The Hidden Impacts: Identifying Psychological Burdens During the Covid-19 Pandemic

. The COVID-19 pandemic has increased the complexity of mental health issues and burdens. Psychological problems also arise as a domino effect of the massive crisis of the pandemic. Various studies and rapid assessments have been carried out and confirmed the alleged increase in psychological problems. However, identifying the psychological burdens that arise during the pandemic has not been explored qualitatively. For this reason, this study was conducted to identify the psychological burdens that arise during a pandemic to understand how the COVID-19 pandemic affects mental health. This study used an exploratory qualitative approachby collecting data through online open-ended questions. Seven hundred and four people (462 women; x̄ age of 27.06 years) participated by purposive technique. Thematic analysis was applied to identify and analyze patterns of meaning perceived as psychological burdens during the pandemic. The study found five themes: stress related to the pandemic, anxiety, depression, emotional instability, and loneliness. This research encourages efforts to anticipate increased mental health problems when dealing with a pandemic and provide access to psychological assistance for vulnerable groups.


INTRODUCTION
Covid-19 has become a global pandemic and has hit Indonesia since early March 2020 at a frightening rate of transmission (World Health Organization [WHO], 2020). Indonesia also became the epicenter of the delta variant in July 2021 and caused a Covid-19 tsunami that was not easy to handle (Dyer, 2021). Since the announcement of the pandemic, authorities have taken various policies to prevent massive transmission by closing international travel, closing schools and universities, moving public services online, and strictly banning the mobility of all citizens (Kementerian Kesehatan RI, 2020).
The government's policies during the pandemic that required the public to follow the Covid-19 prevention protocol and restrictions on mobility led to changes in activity and financial distress. The Central Statistics Agency report (2020) showed a portrait of changes in work routines experienced by the community because of mobility restrictions, with details of working from home (39.09%), some work from home with still scheduled to come to the office (34.76%), and respon-

Data Analysis
The data in this study were participant responses through open-ended questions, managed using MAXQDA 2020 for systematic coding and data management processes. This study applied reflexive thematic analysis (Braun & Clarke, 2019) to understand participants' perceptions and experiences of pandemics and to identify theme patterns regarding the reported psychological burdens of study participants. The first, second, and four trained assistants worked to familiarize the dataset by re-reading it, taking notes, and marking the data set.
Initial code was carried out independently by the first author (F.A.N) and two assistants and the second author (E.P.H) with another assistant. After that, the authors discussed the codes developed in regular weekly meetings and built a consensus on the different codes between the first and second authors. These meetings continued to refine coding and find consensus on potential themes. This procedure is vital to maintain and ensure the coding quality and was carried out until emerging themes were identified. Next, the first and second authors identified and reviewed potential themes by grouping codes with nuances and ideas representing patterns of coherent meaning with the data. The names and definitions of the themes were given based on the thematic maps that the authors compiled.

RESULTS AND DISCUSSION
This study found five themes identified as psychological burdens based on participant reports in open-ended questions. The theme 'stress related to the pandemic' provided information on various forms of pressure felt related to changes in lifestyle during a pandemic. The three themes of 'anxiety', 'depression', and 'emotional instability were responses to psychological discomfort and threats to the pandemic. Meanwhile, the theme of 'loneliness' described how the pandemic affected the form of relationships, restrictions on interaction, and being separated from the social world. The theme findings synthesized in this study can be seen in Table 2.

Theme 1: Stress related to the pandemic
This theme summarized the responses of participants who experienced various psychological distresses caused by the pandemic, such as restrictions on mobility, the use of masks, physical distancing, and the deteriorating financial impact. The pandemic placed respondents in different ways of life than before, such as massive digital migration in learning, work, social interaction, worship, mobility restrictions, and Covid-19 infection prevention protocols.  The pandemic was also reported to cause financial pressures in the form of decreased income, increased health spending and expenditure, and multiple targets and work demands. For example, a private employee with two years of work experience got a workload to do double duty due to labor efficiency, stating, "I get an assignment from a friend who was dismissed some time ago, so I have to double-job. I am also afraid of being fired if my performance drops" (RESP-347, 26 years old). Distress reported by participants was also perceived as prolonged stress in adjusting to new habits and ways of life, such as washing hands, using masks, activities at home, and virtual social life. In this case, a woman who worked as a financial auditor stated that she experienced a change in working hours that became longer, and there was no clear boundary between personal time and work. She revealed, "The work pressure is erratic. Due to the mobility ban, the company asked me always to be available. The financial pressure is also very much felt, given the family shop not operating as it should" (RESP-446, 27 years).
Prevention of transmission through instructions for implementing health protocols was experienced as a barrier to intimate interactions and relationships. For example, a teacher in Temanggung wrote that he had difficulty interacting with his students, "The health protocol prevents me from meeting and being close to my students" (RESP-301, 34 years). Likewise, a student in Bali revealed that the use of masks made him limited in interacting. He admitted, "I feel stressed because the world has changed. The health protocols made me uncomfortable and felt congested. Meeting people has also become limited and uncomfortable" (RESP-138, 22 years).

Theme 2: Anxiety
The theme of anxiety synthesized distress expressions in the form of overthinking, worry, anxiety, fear, panic, tension, and heart palpitations. The anxiety experienced by participants was related to health conditions and the threat of being infected with Covid-19. Participants mentioned that they were worried about the possibility of being infected, which could infect those closest to them and who were more vulnerable. A Batak ethnic student wrote of his anxiety about contracting Covid-19, "I have become more and more worried about many things and afraid that I will be exposed to ; especially if I cause people around me to get Covid-19" (RESP-586, 22 years).
Likewise, a Muslim woman living in Surakarta worried about her siblings who lived outside the city. She said, "Even though I was at home, I was worried that I might catch Covid-19. I was also worried that my family who lived scattered in various cities could be infected" (RESP-355, 39 years). This anxiety was perceived because some people tend to ignore the health protocol instructions. One participant who worked as an engineer stated, "Too many people do not follow health protocols. It makes me uncomfortable and so depressed (contagious)" (RESP-468, 32 years). Besides the harmful effects, Covid-19 infection was feared to cause discrimination and social exclusion. For example, an entrepreneur living in Banten expressed his fear of being infected, which could lead to discriminatory treatment. He admitted, "I was worried about getting infected. It was because when exposed to Covid-19, one will get inhumane treatment or shunned; they are deemed not to need help" (RESP-486, 29 years). Furthermore, the theme of anxiety represented worries about the future, uncertainty, anxiety about the unknown when the pandemic will end, and pessimism about the future. A student from Papua stated, "I am burdened and feel anxious about my future. Will this Covid-19 ever end?" 20 years).
Participants also reported that they often experienced anxiety due to the flood of information about Covid-19, such as sad news, infected people closest to them, daily case reports, and difficultto-confirm news. Participants stated that they received hoax, erroneous, or unvalidated information on an ongoing basis and could not separate true and reliable sources of information. A Javanese housewife experienced anxiety when she received information about her grief from those closest to her, "I hear too much sad news. I became more and more worried about death, whether it was myself who died, my family, or those closest to me" (RESP-109, 55 years). Massive information was anticipated by minimizing the use of social media; as an employee in the culinary field said, "… when I want to post something on social media, I am afraid to find information about Covid-19. I am even lazy to open WhatsApp" (RESP-310, 20 years). In addition, the inconsistency of authorities in communicating the pandemic was considered to have also caused anxiety. A factory worker stated that the psychological burden he experienced was caused by inconsistent information from authority figures, "The news is confusing, both from information on virus developments, vaccines, and changing government policies" (RESP-480, 33 years).

Theme 3: Depression
The pandemic has affected the quality of life, relationships, and livelihoods. Depression themes the participants reported in this survey were related to sleep and eating disorders, loss of interest or satisfaction in activities, withdrawal, feelings of worthlessness and guilt, self-blame, perceptions of low self-esteem, decreased concentration, and depressed mood. One student wrote, "I became more closed to my surroundings. In addition, I became more reserved and preferred to be at home. I often blame myself for what happened" (RESP-598, 21 years). Or a student reported feeling lost since the pandemic and had been self-harming, "I have been under stress for a few months since the pandemic. Then, I once vented that stress by self-harming" (RESP-292, 20 years).
Another symptom that participants reported was extraordinary burnout, characterized by boredom, fatigue, frustration, poor sleep quality, and lack of enthusiasm in carrying out activities. In this case, everyone was instructed to stay home for several weeks to months with limited movement and activity. The male participant stated that fatigue was a noticeable change during the pandemic, "I experienced acute burnout. I become increasingly lazy because there is no transition of activities in boarding houses and campuses. Everything at the boarding house!" (RESP-124, 24 years). Or the opinion of a woman who lived in Medan stated, "I feel tired more easily, get stressed easily, and give up easily. Much pressure during working at home and the workplace" (RESP-176, 24 years).

Theme 4: Emotional instability
This theme underscored the more intense mood and emotional changes experienced by participants during the pandemic, including sensitivity (irritability, provoked), irritability (outbursts, anger), and moody. It was said, "Psychologically, I am more emotional (angry, irritable) than before the pandemic" (RESP-416, 22 years). Another participant reported "less able to control emotions" (RESP-402, 22 years), "feel more sensitive and irritable" (RESP-392, 22 years), or "Right now, I feel more irritable and want to vent" (RESP-229, 22 years). One of the emotional changes reportedly emerged during the pandemic was moody. One student stated, "My mood changed. During the COVID pandemic, I feel more sensitive in dealing with many things, ranging from being easily sad and angry" (RESP-190, 20 years).

Theme 5: Loneliness
Mobility restrictions and stay-at-home instructions caused lonely distress due to the absence of physical interaction with other people, immobile, isolated, and lack of social activities. This loneliness was primarily due to limited access to meet friends and relatives and limitations in physical communication. A regional student in Salatiga stated that he was lonely because his friends had returned to their villages, and was alone in the boarding house. He said, "Limited to get out of boarding house; and lonely because friends go back to their respective hometowns. Now, I am in the boarding house alone" (RESP-487, 20 years). Or postgraduate students in Yogyakarta argued, "Not meeting friends or not being able to get a supportive atmosphere to complete a thesis and other work. If there are friends who can work on the thesis together, it feels like there are friends who are also fighting. Now, nothing is done alone" (RESP-116, 27 years). This theme also summarized the participants' inner experiences related to loneliness, such as being alone, isolated, and empty. Participants stated, "My life is quiet. Cannot do activities outside the home and cannot meet friends in person" (RESP-518, 21 years old). Likewise, a student from Kupang admitted, "Since the pandemic, I have only been at home and only gone out if it is necessary. I also cannot freely meet friends or have picnics every weekend, which I used to do before the pandemic. I feel lonely and depressed" (RESP-178, 20 years).
The data also revealed that virtual communication could not replace face-to-face encounters or compensate for longing for physical activity and interaction. Meanwhile, participants also perceived that they experienced decreased interpersonal skills, felt inferior speaking, and affected their confidence in initiating a conversation. Participants experienced obstacles in maintaining intimate relationships and opening new friendships in this case. An employee from Bogor who migrated to Yogyakarta said she felt alone and lost contact with those closest to her during the pandemic. She said, "This pandemic has made me feel isolated because I am migrating alone. Coupled with the demands of work plus the pandemic conditions that made it impossible for me to return home, I also had difficulty maintaining virtual relationships with those closest to me, so without realizing it, I began to lose contact with those closest to me. I feel more and more lonely." (RESP-109, 22 years).
This study identifies qualitative themes perceived as psychological burdens during the Covid-19 pandemic. The data collection was carried out in the second year of the pandemic following the easing of mobility restrictions and quarantines in several provinces in Java and Bali with concerns that the Omicron variant would cause. At that time, Indonesia faced great and frightening pressure in controlling the second pandemic wave caused by the Delta variant tsunami (Dyer, 2021). In the second wave phase, the government tightened region-based mobility restrictions to prevent a worse impact of the pandemic.
Through a qualitative study, this research underscores the distress expressed by participants concerning the spread of Covid-19 infection and the handling of the pandemic. The qualitative themes synthesized in this study included: (1) distress related to life during a pandemic; (2) anxiety; (3) depression; (4) emotional instability; and (5) loneliness. This study provides qualitative evidence that psychological distress arose as an unanticipated impact of changes and new habit patterns, including changes in daily activity patterns, patterns and quality of social relations, economic crises, layoffs, school closures and online learning, mobility restrictions, and stay at home instruction. In this case, the pandemic is associated with psychological burdens due to uncertainty, threat, fear, panic, and terror (Abdullah, 2020;Olivia et al., 2020).
This study also elaborates on the experience of psychological distress thought to be driving the emergence of widespread psychiatric disorders at a time when the global health system concentrated on dealing with the pandemic. The results of this study summarized the depression symptoms reported by participants, such as feeling useless, decreased concentration, loss of interest and desire to do certain activities, boredom in monotonous activities, low self-esteem, high burnout, and worsening sleep quality. Kramer and Kramer (2020) have explained that the threat of depression is related to mobility restriction policies and stay-at-home instructions. We realize that most people could not enjoy a prolonged stay at home, given the limited, cramped housing and housing standards, which do not allow them to stay at home longer. On the other hand, mobility means the movement to make a little money to keep the household economy secure amid the absence of financial assistance. Prolonged mobility restrictions became a frightening specter and impacted various mental health problems (Anindyajati et al., 2021;Kwong et al., 2021). In this study, participants reported that they were in a threatening situation by a perceived viral infection that was getting out of control, along with the increase in cases and the outbreak condition that did not improve. The uncertainty of the pandemic also puts hope into sway, and mobility restrictions become a scourge that makes everyone a ghost in their home. This situation is made worse because the perceived stay at home to prevent transmission, in fact, did not reduce the graph of transmission and death.
The theme of emotional instability also emerged as a participant's response to the distress they experienced during the pandemic. The inductive analysis described the tendency of participants to experience sensitive emotions, temperaments, and mood swings. Anxiety is associated with reports of increased cases, deaths, media coverage, and the threat of uncontrolled Covid-19 (Cénat et al., 2021;Pera, 2020). This anxiety arose as a domino effect of the fear of being infected with the virus, social discrimination, uncertain situation, a flood of news about Covid-19, and terror from news whose validity was difficult to ascertain. In addition, misinformation related to Covid-19 hinders healthy behavior, reduces public participation in implementing transmission prevention protocols, lowers the quality of physical and mental health, and creates a reluctance to follow health authorities (Tasnim et al., 2020). In this case, we argue that hoaxes and rumors create a new stigma about Covid-19 that hinders community unity in breaking the chain of transmission.
Moreover, mobility restrictions isolate life from the social world and encourage disruption in established social relationships and interactions (Ganesan et al., 2021;Loades et al., 2020). Social isolation also limits a person from accessing support and sources of social assistance from other individuals, groups, or the larger community. In this regard, loneliness can be considered a hidden plague with the potential to have a worse domino effect on mental health problems during a pandemic. On the other hand, the use and access to technology and social media increased tremendously during the pandemic (Vargo et al., 2021). However, technology cannot facilitate chronic problems of loneliness and social isolation (Shah et al., 2020). Studies have reported the adverse effects of loneliness on mental health problems such as symptoms of depression, anxiety, negative self-esteem, sleep disturbances, eating disorders, self-harm, and suicide (Beutel et al., 2017;Lee et al., 2020;Okruszek et al., 2020).
At the beginning of the pandemic, the campaign to prevent the spread of Covid-19 was carried out with the jargon of "social distancing," which further limited social relations and seemed to place social isolation as an effort to prevent infection (Thunström et al., 2020). Then, the jargon "physical distancing" was used more to anticipate the problem of loneliness and encourage solidarity and social bonds during quarantine (Wasserman et al., 2020) by instructing distancing between individuals. However, this change in campaign jargon did not eliminate the effects of discrimination received by survivors. We highlighted that social support is not only important for minimizing psychological distress but is also crucial for promoting adaptive behavior in a new life with Covid-19. Along with the ongoing easing, it is vital to maintain the quality of social relations, social support, and empathy for each other while also paying attention to the potential for transmission.
The study also found that not all participants experienced a burden that worsened their mental health. Few participants reported experiencing growth during the pandemic, such as creativity and opportunity, self-management of potential, productivity, awareness about health, and being with family. This study also uncovered that some participants could survive in situations of uncertainty and threats that came repeatedly. Previous research has shown that adaptability (Picó-Pérez et al., 2021), tolerance for uncertainty (Parlapani et al., 2020), and resilience (Aruta, 2021) have relevance in dealing with health crises, promoting adaptive coping strategies, and finding opportunities amid limitations. This research also encourages increasing individual and community resilience and implementing adaptive behavior in the face of pandemic stress. In addition, this research report demonstrates an urgent need to develop psychosocial interventions during a pandemic crisis, especially among vulnerable groups. Handling mental health problems can be done by considering everyone's accessibility by optimizing the use of technology and the internet (Figueroa & Aguilera, 2020). Thus, this research encourages the use of technology that can offer opportunities to meet social needs and quality interpersonal relationships. Technology is also deemed important in connecting social networks to promote mental resilience to distress, suppress potential psychological problems during a pandemic, and develop psychological wellbeing (Torous et al., 2020). This study also urges to prioritize various promotions related to coping strategies in managing pandemic-life distress, positive attitude towards change, and adaptation to pandemic life. Besides, psychosocial interventions related to loneliness and isolation can be carried out by promoting self-disclosure and identifying sources of help.
Furthermore, the findings of this study are the themes of distress reported by the participants by directly mentioning the situations and events they experienced. Previous studies have reported hypothetical mental health conditions during a pandemic (Anindyajati et al., 2021;Pramukti et al., 2020;Wiguna et al., 2020). However, to the best of our knowledge, no qualitative studies have been conducted to reveal psychological burdens during the Covid-19 pandemic. For this reason, this study complements the need for exploration related to the psychological distress that people experience. This research also provides information on themes of mental health issues and complements the understanding of pandemic distress. Although this study was conducted through open-ended qualitative questions, the information provided by participants was a description of their knowledge and experience of pandemic distress.
Still, we need to reveal some limitations of this study. Participants in this study were dominated by young people and women and did not include elderly participants. Furthermore, this study did not carry out clinical assessment or screening to determine the eligibility for participant recruitment. Hence, participants' burdens of psychological problems were solely subjective perceptions and not clinical assessments.

CONCLUSION
This study identifies qualitative themes of psychological burdens that arise during the Covid-19 pandemic. Pandemic-related stress, anxiety, depression, emotional instability, and loneliness were the themes identified as psychological burdens. This article further confirms previous studies that the pandemic has caused a prolonged psychological crisis, radical life changes, and exacerbated the risk of mental health problems. In this study, we found that the pandemic had increased and exacerbated psychological problems, especially for people susceptible to Covid-19 infection and those who, before the outbreak, had mental disorders. Thus, we suggest that responding to a pandemic should consider anticipating a wave of mental health problems by providing psychological services and assistance, especially for vulnerable groups. This study also recommends providing access to mental health assistance that the wider community can reach by utilizing technology and digital through telemental health.
Moreover, the literature reviewing psychological responses to macro-crises and pandemics tends to describe the major disadvantages for mental health. Although this study was limited to psychological burdens, we argue that the pandemic has relevance to growth, creativity, and resilience in response to life's various stressors.