Introduction

The unexpected outbreak of the 2019 coronavirus disease (COVID-19) has considerably increased worldwide mortality and morbidity (WHO, 2019). Healthcare systems and economies have been striving to manage COVID-19-related challenges. Most countries have imposed measures that have included quarantines, spatial distancing, stay-at-home orders, lockdowns, and border closures to limit the spread of this novel pathogen (Chaudhry et al., 2020; Tabari et al., 2020). While healthcare providers and public health specialists have focused on containing the virus’ spread, the COVID-19 pandemic and associated restrictive measures have taken a significant toll on individuals’ mental health and well-being (Bueno-Notivol et al., 2021; Deng et al., 2021; Hossain et al., 2020b; Salari et al., 2020).

The COVID-19 illness and pandemic have been associated with neuropsychiatric symptoms including delirium, anxiety, depression, insomnia, and suicidality (Troyer et al., 2020). Multiple studies focusing on mental health during lockdown revealed that when people become limited to a certain setting, their mental health often suffered (Amerio et al., 2020; Rossi et al., 2020; Singh et al., 2020; Webb, 2021). Quarantines have previously been linked to mental health issues, notably anxiety, depression, panic, irritability, somatic disorders, and insomnia (Hossain et al., 2020a). Fear and uncertainty about the disease, particularly perceived vulnerability, treatment, and control measures, exposure to misinformation in the media concerning COVID-19, social isolation and loneliness, and economic challenges have all contributed to mental health problems (Hossain et al., 2020a; Tasnim et al., 2020). Previous research suggests that emergency health crises have had deleterious influences on people’s mental health (Chong et al., 2004; Wu et al., 2009; Yip et al., 2010). For instance, during the Severe Acute Respiratory Syndrome (SARS) and Ebola outbreaks, there were upsurges in depression, anxiety, panic attacks, and suicidal behaviors (Chew et al., 2020). Certain groups may be particularly vulnerable. For example, elderly people and migrant workers may lack economic flexibility and be vulnerable to medical concerns, potentially increasing health risks related to the pandemic and their social impact. People with pre-existing mental disorders may be at higher risk of health concerns including infections due to lack of supervision and inadequate adherence to preventive measures (Hao et al., 2020b). To date, most research has been conducted via online surveys that have employed non-specific methods to measure overall mental well-being.

Due to dense populations and limited resources, develo** countries, particularly those in South Asia, had already been working to address high mortality and morbidity rates, and such efforts often needed to be increased during the COVID-19 pandemic (Bhutta et al., 2020). During the onset of the pandemic, mental health services were often reduced, despite an increased demand for psychiatric treatment (Galea et al., 2020; Roy et al., 2021). During the pandemic, it has been challenging to systematically identify people with mental disorders who have been affected by the outbreak, especially in countries with limited resources (Kar et al., 2020; Rahman et al., 2020). Limited mental health care was (and often continues to be) available in develo** countries during the pandemic. According to the World Health Organization (WHO), 80% of industrialized countries have been providing mental health care through telemedicine and teletherapy, whereas less than half of underdeveloped countries have been doing so during the early stages of the pandemic (WHO, 2020). During the COVID-19 pandemic, a study was conducted in Bangladesh to evaluate the prevalence of psychological issues such as perceived stress, anxiety, and depression among Bangladeshi citizens and found that a wide variety of participants had various levels of depression, anxiety, and stress (Ahmed et al., 2022). According to a recent meta-analysis, the worldwide prevalence of stress remained at 29.6%, anxiety at 31.9%, and depression at 33.7% (Salari et al., 2020). Suicidal behaviors, daily activities in home quarantine, and failure to take COVID-19 preventive measures have been correlated with depression (Islam et al., 2021), whereas higher levels of insomnia have been linked to generalized anxiety (Lahiri et al., 2021). The South Asian Association for Regional Cooperation (SAARC) countries account for 23.7% of the global population, with a large part of this group being under the age of 35 years old; i.e., the working class and hence an economically productive population. In comparison to other Asian and Western countries, South Asian countries (including the SAARC countries) have greater rates of COVID-19 infections in young populations, thus impacting the global economy (Sultana & Reza, 2020). Jean Goff, regional director of the United Nations Children’s Fund (UNICEF) in South Asia, recently said that natural calamities, such as massive flooding, rain, and landslides, complicate efforts to address the COVID-19 pandemic in South Asian countries. These events may generate significant social and environmental impact and change (UNICEF, 2020). Furthermore, the mental health gap (mhGAP) can reach up to 90% in low- and middle-income countries (LMICs), many of which are in South Asia (Patel et al., 2010).

Given the vulnerability of South Asians to the psychological stressors associated with the current COVID-19 pandemic, various studies, as well as systematic reviews, have been conducted to investigate mental health concerns, including mood disorders, stigmatization, fear, anxiety, depression, suicidal behavior, insomnia, low self-esteem, poor self-control, and other adverse mental health measures (Hossain et al., 2021b; 2020a). However, to the best of the authors’ knowledge, there is a dearth of evidence that has been compiled on estimates of the prevalence of common mental health problems like fear, stress, anxiety, depression, suicidal behaviors, and insomnia at the regional and national levels. Consequently, to fill this knowledge gap, a systematic review was performed considering the prevalence of common mental health problems (e.g., depression, fear, anxiety, stress, insomnia, and suicidal tendencies) and associated factors among the general population in South Asia, which may well guide future investigation on mental health in this region and inform health-related decision-making.

Methods

Search strategy

The current study followed the Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guideline for performing a comprehensive review (Moher et al., 2010). A comprehensive literature search was conducted from September 2021 to March 2022. Databases included PubMed, Scopus, and Global Health; Google Scholar and ResearchGate, which were searched to retrieve articles. The following keywords were used in the search strategy: (depression OR anxiety OR stress OR mental health OR psychological impact OR fear OR suicidal tendency OR insomnia); AND (COVID-19 OR pandemic); AND (South Asia Region OR South Asians OR Bangladesh OR Bhutan OR India OR Pakistan OR Nepal OR Sri Lanka OR Afghanistan OR Maldives); AND (COVID-19 OR pandemic).

Study selection criteria

Initially, each publication was screened based on its title and abstract. Then, the full-text article was reviewed to determine whether it should be added or not. Articles were included in this review if the studies met the following criteria: (i) from a South Asian jurisdiction, (ii) a cross-sectional investigation, (iii) conducted after the onset of the pandemic, (iv) used standard tools for assessing mental health problems, (v) reported prevalence and/or correlates of common mental health problems (e.g., depression, fear, anxiety, stress, insomnia, and suicidal tendencies), (vi) published in a peer-reviewed journal, and (vii) published in English.

Data eligibility

There were 479 articles initially gathered from different sources, and 79 of those articles were found through keyword searches in other sources such as Internet references, empirical or evidence-based articles, thesis and dissertations, conference proceedings, and papers to add linked literatures, with 350 articles remaining after the duplicates were removed. Next, titles and abstracts for each article were reviewed, and 290 articles were removed for not being appropriate. Of the remaining 60 full-text articles, 22 studies met inclusion criteria and were included in the final analysis. Thirty-eight of the full-text articles were excluded for being (i) review articles, (ii) qualitative studies, and (iii) mixed-method studies (i.e., both qualitative and quantitative) (Fig. 1).

Fig. 1
figure 1

PRISMA flow-chart of the present systematic review

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Data extraction

A data file was created using Microsoft Excel for the information set of the included articles. The following criteria were used to extract data: (i) first author and year of publication, (ii) specific group and sample size, (iii) sampling method, (iv) sample characteristics, (v) assessment tools, (vi) cut-off scores, (vii) prevalence, (viii) associated factors, and (ix) prevalence assessment criteria.

Results

Characteristics of the included studies

Following the inclusion criteria, 22 cross-sectional survey-based studies were included in this review. All selected studies were conducted between 2020 and 2022. Only twelve studies gave participants’ mean ages, and the number of participants ranged from 340 to 13,654. The Depression Anxiety Stress Scale (DASS-21) was the most commonly used scale for detecting the prevalence of depression, anxiety, and stress (n = 9), with other scales such as the Impact of Event Scale-Revised (IES-R), Center for Epidemiologic Studies–Depression (CES-D), The World Health Organization - Five Well-Being Index (WHO-5), General Anxiety Disorder (GAD-7), Warwick Edinburg Mental Well-being Scale (WEMWBS), Perceived Stress Scale (PSS), Patient Health Questionnaire (PHQ-9), Insomnia Severity Index (ISI-7), Pittsburgh Sleep Quality Index (PSQI), Self-Rating Depression Scale (SDS), Self-Rating Anxiety Scale (SAS), and Coronavirus Anxiety Scale (CAS) also used. Nine studies assessed the prevalence estimates of depression, anxiety, and stress, as well as their associated factors, while the remaining studies assessed depression or anxiety or stress and fear, insomnia, and suicidal ideation (Table 1).

Table 1 Characteristics of the included studies in the present review
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Prevalence of stress, anxiety, depression, fear, suicidal tendencies, and insomnia

The prevalence estimates of stress, anxiety, depression, fear, suicidal tendencies, and insomnia varied across studies.

Stress

The prevalence of stress ranged from 10.56 to 91.77% in twelve manuscripts using instruments including the DASS-21 and PSS (Ahmed et al., 2022; Basnet et al., 2021; Dawa et al., 2021; Faruk et al., 2021; Grover et al., 2020; Hazarika et al., 2021; Islam et al., 2020b; Lahiri et al., 2021; Rahman et al., 2020, 2021; Riaz et al., 2021; Siddique et al., 2021). The pooled prevalence of mild to extremely severe stress was 50.30%. One study that showed the lowest overall prevalence of stress noted significantly higher stress among unemployed individuals (Dawa et al., 2021). In another study, COVID-19-related stress was reported to affect 91.77% of participants and result in insomnia (Lahiri et al., 2021).

Anxiety

The prevalence of mild to severe anxiety ranged from 8.1 to 62.5% (Ahmed et al., 2022; Balkhi et al., 2020; Basnet et al., 2021; Bhatta et al., 2021; Das et al., 2021; Dawa et al., 2021; Faruk et al., 2021; Gaur et al., 2020 ; Grover et al., 2020; Hazarika et al., 2021; Hossain et al., 2021a; Islam et al., 2020a; Rahman et al., 2021, 2021; Riaz et al., 2021; Siddique et al., 2021). The lowest reported prevalence (8.1%) was detected under a low-to-high threshold model, and women had a higher prevalence and more anxiety-related symptomatology (Bhatta et al., 2021). The pooled prevalence of mild to severe anxiety was 35.81%.

Depression

The prevalence estimates of mild to severe depression ranged from 10.5 to 85.9% (Ahmed et al., 2022; Basnet et al., 2021; Das et al., 2021; Dawa et al., 2021; Faruk et al., 2021; Gaur et al., 2020 ; Grover et al., 2020; Hazarika et al., 2021; Hossain et al., 2021a; Islam et al., 2021; Mamun et al., 2021; Rahman et al., 2021, 2021; Riaz et al., 2021; Ripon et al., 2020; Siddique et al., 2021). The pooled prevalence of mild to severe depression was 37.36% and depression seemed most common in older people (89.5%), those with higher education levels (81.2%), those reporting single marital status (84.95%), women (87.1%), and isolated individuals (87.1%) (Ripon et al., 2020).

Fear

Fear was reported in two studies, and the estimated prevalence of mild to severe fear among South Asians ranged from 38.5 to 88.8%, with a pooled prevalence estimate of 63.65% (Balkhi et al., 2020; Grover et al., 2020). Most survey respondents (88.8%) were afraid of going to packed areas like markets and department stores and preferred to stay at home (58%) (Balkhi et al., 2020). In addition, over one-third of individuals (38.5%) felt afraid about becoming infected with COVID-19 (Grover et al., 2020).

Suicidal tendencies

With estimates varying according to age, gender (females at seemingly greater risk), smoking status, or fear of COVID-19, 5–8% of the population appeared at elevated risk for suicidal ideation in relation to severe depression (Islam et al., 2021; Mamun et al., 2021). In one study, the mean score on the item ‘Stress influences my mind to commit suicide was 2.09 out of 6 (1 = not applicable, 6 = strongly agree), indicating that some people were dissatisfied with their current situation and wished to die (Islam et al., 2020b). Suicidal thoughts or ideation were often accompanied by depression (Islam et al., 2021). The pooled prevalence estimate of suicidal ideation was 6.5%.

Insomnia

Insomnia was reported in three studies, with an estimated prevalence ranging from 13.32 to 53.45% (Bajaj et al., 2020; Gaur et al., 2020 ; Lahiri et al., 2021). The prevalence of insomnia was higher among people living in metropolitan regions (26%), Muslim individuals (33%), and women (22%) (Gaur et al., 2020 ). The pooled prevalence estimate of insomnia was 29.25%.

Factors associated with stress, anxiety, depression, fear, suicidal tendencies, and insomnia

Socio-demographic factors

Age

Most studies associated age with depression, anxiety, stress, suicidal tendencies, and insomnia. In two studies, there was no association between age and stress (Dawa et al., 2021; Islam et al., 2020b). Anxiety symptoms were more frequent/severe in an 18–30 year-old age group, compared with a 31–40 year-old age group. On the other hand, a 41–50 year-old cohort showed lower levels of depression, anxiety, and stress than one aged 51–60 years (Ahmed et al., 2022). Regarding insomnia, the comparatively younger population (Age Level A1: age range 19–29 years) experienced considerably more insomnia than the older populations (Age Level A3: age range 36–41 years and Age Level A4: age > 41 years) (Bajaj et al., 2020). Suicidal ideation was also more prevalent among the younger individuals (Mamun et al., 2021).

Gender

Multiple studies indicated a relationship between gender and depression, anxiety, stress, suicidal ideation, and insomnia (Bajaj et al., 2020; Bhatta et al., 2021; Faruk et al., 2021; Gaur et al., 2020 ; Mamun et al., 2021; Riaz et al., 2021; Ripon et al., 2020). Considerably more depression, anxiety, and stress have been reported among females (Ahmed et al., 2022). Participants with suicidality were also more likely to be female (Mamun et al., 2021). Similarly, females were more likely than males to experience insomnia (Bajaj et al., 2020). Females’ mean scores of stress, anxiety, and depression were higher than those of males (Rehman et al., 2021).

Income

Depression, anxiety, and insomnia were two times more likely in those who were worried about losing income and earning less than those who had steady jobs (Gaur et al., 2020 ). Depression was more common (91.1%) among those who earned the equivalent of over 877.74 US dollars per month (75,000 Bangladeshi Taka [BDT]) compared to those who earned less than 228.54 US dollars per month (20,000 Bangladeshi Taka [BDT]) (Ripon et al., 2020).

Education

Graduate students were more likely than undergraduate students to be concerned about their health safety at home and to be worried on a daily basis following the outbreak. A higher percentage of undergraduates considered giving up their studies or requesting a leave of absence from their academic institution due to COVID-19 or delayed or curtailed their usage of healthcare facilities (Balkhi et al., 2020). Participants with secondary education had considerably higher levels of depression, anxiety, and stress than those who had completed their graduation. Furthermore, those with a graduate degree reported less depression and anxiety (Ahmed et al., 2022).

Place of residence

There was a significant link between individuals’ place of residence and anxiety and insomnia. The prevalence estimates of anxiety and insomnia were higher (11% and 26%, respectively) among persons living in metropolitan areas, and they were lowest amongst rural-dwelling individuals (6% and 14%, respectively) (Gaur et al., 2020 ). Considering COVID-19 risk zones, individuals who were the most confident in their current place’s safety appeared to report less stress, whereas those who had the least confident about the safety of their current residence appeared to experience more depression, anxiety, and stress (Rahman et al., 2021).

Marital status

In one study, unmarried participants showed greater levels of depression, anxiety, and stress symptoms than married participants (Ahmed et al., 2022). On the other hand, Bhatta et al. reported more prevalent anxiety among individuals who were married compared to unmarried people (9.9% versus 7.8%) (Bhatta et al., 2021).

Behavioral and health-related factors

Physical and mental health

Participants reported stress, depression, anxiety, fear, and suicidal ideation in relation to their mental and physical health concerns or previous illnesses (Balkhi et al., 2020; Bhatta et al., 2021; Gaur et al., 2020 ; Hazarika et al., 2021; Islam et al., 2021; Mamun et al., 2021; Rahman et al., 2021). When comparing moderately anxious respondents to extremely concerned respondents regarding their mental health, there was a significant link between being moderately anxious and low depression, anxiety, and stress scores. Participants with a history of physical illness or COVID-19 symptoms reported higher levels of depression, anxiety, and stress than those without. People with a previous infection were reported to be more anxious (Rahman et al., 2021). Suicidal thoughts were also associated with health concerns (Mamun et al., 2021).

Sleep problems

COVID-19-related anxiety was more common among people who had trouble slee** as compared to those without sleep difficulties (Bhatta et al., 2021). During the COVID-19 pandemic, sleeplessness was related to the intensity of depression (Bajaj et al., 2020). Loneliness was also linked to insomnia (Lahiri et al., 2021).

Smoking status and alcohol use

Suicidal tendencies and depression have been associated with tobacco smoking and alcohol use (Mamun et al., 2021).

COVID-19-related factors

COVID-19-related perceptions

Suicidal ideation was associated with a lower level of COVID-19-related knowledge and preventative actions. Individuals with suicidal thoughts as compared to those without were more likely to have major depression (Mamun et al., 2021). More than 40% of respondents in one study believed that they had not received sufficient information regarding quarantining, and they were 0.67 times safer than those who reported having such knowledge during the COVID-19 pandemic (Ripon et al., 2020).

Fear of COVID-19 infection

Studies reported that fear of contracting COVID-19 was associated with depression, anxiety, and stress (Grover et al., 2020; Islam et al., 2021; Islam et al., 2020b; Ripon et al., 2020). In contrast, having relatives or friends with COVID-19 appeared to induce anxiety. COVID-19 generated fear in most participants, and the fear along with stress generated by COVID-19 appeared to negatively impact sleep (Islam et al., 2020b).

COVID-19-related symptoms

COVID-19 symptoms (fever, exhaustion, and dry cough) were associated with higher levels of depression, anxiety, and stress. Individuals reporting having experienced COVID-19 infection were more prone to be anxious than those without infection (Rahman et al., 2021).

Other potential risk factors

Other potential risk factors related to depression, anxiety, stress, and fear have included (i) social life (Rahman et al., 2021), (ii) having lost a part-time job (Rahman et al., 2021), (iii) professions (Ahmed et al., 2022), (iv) quarantine (Ripon et al., 2020), (v) worrying about one’s future career (Islam et al., 2020b), (vi) having food crisis (Islam et al., 2020b), (vii) financial difficulties (Islam et al., 2020b), (viii) working in the public sector (Hazarika et al., 2021), (ix) cognitive emotion regulation (Riaz et al., 2021), (x) sickness in a family member or among peers (Balkhi et al., 2020; Islam et al., 2020b), (xi) living in a COVID-19 risk zone (Bhatta et al., 2021), (xii) unemployment (Dawa et al., 2021), and (xiii) obesity (Das et al., 2021).

Discussion

In the context of the COVID-19 pandemic, this review explored mental health concerns among people living in South Asia. In addition to estimating prevalence rates for mental health concerns in general populations living in South Asia, we systematically identified 22 cross-sectional studies following the PRISMA guideline and statistically analyzed the pooled prevalence of depression, fear, anxiety, stress, insomnia, and suicidal ideation in the collective sample.

The COVID-19 pandemic has negatively impacted people’s psychology globally. The existing social systems have undergone significant modifications as a result of the COVID-19 pandemic (Ramkissoon, 2022a). Fear, anxiety, and depression have been described as psychiatric responses to infectious breakouts. Interruptions in regular activities, uncertainties about one’s employment and economic instability, well-being of one’s friends and family, available treatments, and disease information have been described as contributory factors for generating such symptoms (Chew et al., 2020). Furthermore, those reporting suicidality were more likely to experience severe depressive symptoms, be unfamiliar with COVID-19, and participate in fewer COVID-19 preventative practices (Mamun et al., 2021). The findings suggest that as a result of the lockdown, South Asians appear at elevated risk of mental health problems. Ramkissoon’s (2020, 2022b) research demonstrates that people who live alone can naturally take pro-social and pro-environmental stances, which can be beneficial for both their health and the health of the planet.

To the best of our knowledge, the present review is the first to systematically consider South Asians’ stress, anxiety, depression, fear, suicidal tendencies, and insomnia during the COVID-19 pandemic. South Asians were found to frequently experience depression (10.2–85.9%), fear (38.5–88.8%), anxiety (8.1–62.5%), stress (10.56–91.77%), insomnia (13.32–53.45%), and suicidal ideation (5–8%) during the COVID-19 pandemic. The pooled prevalence estimates of depression, fear, anxiety, stress, insomnia, and suicidal ideation were 37.36%, 63.65%, 35.81%, 50.30%, 29.25%, and 6.5%, respectively. The findings resonate with a large-scale survey conducted in China during the COVID-19 pandemic. Huang and Zhao studied 7,236 people in China and found high prevalence estimates of general anxiety (35.1%), depression (20.1%), and sleep problems (18.2%) in the general population (Huang & Zhao, 2020). Health-care workers (HCWs) had particularly poor quality of sleep and slept for the shortest amounts of time. HCWs showed signs of health-related worry and remorse. Roughly half of health professionals reported depression, while 44.7% and 36.1% reported anxiety and slee** problems, respectively, in a survey conducted in China (Liu et al., 2021), as research on depressive symptoms (43.5%) during the COVID-19 pandemic has linked them to routine activities during home confinement such as playing videogames (Islam et al., 2021).

It has been proposed that psychological health or educational authorities should hold regular seminars on mental health wellness to encourage and assist the general public in managing their health concerns. Furthermore, governments should provide assistance based on the circumstances and conditions of those who have been suffering.

Individual efforts such as quitting smoking, drinking less alcohol, taking care of one’s health, and getting sufficient high-quality sleep may help people cope with psychological symptoms. Moreover, cognitive behavior therapy (CBT), particularly internet-based CBT, may represent an important evidence-based treatment for mental health concerns during a pandemic (Ho et al., 2020; Zhang & Ho, 2017). Additionally, protecting against the dissemination of false information that might generate fear and anxiety among the general population appears important.

Strengths

This article systematically reviewed studies of general populations in South Asia with respect to common mental concerns (depression, anxiety, fear, suicidal tendencies, insomnia, and stress) experienced during the COVID-19 outbreak. The article examined and summarized the literature, highlighted potential risk factors and made recommendations for addressing mental health concerns during the pandemic.

Limitations of the study

The present study has some limitations. The study may not be representative of each psychological outcome as there were differences in the assessment tools used in the primary research and a limited number of studies for particular measures. We cannot establish causal relationships as only cross-sectional studies were included. Furthermore, no qualitative or mixed-methods papers were included; thus, the review was not comprehensive, and rather focused on studies that were exclusively quantitative. Selection biases also cannot be excluded. Online-based studies are also subject to biases in data collection and may have limited representation. Only including English-language articles may turn out to be a drawback as well. As a result, generalizations regarding mental health among the general population should be made cautiously.

Conclusion

The psychological toll of the pandemic on South Asians appears to be significant. The current review presents a summary of depression, anxiety, stress, fear, suicidal tendencies, and insomnia prevalence estimates, as well as related factors, among populations in South Asia during the early portion of the COVID-19 pandemic. An unprecedented threat to the general population’s mental health in South Asian nations is posed by the COVID-19 pandemic. In addition to leveling the viral transmission pattern, prevention must be given top emphasis. Government policy that combines viral risk reduction with measures to lessen risks to mental health seems very much needed. Mental health should be included within primary health care systems.