key: cord-0721090-brb78mcb authors: Taghizadeh, F.; Hassannia, L.; Moosazadeh, M.; Zarghami, M.; Taghizadeh, H.; Fathi Dooki, A.; Alizadeh Navaei, R.; Hedayatizadeh-Omran, A. title: Anxiety and Depression in Health Workers and General Population During COVID-19 Epidemic in IRAN: A Web-Based Cross-Sectional Study date: 2020-05-09 journal: nan DOI: 10.1101/2020.05.05.20089292 sha: 8d453396e9c8a326c26381b8f3e90e333d60d400 doc_id: 721090 cord_uid: brb78mcb The COVID-19 outbreak has exerted a great deal of psychological pressure on Iranian health workers and the general population. In the present study, the prevalence of anxiety and depression symptoms along with the related variables in this epidemic were investigated.An online cross-sectional study was conducted for the general public and healthcare workers in IRAN using a questionnaire comprised of demographic questions and Hospital Anxiety and Depression Scale. Chi square test was used to compare categorical variables, and univariate and multivariate logistic regression models were conducted.Of the 2045 participants,1136 (65.6%) were considered to have moderate and severe anxiety symptoms, and 865(42.3%) had moderate and severe depression symptoms. Based on the logistic regression models, the prevalence of anxiety was higher in the females than in the males (OR=1.4, 95% CI: 1.123-1.643, P=.002); the prevalence of anxiety was significantly higher in those aged 30-39 years than in other age groups (OR=1.6, 95% CI: 1.123-2.320, P=0.001); furthermore, the prevalence of anxiety and depression was significantly higher in doctors and nurses compared with other occupations (OR=1.9, 95% CI: 1.367-2.491, P< 0.001) and(OR=1.5, 95% CI: 1.154-2.021, P=0.003). In addition, the prevalence of anxiety symptoms in the likely-infected COVID-19 group was higher than in the noninfected COVID-19 group (OR=1.35, 95% CI: 1.093-1.654, P=0.005).A majority of health workers and general population have anxiety and depression symptoms. These symptoms are more widespread in doctors and nurses in comparison to other occupations, and psychological interventions might be conducive to reducing the negative symptoms. Wuhan, Hubei Province, China (1) .In addition to causing physical injuries, this disease has seriously impacted the human mental health (2) . On January 20, China confirmed the transfer of COVID-19 from human to human (3) . Since then, people have shown behaviors associated with anxiety. Those in quarantined areas may experience boredom, anger, and loneliness. The symptoms of a viral infection such as cough and fever may cause cognitive distress and anxiety (4, 5) . Several mental disorders such as depression, panic attack, delirium, suicidal thoughts, anxiety, and psychotic symptoms were reported during the early stages of SARS disease (4) . During the COVID-19 epidemic and SARS disease in China, major psychological health issues were observed in young people, those spending a great amount of time on the disease, and healthcare workers (6) . Due to the increase in the virus-related mortalities , both the medical staff and the general public have experienced psychological problems such as anxiety and depression (7) . On average, the medical personnel work for 16 to 22 hours per day, putting their mental health at risk ) 8 ( . High-risk positions with constant contact with the infected, high-risk infected environments with inadequate protection from contamination, lack of contact with family members, frustration, prejudice, loneliness, and fatigue further cause mental health issues such as stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear (7) . Mental health problems not only affect the medical staff's attention, understanding, and decision-making ability, but may also prevent them from combatting the virus (7) . Many of the medical and nursing staff working in Wuhan had mental health disorders (9) . Medical staff not only tolerate the excess workload, but also run a high risk of infection. Furthermore, prolonged stress increases susceptibility to depression or other mental illnesses, leading to the increased risk of infection (10) . Therefore, it is necessary to pay attention to protective factors and the process of successful adaptation to adverse conditions (11) . The paucity of research in Iran, which is currently affected by this virus, has led researchers to investigate the effects of the pandemic on depression and anxiety in the general public and healthcare workers. Finally, it is important to establish early purposive mental health interventions throughout Iran. The target population was the general Iranian population and health workers. Inclusion criteria were Iranian nationality, 15 years of age or more, willingness to participate, and ability to understand Persian language. Exclusion criteria were less than 15 years of age, major psychological disorders, and unwillingness to be studied. The project was conducted during quarantine from April 6 to April 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. (which was not certified by peer review) Informed consent was obtained electronically prior to data collection. To ensure the quality of the survey, a response range was considered for items such as age which was restricted to years, and the respondents were encouraged to carefully read the questionnaire instructions. Ultimately, a total of 2045 participants who completed the questionnaires were included in the data analysis. The study was conducted during quarantine, including inter-provincial travel ban, prohibition of nonessential business activities, and closure of schools and universities. Electronic "Porseline" Questionnaire was used as the survey tool and a professional online survey platform which can be used for the questionnaire survey, evaluation, and other purposes. Participants were recruited via advertisements on social media such as WhatsApp, Telegram, LinkedIn, and Instagram. The present study made use of online demographic questionnaires and Hospital Anxiety and Depression Scale (HADS) for the general public and healthcare workers Information: a self-designed questionnaire was devised, comprising items related to the province of residence, age, gender, job, level of education, marital status, and an additional question about the infected individuals. This questionnaire was developed by The questionnaire consists of two subscales, one related to depression and the other associated with anxiety (12, 13) , and it includes a total of 14 questions. This scale is used to classify participants into three categories: without anxiety and/or depression (scores of 0 to 7), possible anxiety and/or depression (scores ranging from 8 to 10), and anxiety and/or depression (scores varying from 11 to 21) (14) . This questionnaire was used on a general population of 6659 individuals aged 65-80 in Sweden; the internal consistency was 0.92 for the anxiety subscale and 0.88 regarding the depression subscale; moreover, the Cronbach's alpha was 0.87 on the anxiety subscale and 0.81 on the depression scale (15) . In Iran, the scale had an acceptable validity and reliability (Cronbach's alpha of 0.78 and 0.86 on anxiety (HADS-S) and depression (HADS-D), respectively) (16, 17). . 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 9, 2020. . https://doi.org/10.1101/2020.05.05.20089292 doi: medRxiv preprint Descriptive analyses were performed to describe the demographic characteristics of the Iranian population. The prevalence of anxiety and depression symptoms, stratified by gender, age, education, occupation, and infection with COVID-19, was determined. Chi square test (χ 2 ) was used to compare the categorical variables while independent sample t-test and ANOVA test compared the continuous variables with normal distribution. Univariate and multivariate logistic regression models were conducted to explore the potential contributing factors for anxiety and depression symptoms during COVID-19 outbreak. Odds ratio (OR) and 95% confidence interval were analyzed from logistic regression models. All data were analyzed using Statistical Package for Social Sciences (SPSS) version 24.0. P-values of less than 0.05 were considered as statistically significant (two-sided tests). 93% of the respondents completed the questionnaire on WhatsApp, 6% on Telegram, and 1% on other applications. The response rate was 59%, and the average time of response to questionnaire was 08.17 minutes. The results of this study are as follows: Based on the online survey, had lower education levels. Tables 2 and 3 show the prevalence of anxiety and depression symptoms stratified by gender, education, marriage, age, and occupation. Univariate and multivariate logistic regression models are presented in Tables 5 and 6 . Of the 2045 participants, 1136 (65.6%) had moderate 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 9, 2020. . https://doi.org/10.1101/2020.05.05.20089292 doi: medRxiv preprint severe anxiety symptoms, and 865 (42.3%) had moderate and severe depression symptoms. According to Tables 5 and 6 and the logistic regression models, the prevalence of anxiety in females was significantly higher than in males (OR=1.4, 95% CI: 1.123-1.643, P=.002). However, there were no significant differences between males and females concerning the prevalence of depression (OR=1.1, 95% CI: .912-1.336, P=.312). The prevalence of anxiety and depression in the age group 30-39 was significantly higher than in other age groups (OR=1.6, 95% CI: 1.123-2.320, P=0.001), (OR=1.17, 95% CI: .815-1.679, P=.394). The prevalence of anxiety and depression was significantly higher in doctors and nurses compared with other occupations (OR=1.9, 95% CI: 1.367-2.491, P< 0.001), (OR=1.5, 95% CI: 1.154-2.021, P=0.003).Other findings showed that the prevalence of anxiety and depression was not related to the marital status (P=.982, .354). Furthermore, the prevalence of anxiety in specialist physicians was significantly higher than in general physicians, and the anxiety of both groups was significantly higher than other education levels (X2=30.346, P=0.007); however, , the prevalence of depression was not significant in education levels (X2=22.800, P=0.064). The results of the analysis of the infected are shown in Table 4 The aim of this study was to investigate the anxiety and depression symptoms in health workers and the general public during COVID-19 pandemic in Iran. Based on the results of the current study, 65.6% of the participants had anxiety symptoms, and 42.3% had depression symptoms. Furthermore, women had more anxiety than men, and anxiety in those aged 30-39 was significantly higher than in other age groups. Anxiety and depression were significantly more prevalent in doctors and nurses compared with other occupations. Additionally, anxiety symptoms in the likely-infected COVID-19 group was higher than in the noninfected. . 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 9, 2020. . Previous studies reported emotional distress severity and symptoms of stress and anxiety in many people and health workers. The following are some of these studies: Lee SM et al. made use of interviews and HADS and found that 11% of the participants were anxious, and 15.1% were depressed in the early stages of the outbreak (18) . Cao et al. examined the psychological impacts of the COVID-19 pandemic on the students of a Chinese university; they reported that 0.9% of the students had severe anxiety, 21.3% had mild anxiety, and 2.7% had moderate anxiety (19) . In the present study, 24.7% of the students had moderate anxiety, and reported moderate to severe depressive symptoms, and 28.8% reported moderate to severe anxiety symptoms. Females, students, and those with physical symptoms and poor health had significantly higher levels of anxiety and depression (22) . This is in line with a systematic review where students, females, and individuals with the symptoms of COVID-19 had higher rates of depression and anxiety (23) . 65.6% of the participants in our study had anxiety symptoms, and 42.3% had depression symptoms. The odds ratio of anxiety symptoms in females was 1.4 times more than that of male. Huang Y and Zhao N investigated 7,236 volunteers and reported that the overall prevalence of depressive symptoms in the general public was 20.1%. Moreover, young people had a significantly higher prevalence of depression symptoms in comparison with others (24) . The multivariate logistic regression in our results revealed that the prevalence of depression symptoms in the age group >=60 years and the anxiety symptoms in those aged 30-39 years were higher than others. The physicians showed higher scores of anxiety and depression compared with other medical staff (4). Mo Y et al. found that stress of 180 nurses taking care of COVID-19 patients was . 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 9, 2020. (1). Previous studies reported that the mental health of medical workers was in a worse state compared with the general population (28) (29) (30) , which is consistent with the present results. Zhu J et al. found that the prevalence of anxiety and depression symptoms was 11.4% and 45.6% in physicians and 27.9% and 43.0% in nurses (31) . In a study in Singapore and India, the depression symptoms was reported 10.6% and anxiety symptoms was In the current study, 51.4% and 52% of the nurses and doctors had depression symptoms while 68.6% and 68.5% had anxiety symptoms .The nurses and doctors in Iran have experienced higher symptoms of anxiety and depression than the chines(31) and other countries(32) during the outbreak. Perhaps, one of the reasons is the lack of sufficient personal protective equipment such as gloves and masks at the beginning of the outbreak due to the Iran economic sanctions. Among the 994 medical and nursing staff in Wuhan, 36.9% had sub-threshold mental health disorders, 34.4% had mild disorders, 22.4% had moderate disorders, and 6.2% had severe disorders (9). Huang Y and Zhao N found that compared with other occupational groups, healthcare workers were likely to have a lower quality of sleep (24) . Zandifar and Badrfam (33) stated that the severity, uncertainty, and unpredictability of COVID-19, social quarantine, and misinformation contributed to anxiety. They further highlighted the . 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 9, 2020. . https://doi.org/10.1101/2020.05.05.20089292 doi: medRxiv preprint need for both mental health services, particularly for vulnerable populations, and the establishment of social wealth to reduce the adverse psychological effects of the outbreak. Anxiety symptoms in infected COVID-19 likelihood was higher than the no infected COVID-19 group and, comparing to the confirmed infected group was not statically significant. While, depression symptoms in infected COVID-19 likelihood was not statically significant comparing to the no infected and infected groups. Nguyen HC et al. found that the people with Suspected COVID-19 symptoms had a higher depression likelihood than those without COVID-19 (34) . The majority of the medical staff and general population in our study experienced anxiety and depression symptoms. To address the concerns about COVID-19 in Iran, a free 1480 hotline has been provided, mental health professionals are providing guidelines in hospitals and medical centers, and NGO groups consisting of psychologists are counselling for free. Healthcare providers can also offer suggestions for coping with anxiety and depression and link patients to social and mental health services. Since media reports can be emotionally distressing, COVIDrelated news should be checked and restricted. Researchers should also assess the effects of COVID-19 on other vulnerable people, including children and adolescents, those residing in rural areas and lacking access to healthcare, and individuals belonging to lower socio-economic states. It is also necessary to develop mental health interventions which are time-limited, sensitive to culture, and can be taught to volunteers and healthcare workers. In this cross-sectional study, we were not able to establish a causal link; furthermore, we used the self-rating scale to evaluate the depression and anxiety symptoms of the medical staff and the general public. Finally, the age group did not include those above 60 years of age possibly due to the lack of access to Internet smartphones, or applications. . 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 9, 2020. . The authors declare that they do not have any interests that could constitute a real, potential or apparent conflict of interest with respect to their involvement in the publication. The authors also declare that they do not have any financial or other relations with companies, trade associations, unions or groups that may gain or lose financially from the results or conclusions in the study. All procedures were conducted according to the Declaration of Helsinki and was approved by the FT conceptualized and designed the study, review and revised the manuscript, and approved the final manuscript as submitted. LH, RA and AH designed the data collection instruments, coordinated and supervised data collection, carried out the initial analyses, and interpreted the data, drafted the initial manuscript, and approved the final manuscript as submitted. HT, MF, FF and MZ agree to be cooperation for all aspects of the study. All of the authors edited and approved the manuscript. This study was supported and funded by Mazandaran University of Medical Sciences. . 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 9, 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 9, 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 9, 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 9, 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 9, 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 9, 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 9, 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. (which was not certified by peer review) The copyright holder for this preprint this version posted May 9, 2020. . https://doi.org/10.1101/2020.05.05.20089292 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. 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Iranian mental health during the COVID-19 epidemic People with Suspected COVID-19 Symptoms Were More Likely Depressed and Had Lower Health-Related Quality of Life: The Potential Benefit of Health Literacy The authors are grateful to Mazandaran University of Medical Sciences, all the respondents who participated in this study, and the research assistants and colleagues who kindly cooperated in the conduct of the study.