three times more signs of severe and extremely severe negative emotions compared to those aged 55 and above. 19 – 25% of the younger respondents reported severe and extremely severe stress, and approximately 33% reported the same level of anxiety and depression.

Figure 3a: Differences in Reported Depression Levels by Age Group

Figure 3b: Differences in Reported Anxiety Levels by Age Group

Figure 3c: Differences in Reported Stress Levels by Age Group

Living conditions, the MCO and mental well-being

We asked our respondents a number of questions about where they lived, who they were staying with and their access to personal space during the MCO, and we linked this to their levels of depression, anxiety and stress as measured by the DASS-21 scale.

With respect to areas where they lived, 57% of the respondents reported residing in urban surroundings, with the remainder (43%) staying in suburban and rural areas. In terms of housing, 48% reported living in terraced houses, followed by 22% residing in condominiums and apartments (Figure 4). 3% of respondents stated that they lived in low-cost housing.

For the analysis of living conditions, we excluded hostels from our analysis. Outliers and irregular responses were also omitted.

Figure 4: Housing types in developed environments

Do different types of housing affect mental well-being?

Figures 5a – 5c summarise how different types of housing affect mental well-being. Levels of reported depression seem to afflict all residential types in equal measure except for those living in bungalows and semi-detached housing.

When it comes to reported anxiety and stress, however, the variability between different housing types is more apparent – for example: those in low-cost housing and apartment/condominiums were experiencing slightly higher levels of compared to those who live elsewhere.

Overall, residents of low cost housing units experience higher levels of depression, anxiety and stress compared to those living in other types of housing. In particular, they reported more extreme signs of depression, anxiety and stress, with 25-32% classified as severe and extremely severe.

Figure 5a: Residential type and depression

Figure 5b: Residential type and anxiety

Figure 5c: Residential type and stress

Crowding and mental well-being

As well as the type of housing, we also explored how crowding affected mental well-being. We asked respondents about the number of rooms they had in their homes and the number of people sharing their residence during the MCO. (Respondents were also asked about the square footage of their residential unit, but less than 40% were able to provide an approximate size).

On average, respondents reported living with 3 other persons during the MCO (total number of residents per unit: 4). The average residential unit, meanwhile, typically had 3 bedrooms, 1 bathroom, 1 kitchen, and 1 living room.

We created a proxy score for crowding by calculating the ratio of persons to bedrooms. This ratio was then grouped into three: low, medium and high, in reference to the increasing numbers of persons per bedroom.

NOTE: This measure is more of an indicative or proxy measure of crowding, and does not take into account the interpersonal relationships of the people living in a particular unit of residence, which would also impact mental well-being.

Figure 6a shows that while those living in medium crowding households exhibit comparable levels of depression to those in low and high crowding households, the severity of negative emotions reported in households with high crowding are much higher (28%) than that reported by respondents in households with low crowding (19%). 

A similar pattern can be observed for anxiety levels (Figure 6b): more respondents living in medium crowding households report experiencing anxiety, but those reporting more severe signs are from households with high crowding. 

For stress (Figure 6c), respondents from households with high crowding report just slightly higher levels of stress (37%) compared to households with low (33%) and medium (36%) crowding, although the reported levels of severe and extremely severe stress are higher – 19% for high crowding compared to 14% and 16% for low and medium crowding respectively.

Figure 6a: Crowding score and depression

Figure 6b: Crowding score and anxiety

Figure 6c: Crowding and stress

An interesting subgroup of those living in households with low crowding are single occupants. These are individuals who are spending the MCO in isolation as they are living alone. To understand more about their situation, we cross-tabulated the level of household occupancy and mental well-being.

Figures 7a-7c show levels of depression, anxiety and stress experienced categorised by household occupancy. Respondents were divided into those who were in single occupancy households, multiple occupancy households or intergenerational households. (For our purposes, intergenerational households are defined as multiple occupancy households with intergenerational family members, i.e. grandparents, parents and children).

The level of negative emotions experienced by single occupants are much higher compared to those who live with other people. 54% of residents living in single occupancy households report signs of depression, followed by 50% and 37% reporting signs of anxiety and stress respectively. It is therefore not surprising that single occupancy households also report high levels of severe and extremely severe negative emotions.

Respondents from intergenerational households reported experiencing slightly lower levels of severe and extremely severe depression, (Figure 7a) while the levels of severe and extremely severe anxiety (Figure 7b), is comparable across all three groups. However, the level of severe and extremely severe stress (Figure 7c) reported by those in intergenerational households is comparable to single occupancy households.

Figure 7a: Household Occupancy and Depression

Figure 7b: Household Occupancy and Anxiety

Figure 7c: Household Occupancy and Stress

Personal space and satisfaction with living arrangements

We also asked respondents two questions with regards to their current living conditions: 1) did they have access to their own personal or private space, and 2) were they satisfied with their current living conditions.

78% of respondents indicated that they had their own personal/private space and 82% reported being satisfied with their current living arrangements during the MCO.

From Figures 8a-8c, we observed that those with no access to a private/personal space reported higher levels of depression, anxiety and stress. Unsurprisingly, a similar pattern can also be seen among those who were unsatisfied with their current living arrangements.

Comparing the two, however, a higher proportion of those who were unsatisfied with their living arrangements reported experiencing depression (76%), anxiety (70%) and stress (63%) compared to those who did not have access to personal space (56%, 51% and 42% respectively).

Figure 8a: Current living conditions and depression

Figure 8b: Current living conditions and anxiety

Figure 8c: Current living conditions and stress

What are People Worried About?

Worried about loved ones, over themselves

As part of the survey, we also asked Malaysians what they were worried about in particular surrounding the MCO. The list of concerns is not exhaustive, as this was not the main remit of our study, but nonetheless revealed an interesting insight: during the MCO, respondents by far were more worried about their loved ones compared to themselves. 62% reported feeling worried about their own health, compared to 81% reporting feeling worried about the health of their loved ones. Similarly, 61% reported being worried about their safety, compared to 76% feeling worried about the safety of their loved ones.

Another interesting observation was that respondents were more worried about their personal finances after MCO (56%) compared to during the MCO (47%), showing an awareness that the economic fallout of the MCO may well last beyond the restrictions themselves. (A more detailed discussion about the financial impact of the MCO will be published in Part 2).

Figure 9: Major concerns during COVID-19 Movement Control Order (MCO)

Policy Considerations

The study has revealed troubling yet not unexpected findings: a little under half of our respondents were experiencing some form of negative emotional states. 22% reported experiencing severe and extremely severe anxiety, with 20% and 15% experiencing similarly alarming levels of depression and stress. (In the absence of a baseline to refer to, however, we are unable to compare these with levels outside a time of crisis).

It is important to note that the mental health issues we are facing did not just emerge over the MCO period, or were specifically caused by Covid-19. However, the MCO has shone a spotlight on the severity of the problem and the urgency with which action needs to be taken. The ‘new normal’, as the post-Covid19 world is popularly referred to, offers an opportunity to make the necessary changes and adjustments. 

The importance of mental health to the country and the economy means we need to prioritise improving and developing mental health services and support. Latest numbers estimate there to be about 700 psychologists and 400 psychiatrists in Malaysia. In a country with an estimated 32 million population, there is a clear need to not just increase the number of qualified mental health professionals, but also trained counsellors and volunteers so that access to mental health can be widened to all levels of society and within communities. As our study has shown, depression, anxiety and stress are reported by respondents living in low-cost housing as well as those in bungalows.

Efforts to de-stigmatise mental health also needs to be ramped up. This would include initiatives such as increasing mental well-being literacy in education and improving awareness of mental health in the workplace.

Furthermore, the MCO has exposed the real nature of inequality, starting with our homes. Moving forward, policies should give consideration of mental well-being when designing and developing living spaces, especially for the most vulnerable of society who live in low-cost housing. While affordable housing has been a key issue in recent years, providing them should not be at the cost of sacrificing livable conditions. This is important in minimising the socioeconomic gap.

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In Part 2 of our study which focuses on how the MCO has upended the financial situations of many, we discuss aspects of mental well-being related to the economic and financial concerns of our respondents.

If you are experiencing emotional distress or mental health difficulties a result of the Movement Control Order (MCO), you can seek support via these hotlines: Mercy Malaysia and the Ministry of Health Crisis Preparedness and Response Centre’s psychosocial support hotline at 03-29359935; and Ministry of Women and Family Development’s Talian Kasih hotline at 15999 or WhatsApp 019-2615999.