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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 273-280

Depression, anxiety, and stress among the community during COVID-19 lockdown in Saudi Arabia

1 Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Students, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission08-Jun-2021
Date of Decision31-Mar-2022
Date of Acceptance18-Apr-2022
Date of Web Publication08-Jul-2022

Correspondence Address:
Sulaiman A Alshammari
Department of Family and Community Medicine, College of Medicine, King Saud University, P. O. Box 2925, Riyadh 1146
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsm.jnsm_62_21

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Objectives: (1) We aimed to measure the levels of depression, anxiety, and stress among the Saudi population during COVID-19 lockdown and their association with different personal characteristics. (2) The secondary aims included assessing the perceived social and physical impacts of COVID-19 lockdown on individuals and the different coping strategy practices during this tough period. Methods: A cross-sectional study was conducted between May and June 2020 in Saudi Arabia. We collected data from both sexes aged 18 years and older using social media. The online questionnaire collected data on their sociodemographic, physical, and social conditions, and the presence and control of chronic diseases as well as their evaluation according to the Depression, Anxiety, and Stress Scale-21. Results: Of the 878 participants, 56.6% were female, 54.6% were aged between 35 and below, 52.6% were married, and 97.4% had a secondary school and above. Approximately a quarter of the participants or relatives had been diagnosed with COVID-19. Moderate-to-severe depression, anxiety, and stress were reported in 32.6%, 28.7%, and 22.6% of the participants, respectively. The younger than 35 years, unmarried, not working, and the previous diagnosis of COVID-19 were associated with higher scores of depression, anxiety, and stress. In addition, the participants reported several coping strategies such as doing physical exercise, hobbies, chatting over social media, watching TV/movies, playing electronic games, increasing religious prayers, and getting psychosocial help. Conclusion: A quarter of the participants reported a moderate-to-severe psychological impact. They adopted various strategies to reduce the adverse lockdown effect. In a future pandemic, health-care providers and policymakers can focus on potential risk factors and coping strategies to prevent, intervene early, and treat sufferers.

Keywords: Anxiety, COVID-19, depression, Depression, Anxiety, and Stress Scale-21, lockdown, stress

How to cite this article:
Alshammari SA, Alotaibi RS, Almajed AA, Omar TA. Depression, anxiety, and stress among the community during COVID-19 lockdown in Saudi Arabia. J Nat Sci Med 2022;5:273-80

How to cite this URL:
Alshammari SA, Alotaibi RS, Almajed AA, Omar TA. Depression, anxiety, and stress among the community during COVID-19 lockdown in Saudi Arabia. J Nat Sci Med [serial online] 2022 [cited 2022 Aug 17];5:273-80. Available from: https://www.jnsmonline.org/text.asp?2022/5/3/273/350303

  Introduction Top

A coronavirus outbreak occurred in December 2019 in Wuhan, China.[1] The sickness was caused by the severe acute respiratory syndrome coronavirus-2, which spread by microscopic droplets during coughing, sneezing, or speaking. On March 16, 2020, the WHO announced the outbreak of COVID-19 was a pandemic.[2] In Saudi Arabia, the first case was confirmed on March 2, 2020.[3] As a result, the Saudi government decided to suspend attendance at most government agencies.[4] A total lockdown of the citizens and residents began on March 6, 2020.[5] On March 17, the private sector was instructed to work remotely, and the Friday prayers and group prayers were banned in mosques.[6],[7]

There is no doubt that this pandemic has caused harm to families, health-care systems, and the global economy.[8] Mental well-being is an essential aspect of general health, and maintaining it is crucial to leading a healthy life.[9],[10] The lockdown responding to the COVID-19 pandemic had multiple psychological impacts on the general population, including depressive symptoms, anxiety, stress, social isolation, loneliness, and posttraumatic stress, among other psychological consequences.[11] Emotional disturbances cause sleep problems, which affect the next day's work quality.[12] Furthermore, anxiety and stress have been identified as possible factors impeding the strategies for prevention and control.[13]

In China, the Impact of Event Scale-Revised and Depression, Anxiety, and Stress Scale-21 (DASS-21) showed that 53.8% of the participants experienced some sort of psychological impact from COVID-19. Participants who reported moderate-to-severe depression accounted for 16.5% of the participants. Furthermore, 28.8% reported moderate-to-severe anxiety symptoms, and 8.1% reported moderate-to-severe stress levels.[14] Furthermore, the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 questionnaire, which measured depressive and anxiety symptoms among adolescents, showed that 43.7% of the participants reported depressive symptoms, while 37.4% reported anxiety symptoms during the COVID-19 outbreak, in China.[15] Another study using the DASS-21 scale showed that 9.3% of the participants experienced severe anxiety, while 9.8% experienced very severe anxiety.[16]

Various factors were associated with higher anxiety, depression, or stress levels. For example, according to the results of one study, anxiety, depression, and stress were associated with age <40, being single, and history of COVID-19, but not to the gender of the participants.[14],[17],[18]

In the Gulf Cooperation Council countries, it was found that being female, being single, being of young age, and having medical conditions were all positively associated with developing depression, anxiety, insomnia, and posttraumatic stress.[19]

In a study from Qatar, several personal characteristics were identified as increasing the odds for moderate-to-severe depression. These included being of Arab ethnicity, single, history of psychiatric disorders, elevated concerns caused by social media use for COVID-related news and updates, history of COVID-19, loneliness, and lower levels of religiosity.[20] In addition, several characteristics were associated with an increased risk of depression or anxiety. For example, a study measuring posttraumatic stress after lifting the lockdown measures found a substantial increase in psychological distress among the Saudi population where 27.8% reported severe or extremely severe stress, 31.4% reported having anxiety, and 39% reported depressive symptoms.[21] Unlike preventative actions such as hand hygiene and mask wearing, following specific up-to-date and accurate health information lowers the chance of depression or anxiety symptoms.[22]

The use of humor on social media was particularly effective at increasing participants' feelings of happiness while simultaneously reducing their anxiety levels.[23],[24] People with severe stress symptoms can also benefit from cognitive-behavioral therapy.[25] These measures should be supplemented by a psychological home intervention that helps quarantined people overcome their anxiety and negative coping styles.[26]

Numerous studies in Saudi Arabia have examined the mental health of medical field workers. However, few studies examined the mental health aspects of the community as a whole during the pandemic lockdown period. Our study is concerned with community psychological health during the outbreak and lockdown. Therefore, we aimed:

  1. To measure the levels of depression, anxiety, and stress among the Saudi population during COVID-19 lockdown and their association with different personal characteristics
  2. Secondary aims included assessing the perceived social and physical impacts of COVID-19 lockdown on individuals and the different coping strategies practices during this tough period.

  Methods Top

The investigators conducted a cross-sectional study in Saudi Arabia from May to June 2020. A self-administered online questionnaire was distributed using the snowballing method via WhatsApp. The questionnaire was administered electronically using SurveyMonkeyÒ software. The participants included both men and women aged 18 years and older. In addition, we excluded non-Saudis and adults with known cases of depression and anxiety based on the “self-report” of the participants.

After reviewing the previous studies,[14],[17],[18] the required sample size to detect the level of depression, anxiety, and stress among the Saudi community during the outbreak of COVID-19, the average prevalence of these three psychiatric conditions was 57.8%. Thus, assuming a proportion of 57.8%, a confidence level of 95%, and an error of 0.05, the calculated sample size was 375. After assuming a response rate of 90%, the adjusted minimum required sample size was 417.

The questionnaire consisted of five sections. The first section inquired about demographic data such as age, sex, nationality, education level, marital status, socioeconomic status, and occupation. The second section included the DASS-21 scale items, which assessed the level of depression, anxiety, and stress. The third section covered the perceived impact of the COVID-19 lockdown on their physical conditions. The fourth section covered the perceived social impact, and the fifth section covered the perceived impacts of the COVID-19 lockdown on people with chronic diseases.

The DASS-21 consists of 21 statements. The respondents' rate each item on a four-point Likert scale (0 = never, 1 = sometimes, 2 = often, and 3 = almost always). The cutoff scores for defining normal, mild, moderate, severe, and extremely severe depression, anxiety, or stress for each DASS subscale are shown in [Table 1].
Table 1: Cutoff points used for each psychological construct in the Depression, Anxiety, and Stress Scale-21

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The Institutional Review Board of the College of Medicine, King Saud University, approved the project (Research Project No. E-20-5094). All the participants provided written informed consent.

Statistical analyses were conducted using the Statistical Package for the Social Sciences version 26 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, version 26.0. Armonk, NY, USA: IBM Corp.). First, we calculated the categorical data's median, frequencies, and percentages. Then, three logistic regression models, each having one of the DASS constructs (depression, stress, and anxiety) as the dependent variable, were done to report odds for “depression” or “anxiety” or “stress” with the risk factors. The age, marital status, work arrangement, past diagnosis of COVID-19, and presence of chronic diseases were considered independent variables. We reported odds ratios and 95% confidence intervals (CI) for regression analysis.

  Results Top

A total of 900 participants completed the questionnaire voluntarily. However, only 878 participants fulfilled the criteria and were included in the study. Of the 878 participants, 497 (56.6%) were women. Most of the respondents, 54.6%, were aged 35 years and below; 52.6% were married; and 97.4% had a secondary school and above. In addition, 7.6% were health-care professionals. Of the participants, 19.2% had chronic diseases, and 25.7% had past or family history of COVID-19 diagnosis. Those participants who experienced moderate, severe, and extremely severe symptoms of depression were 15.7%, 7.4%, and 9.5%; anxiety 13.8%, 6.0%, and 8.9%; and stress 9.1%, 8.3%, and 5.2%, respectively [Table 2].
Table 2: Demographic and clinical characteristics of the participants by Depression, Anxiety, and Stress Scale-21 subsets

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The odds ratio (95% CI) in the regression analysis assessed the association of high versus low depression, anxiety, and stress with other characteristics. The low depression score was associated with the older age group 95% CI 0.491 (0.331–0. 728), while the high depression score was associated with being not married 95% CI 1.197 (1.808–1.774), not in working status 95% CI 1.112 (0.812–1.522), the previous diagnosis of COVID-19 infection 95% CI 1.353 (0.991–1.847), and having chronic diseases 95% CI 1.332 (0.924–1.922).

High anxiety score was associated with being not married 95% CI 1.370 (0.922–2.034), not in working status 95% CI 1.017 (0.740–1.398), history of COVID-19 infection 95% CI 1.906 (1.394–2.606), and having chronic diseases 95% CI 1.198 (0.826–1.739). The high stress score was associated with being not married 95% CI 1.162 (0.786–1.718), working from office or not in working status 95% CI 1.320 (0.855–2.039) and 95% CI 1.141 (0.836–1.557), and history of COVID-19 infection 95% CI 1.330 (0.977–1.811) and having chronic diseases 95% CI 1.217 (0.849–1.743) [Table 3].
Table 3: Regression analysis for assessing the association of high versus low depression, anxiety, and stress with other characteristics

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During the COVID-19 lockdown, 65.5% did not report a change in their appetite, while 20.8% had overeaten, 46.4% did not change their weight, and only 31.3% gained weight. Most participants did not notice any change in their sleep patterns, but 29.6% experienced interrupted sleep. Among the respondents, 50% were less physically active than usual. On the other hand, 30.5% of the participants had increased physical activity levels. This study also showed that 43.8% washed their hands as instructed by the health authorities. Regarding smoking habits, 87.1% were not smokers, while 5.5% were smokers [Table 4].
Table 4: Physical impacts of COVID-19 pandemic lockdown as reported by participants

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The majority of our participants had no problems following the preventive precautions such as wearing masks, maintaining social distance, avoiding the traditional gatherings with relatives and friends, and avoiding gatherings with relatives and friends. However, more male participants reported embarrassment with these precautions than female counterparts.

However, more women than men avoided public utilities and thought that lockdowns increased domestic violence [Figure 1].
Figure 1: Social impact during COVID-19 lockdown

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Most of our participants reported doing something to cope with the lockdown situation. Both sexes reported involvement in physical exercise, hobbies, chatting over social media, watching TV/movies, playing electronic games, increasing religious prayers, and getting psychosocial help. However, women showed more involvement in such coping strategies than men except in playing electronic games [Figure 2].
Figure 2: Coping strategies of the participants by sex

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  Discussion Top

Psychological disorders caused by viral outbreaks, either direct or indirect exposure, continue to affect millions of people worldwide, and they must be appraised, and strategies for their care developed. The majority of our participants reported a normal DASS-21 score. However, only 32.6% reported moderate-to-severe depression, 28.7% reported moderate-to-severe anxiety, and 22.6% reported moderate-to-severe stress.

While the findings of our study were similar to the findings of a study conducted in China, where 16.5% of their participants experienced moderate-to-severe depression, 28.8% moderate-to-severe anxiety, and 8.1% moderate-to-severe stress,[14] the levels of severity of these mental health conditions among our study population were similar to what has been reported in India, where 22.2% experienced moderate-to-severe depression and 18.2% moderate-to-severe anxiety. On the other hand, that Indian study reported a lower stress level (2.0%).[27]

Similarly, our study reported lower depression, anxiety, and stress scores than a Spanish report which showed that 37.22% experienced depression, 46.42% anxiety, and 49.66% stress during the COVID-19 pandemic.[28] The lower levels of depression, anxiety, and stress reported in our participants could be due to the health authority's efforts to increase awareness about COVID-19 and provide free health-care support through online consultations, free-of-charge swabbing, and clinical management.[29] Moreover, the number of critical cases and mortality of COVID-19 were relatively lower in Saudi Arabia than in other countries, which may have contributed to the lower DASS-21 construct score level.[30]

The present study found that being younger than 35 years, being unmarried, having a history of COVID-19, and having chronic diseases were associated with higher odds for anxiety, depression, or stress, consistent with a previous study.[12] These findings aligned with studies conducted in India and the Philippines.[14],[27],[31] However, unlike other studies, we found no correlation between educational level and DASS-21 construct score.[14],[27] Furthermore, there was no statistical difference in mental well-being between males and females similar to a previous study.

Most of our participants had no problem taking precautions during the pandemic, which was consistent with previous studies.[32],[33] In addition, women showed more compliance with precautions than men, consistent with previous studies.[34],[35] However, men were more embarrassed by wearing masks and avoiding gatherings with relatives and friends, making them less compliant. In our community, men were more socially active than women, with some interacting with people daily. Thus, compliance with some preventive precautions may be perceived as embarrassing and more difficult. In addition, about one-third of our respondents gained weight due to overeating, snacking, and low physical activities. Similar findings were reported in Poland and the UK.[36],[37]

Furthermore, half of the respondents were less physically active than usual in this study. In addition, several studies found a decrease in participants' physical activity.[38],[39] These findings are understandable as the options for performing physical activities were limited during the COVID-19 lockdown. Emotional disturbances cause sleep problems, which affect the next day's work quality. In this study, about one-third of the participants experienced interrupted sleep. However, poor sleep quality has also been reported in surveys conducted in a previous study.[12] Only 5.5% of the smokers in this study noticed an increase in smoking patterns. Another study showed that 3.3% of the smokers decided to quit smoking which meant that the lockdown had a positive effect.[40]

As the disease spreads, it will be vital to gather data on digitally aided psychotherapy effectiveness and educate patients. Studies link coping strategies to anxiety symptoms and emotional suffering. For example, problem avoidance was the most popular coping strategy, but it did not diminish anxious symptoms. Expressed emotions and social support had the opposite effect.[41],[42]

Most of our participants reported doing something to cope with the lockdown situation. However, women showed more involvement in such coping strategies than men except in playing electronic games. In general, the use of social media is the primary coping mechanism for adverse psychological effects during pandemics. However, unlike other strategies, social media helped increase happiness among the participants in a previous study.[23] In addition, the usage of humor was associated with significantly lower anxiety levels.[24] Therefore, providing free Internet subscriptions and good connections for people to be active on social media and communicating with their loved ones can be one of the measures used to cope with a lockdown with minimal psychological effects. Moreover, such a maneuver may increase the level of caring for family members, support them, and share feelings with them, as seen in a previous study.[17]

About 50% of the participants resorted to prayer more among women, which is different from a study conducted in the USA that showed that two of the least common mechanisms were therapy and prayer.[43] Approximately half of the participants reported physical exercise as a coping mechanism consistent with a previous study.[44] There were no significant differences in the DASS-21 scores between those with chronic diseases and those free from them. There were still a variety of findings in the literature about the impact of chronic diseases on mental health during the pandemic.[45],[46] Therefore, it is advisable to focus on treating individuals rather than the entire community. For example, cognitive-behavioral treatment is indicated for those who suffer from severe stress symptoms for weeks following the traumatic event. This therapy has been proven to be effective.[25] In addition, the Ministry of Health's phone consultation services should be supplemented by a psychological home intervention that helps quarantined people overcome their anxiety and negative coping styles.[26]

This study had some limitations. First, the survey was distributed via WhatsApp because of the lockdown, resulting in selection bias and nongeneralizability. Due to the snowballing method used for sampling, we were unable to identify the number of individuals who received the questionnaire link, so we cannot estimate a response rate. Finally, because the participants were asked about symptoms that had occurred over a while, it is possible that they under- or overreported the severity of their symptoms (recall bias). Notably, the DASS-21 is a symptom screening tool. As a result, future research should use diagnostic tools whenever possible to accurately assess the true prevalence of these disorders.

  Conclusion Top

Over a quarter of the subjects experienced moderate-to-severe psychological effects. In addition, the high COVID-19 score was associated with younger than 35 years, unmarried, past diagnosis with COVID-19, and having chronic diseases. Most participants took the pandemic precautions. Nevertheless, a third of the group gained weight. They tried to cope with overwhelming emotions and stress by exercising, chatting on social media, and seeking psychosocial/psychological support. These findings may help decision-makers and health professionals minimize the psychological impact of lockdowns in future pandemics, especially among high-risk groups.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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