key: cord-343168-gphud9yx
authors: Alyami, H. S.; Naser, A. Y.; Dahmash, E. Z.; Alyami, M. H.; Al Meanazel, O. T.; Al-Meanazel, A. T.
title: Depression and anxiety during 2019 coronavirus disease pandemic in Saudi Arabia: a cross-sectional study
date: 2020-05-15
journal: nan
DOI: 10.1101/2020.05.09.20096677
sha: 
doc_id: 343168
cord_uid: gphud9yx

Background: COVID 19 outbreak in 2020 was associated with a high rate of depression and anxiety among individuals in the affected countries. The aim of this study is to explore the influence of the COVID 19 epidemic on the psychological distress of residents of the Kingdom of Saudi Arabia. Methods: A cross sectional study using an online survey was conducted in Saudi Arabia between 27th of March and 27th of April 2020. The Patient Health Questionnaire (PHQ 9) and Generalized Anxiety Disorder-7 (GAD 7) were used to assess depression and anxiety. Logistic regression analysis was used to identify predictors of depression and anxiety. Results: The prevalence of depression and anxiety among the entire study participants was 9.4% and 7.3%, respectively. Non-Saudi residents, aged 50 years and above, divorced, retired, university students, and those with income (2000 to 10,000 RS) were at higher risk of developing depression. Saudi individuals, married, unemployed, and those with high income (> 10,000 RS) were at higher risk of developing anxiety. Conclusions: There is a wide range of the Saudi residents who are at higher risk of mental illness during COVID 19 pandemic. Policymakers and mental healthcare providers are advised to provide continuous monitoring of the psychological consequences during this pandemic, and provide mental support.

Wuhan, Hubei Province, China in December 2019 [1] . In early March 2020, the first case of COVID-19 was confirmed in the Kingdom of Saudi Arabia, and since then, it caused 209 deaths out of 31,938 patients who got infected with this disease [2, 3] .

The causative agent for COVID-19 has been identified as a new RNA virus from the beta-coronavirus family; the transmission rate of it is considered high because it transmitted through respiratory droplets and close contact. The World Health Organization (WHO) has categorized Covid-19 as a pandemic infection since the respiratory illness caused by the COVID-19 is highly contagious [4] because of the novelty of the virus, fast spread, and the lack of therapeutic and preventative strategies [5] .

The Kingdom of Saudi Arabia has taken the deadly coronavirus outbreak gravely even before the ministry of health announced the first confirmed COVID-19 case, for example, it announced the temporary suspension of entry to Makkah and Madinah in February 2020 [6] .

After the first confirmed case, the Saudi Arabian government announced series of extreme measures to control the spread of the virus beginning by panned all transport in and out of the Qatif Governorate on March 8, and most recently on April 6, to announcing a 24-hour curfew implemented in the major cities with movement restricted to only essential travel between 6 a.m. and 3 p.m. on April 6 [7] . The extremely proactive measures taken to prevent the spread of the virus could contribute to provoking public fear, anxiety and/or depression, which is usually neglected during crisis and pandemic management [8] [9] [10] [11] [12] .

COVID-19 has a severe impact on the physical and mental health of the public during the COVID-19 outbreak; therefore, we aimed to assess the mental health burden of citizens and residents inside the Kingdom of Saudi Arabia during COVID-19 pandemic and to identify potential population(s) who might need psychological intervention.

A cross-sectional study using an online survey was conducted in Saudi Arabia between March 27 th and April 27 th , 2020, to explore depression and anxiety among the general population during the COVID-19 pandemic.

A convenience sample of eligible participants was invited to participate in the study. The general population was invited to participate in this study through social media (Facebook and WhatsApp). All participants voluntarily participated in the study and were thus considered exempt from written informed consent. The study aims and objectives were clearly explained at the beginning of the survey.

The inclusion criteria were: a) participants aged 18 years and above and living currently in Saudi Arabia, and b) participants who had no apparent cognitive deficit. Participants were excluded if they were: a) below 18 years of age; b) unable to understand the Arabic language; and c) unable to participate due to physical or emotional distress.

Previously validated assessment scales, the Patient Health Questionnaire (PHQ)-9, and Generalized Anxiety Disorder 7-item (GAD-7) were used to assess depression and anxiety among the study participants. These screening instruments were frequently used and validated as brief screening tools among various populations for depression and anxiety [13] [14] [15] [16] [17] . Also, the following information was collected: participants' demographics (age, gender, income, education level, employment status, and marital status). Furthermore, participants were asked whether they were worried about being infected with COVID-19 or transmitting it to family members (yes/no question) and whether they had underlying chronic conditions (yes/no question).

The PHQ-9 scale is a 9-questions instrument given to participants to screen for the presence and severity of depression [18, 19] . The GAD-7 instrument was used to screen for anxiety [20] . The PHQ-9 and the GAD-7

instruments asked the participants about the degree of applicability of each item (question), using a 4-point Likert scale. Participants' responses ranged from 0 to 3, where 0 means "Not at all" and 3 means "Nearly every day". The PHQ-9 instrument includes 9 items. Items are scored from 0 to 3 generating a total score ranging from 0 to 27. A total score of 0-4 indicates minimal depression, 5-9 mild depression, 10-14 moderate depression, 15-19 moderately severe depression, and 20-27 severe depression [21] . The GAD-7 instrument includes 7 items.

Items are scored from 0 to 3 generating a total score ranging from 0 to 21. A total score of 5-9 indicates mild anxiety, 10-14 moderate anxiety, and 15-21 severe anxiety [22] .

Prevalence rates of depression and anxiety were determined using a cut-off point, as recommended by the authors of the PHQ-9 and GAD-7 scale. In this study, depression was defined as a total score of (≥ 15) in the PHQ-9 instrument, indicating a case with moderately severe or severe depression. Anxiety was defined using the GAD-7 instrument with a total score of (≥ 15), indicating a case with severe anxiety. The higher the score, the more severe the case identified by any scale.

The prevalence rate of depression was estimated by dividing the number of participants who exceeded the borderline score (≥ 15) by the total number of participants in the same population. The prevalence rate of anxiety was calculated using the same procedure.

The target sample size was estimated based on the WHO recommendations for the minimal sample size needed for a prevalence study [23] . Using a confidence interval of 95%, a standard deviation of 0.5, a margin of error of 5%, the required sample size was 385 participants.

Descriptive statistics were used to describe participants' demographic characteristics. Continuous data were reported as mean ± SD for normally distributed variables and median (interquartile range (IQR)) for nonnormally distributed variables. Categorical data were reported as percentages (frequencies). The Mann-Whitney U test/Kruskal-Wallis test was used to compare the median scores between different demographic groups.

Logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for anxiety or . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 15, 2020. . depression. Logistic regression models were carried out using anxiety or depression scores above the cut-off points highlighted above. A two-sided p<0.05 was considered as statistically significant. The statistical analyses were carried out using SPSS (version 25).

A total of 2,081 individuals participated in the study. Table 1 More than half of them were employed (n= 1,272, 61.1%). Around 12,3% (n= 255) of the participants reported that they have a history of chronic disease. The majority (n= 1,587, 76.3%) of the participants reported that they were concerned about contracting COVID-19 or transmitting it to family members. When participants were asked if they have identified any problems over the past two weeks, to what extent have these problems prevented them from doing their work, looking after their household affairs or dealing with people, around half of them (n= 1,053, 50.6%) reported that they faced difficulties.

The prevalence of depression among the participants was 9.4% (n= 196). The proportions of minimal, mild, moderate, moderately severe, and severe depression were 29.6%, 40.9%, 20.0%, 6.2%, and 3.2%, respectively.

The prevalence of anxiety among the participants was 7.3% (n= 151). The proportions of mild, moderate, and severe anxiety were 73.5%, 19.3%, and 7.3%, respectively. Table 2 details the prevalence of depression and anxiety among participants stratified by severity. Table 3 presents participant demographics data and their median depression and anxiety scores. Depression median score significantly differed across participants from different demographical characteristics (p<0.01).

Anxiety median score significantly differed across participants by nationality, gender, and education level (p<0.05).

Non-Saudi resident, females, elderly individuals aged 50 years and above and young individuals aged below 29 years, divorced and single, individuals with low education level, university students, and individuals with low income (2000 SR and below) tend to have higher depression median scores compared to others. Non-Saudi residents, females, and individuals with low education levels tend to have higher anxiety median scores compared to others.

The logistic regression analysis identified the following group to be at a higher risk of depression: a) unemployed individuals and b) university students. On the other hand, the following groups were at a lower risk of depression: a) Saudi resident, b) males, c) married individuals, d) individuals who completed a bachelor degree, and e) individuals with high income (5000 SR and above). Furthermore, logistic regression analysis showed that the following groups were at a higher risk of anxiety: a) unemployed individuals, and b) and

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 15, 2020. . https://doi.org/10.1101/2020.05.09.20096677 doi: medRxiv preprint university students. On the other hand, the following groups were at a lower risk of anxiety: a) males, b) elderly individuals aged (aged 50 years and above), c) divorced, d) individuals with moderate-income (5,000 SR to 10,000 SR) Table 4 .

The spread of the COVID-19 presents serious risks in Saudi Arabia and globally, which has reported 27,011 cases and 184 deaths as of the 4th of May 2020 [24] . Saudi Arabia has exceptional circumstances as it is a hub for millions of foreign workers and pilgrims from across the globe. In response to the pandemic and to combat the spread of the disease, the government took swift decisions and closed the two holy mosques, suspended travels to the country and closed most businesses and limited individuals' movement. Further, the government is also creating a national narrative to encourage citizens' adherence to emergency measures to respond to the pandemic [5] . Therefore, this research aimed at assessing the anxiety and depression among people living in Saudi Arabia during the COVID-19 outbreak.

Overall, the findings in this study demonstrated that more than 29.4% of respondents had moderate-to-severe depression, whereas, the prevalence of moderate-to-severe anxiety exceeded 26%. During stressful conditions such as the case with COVID-19 pandemic, fear and anxiety about the disease can be overwhelming that may cause depression and anxiety among adults and even children [25] . The sudden shutdown of services and lockdown of people are predisposing to such conditions particularly when dealing with the unpredictable status of the outbreak. The fear of getting the disease and losing loved ones [26] is another predisposing factor that may result in such a condition. The prevalence rate of moderate-to-severe depression symptoms in this study seems to be considerably higher than that of those reported by the Chinese study that included 1210 respondents during the COVID-19 outbreak (16.5%) whereas comparable rates for anxiety were noted (28.8%) [3] . Also, it was observed that results vary according to the sample size and the used assessment tool. Where in another nationwide study among Chinese people during the pandemic including 52,730 participants revealed a psychological distress prevalence rate of 35% among all respondents. Distress symptoms according to the employed assessment tool included depression and anxiety [27] .

The study also revealed that non-Saudi residents had significantly higher prevalence rates of depression and anxiety symptoms (p< 0.001) than Saudi individuals. Such results aligned with the percentage of infected cases among the two groups, where, the data showed a pattern in terms of who is more likely to become infected with the new coronavirus. Recent reports showed that among confirmed cases, Saudis account for 19% of total cases while other nationalities account for 81%. These results could be attributed to the status of most non-Saudis in terms of occupation, and residence status. A substantial number of foreign workers are in the labour force who live in heavily crowded areas that in most of it lack the needed social distancing requirements [28] . Previous studies reported that foreign workers experienced the highest level of distress among all occupations. Reasons such as worrying about exposure to coronavirus in public transportation when commuting to and from work, delays in work time, job security, and consequent deprivation of their salary may explain the high-stress level [27] . Such results mandate the government to take and re-enforce specific measures to control the increase of infected cases.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 15, 2020. . https://doi.org/10.1101/2020.05.09.20096677 doi: medRxiv preprint Depression and anxiety symptoms were more likely to occur in men than in women. Such results are in agreement with other studies that investigated depression and anxiety among the Saudi Arabian population. The results of a study conducted by Al-Khathami and co-workers (2002) reported that the prevalence of minor mental illness was significantly higher in women (22.2%) than men (13.7%) (p =0.0073) (29) . Further, the prevalence rate was high in the younger age group which, is in agreement with our study as a higher score of depression was associated with individuals younger than 29 years. Further, the study of Wang et al (2020) revealed that the female gender was significantly associated with a greater psychological impact of the COVID-19 outbreak and had higher levels of stress, anxiety, and depression (p < 0.05) (3) . Several factors can contribute to women's higher depression and anxiety prevalence rates including biological sex differences, culture, diet, female hormonal fluctuations, and education [30] .

Sociodemographic variables association with depression and anxiety were assessed using logistic regression analysis which showed that individuals above the age of 50 years suffer from higher depressive symptoms also, those who are single or with lower education level. Similar findings were reported by Wang et al (2020) that suggested the association of lower education with a greater likelihood of depression during the COVID-19

outbreak. Further, our findings provided data that suggested public's levels of anxiety and depression-related symptoms increase among students and unemployment or those with low income. The results were in agreement with previous research that students were more likely to have depression and anxiety during the pandemic [3] .

The onset of the pandemic was in the middle of the academic year, which contributed to students' fear of losing the year or occurrence of delays in their studies, besides the lack of confidence in remote learning. The closure and social distancing are anticipated to sustain for longer periods, and this apparently will have a direct effect on low income and unemployed individuals [31] , and, therefore. this might put such categories under a higher level of stress that could lead to anxiety and /or depression symptoms.

The results of this research emphasized the impact of the COVID-19 pandemic on the mental health of individuals, expressed in depression and anxiety. The findings of this study, in many aspects, were in agreement with those reported during the pandemic in other countries. Therefore, a worldwide collaborative effort is required to develop measures that can address mental health during the COVID-19 pandemic and manage it.

This study demonstrated several strengths. First, it addressed the prevalence of depression and anxiety within the initial phase of the pandemic and hence will provide valuable information to policymakers that will enable them to make informed decisions and introduce psychological interventions that can minimize psychological untoward effects and mental health status among Saudi Arabian people. Second, the study employed validated tools for the assessment of depression and anxiety that enhanced the reliability of the study. Third, it involved a good sample size that was not limited to specific geographical areas in Saudi Arabia. However, this study has several limitations. First, the study was based on a web-based survey method, then some vulnerable individuals who have no access to the internet and are unfamiliar with online questionnaires were missed. Second, due to the sudden occurrence of the outbreak, an individual's anxiety, and depression prevalence before the outbreak could not be pursued. Third, the survey was administered at a single period and hence the stability of the responses is unknown.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 15, 2020. . https://doi.org/10.1101/2020.05.09.20096677 doi: medRxiv preprint

During the initial phase of the COVID-19 pandemic in Saudi Arabia, more than 29.0% of the respondents had moderate-to-severe depression, and about 26.6% reported moderate-to-severe anxiety. Female gender, student status, low income, and education level respondents were associated with a greater psychological impact of the outbreak and higher levels of anxiety, and depression. Our findings may enable policymakers to introduce several measures and psychological interventions that can enhance mental health during the COVID-19 pandemic.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 15, 2020. 

Ethical approval was obtained from the School of Life and Health sciences at Najran University, Najran, Saudi

Arabia. As participation of the study was voluntary, the research ethics committee approved consent waiver.

Not applicable.

The data that support the findings of this study are available from the corresponding author upon reasonable request.

The authors declare no conflict of interest.

No fund was received for this study.

HA and AN conceived the study, wrote the methods, conducted the formal analysis, and coordinated the study.

AN, EZD, T.A. Osaid, and HA drafted the manuscript with input from all authors. All authors have been involved in drafting the manuscript or revising it critically for important intellectual content. All authors read and approved the final manuscript.

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 15, 2020 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 15, 2020. 10,000 SR and above 6.00 6.00 6.00 5.00 *p < 0.05; **p < 0.01; ***p < 0.001; Abbreviation: IQR, Interquartile Range . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 15, 2020. . https://doi.org/10.1101/2020.05.09.20096677 doi: medRxiv preprint . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted May 15, 2020. . https://doi.org/10.1101/2020.05.09.20096677 doi: medRxiv preprint

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The authors acknowledged the Deanship of Scientific Research, Najran University for funding this work ;