International Journal of Emergency Mental Health and Human Resilience
Open Access

COVID-19, Depression, Anxiety, Stress

The COVID-19 pandemic, which was identified as an acute respiratory syndrome, emerged in December 2019 and was caused by a new type of COVID from the SARS family. In March of the following year, the World Health Organization officially declared an outbreak of this virus, which has since spread to more than 200 countries across the worldwide (Alzueta E, 2021).

These outbreaks have had significant impacts on the health and economy of the countries affected. Recent statistics indicate that over 227 million people worldwide have been infected with various coronavirus mutations, resulting in more than 4 million deaths as of early March. Italy, Spain and the United Kingdom have experienced particularly high rates of infection. Since mid-April, the death toll in the United States has been on the rise, with the southern and western states most affected. Iran, however, has been able to control the number of deaths and casualties at home through quarantine measures, currently ranking 15th worldwide. Latin America has become another major center of the Corona epidemic, with the highest death tolls currently in Panama, Peru, Bolivia, Brazil, Mexico and Colombia. The United States, Brazil, Russia, Mexico, India and South Africa are also seeing rising numbers of cases (Alexander JL, 2007).

Coronavirus has become a global crisis with significant impacts on both physical and mental health. Governments worldwide have implemented various health measures like physical distancing and home quarantine. However, the course of changes and available information about the pathogenicity of COV-SARS2 virus is still limited in terms of control and treatment methods. Currently, the most effective method of controlling or preventing the spread of the virus is through home quarantine.

Quarantine is a temporary measure that involves separating and restricting the movement of people who have potentially been in contact with an infected person. The aim is to identify those who may have developed clinical symptoms and thus reduce the risk of transmitting the disease to others. Individuals in quarantine may be healthy or asymptomatic and the presence of people in quarantine does not necessarily indicate that they have contracted the virus. It is important to note that quarantine is different from isolation, as the latter involves the complete separation of infected patients from healthy individuals (Chew QH, 2020).

During the outbreak of the plague in Italy, the implementation of quarantine was initiated by the government for the first time. The decision to use quarantine as a solution depends on the rate of transmission and spread of the disease. As seen in the cases of China and Canada during the acute respiratory syndrome in 2003, quarantine was employed. Similarly, the United States implemented a three-week quarantine to control Ebola in 2014, while South Korea publicly quarantined the country following the outbreak of acute respiratory syndrome in the Middle East in 2015. In recent years, the use of quarantine as a means of preventing or reducing the spread of diseases has declined due to advancements in medicine. However, in light of the outbreak of the coronavirus and the limited understanding of its transmission, quarantine has been deemed necessary (Chen L, 2021).

While these measures have proven somewhat successful in controlling the spread of the coronavirus, they have had a profound impact on people's daily lives. Self-regulation disorders and reduced social communication have provided a foundation for mental health issues, particularly among vulnerable populations. Previous studies have examined the effect of quarantine on mental health during outbreaks of diseases such as Ebola, SARS and Meres. Fatigue, anxiety, irritability, insomnia and confusion were among the conditions experienced by those in quarantine. Medical personnel who were in quarantine or working in high-risk environments were found to display signs of alcohol abuse or drug dependence after the outbreak of SARS.

In a 2011 study, Wang found that there was no significant difference in mental health between those who were quarantined for SARS and those who were not. However, another study showed that 66% of quarantined individuals described their exposure to SARS as an unpleasant experience. Quarantine treatment staff during the SARS outbreak were also found to exhibit more post-traumatic stress symptoms than their counterparts. Moreover, the results of various studies have indicated that the psychological effects of SARS are significantly determined by the characteristics of the participants. Specifically, individuals with lower levels of education, females and those of a younger age are more likely to experience negative mental states such as depression and anxiety during quarantine. The aftermath of the outbreak was observed to have a profound impact on the general public (Etxebarria NO, 2020).

It is noteworthy that certain demographic factors, such as age, level of education, family status and number of children, have been found to be unrelated to psychological disorders in some studies. However, the duration of quarantine, fear of infection and insufficient information have been linked with anxiety. Few studies have reported a high prevalence of psychological disorders during quarantine, but social exclusion and discrimination in monitoring in different areas can lead to public panic and anxiety. More than a third of the global population underwent quarantine due to the challenges posed by the Coronavirus outbreak, which has caused concern among many countries. Consequently, numerous studies have been conducted on mental health during quarantine. Being in quarantine can have negative impacts on the mental health of individuals in the community, as highlighted by Sprung and Salman.

Stress is characterized as the emotional and physical tension resulting from an event that poses a threat to our lives, while anxiety denotes the fear of the unknown. Depression is defined as a lack of interest in daily activities. The current epidemic of the Coronavirus, for which there is no definitive cure, is believed to be a global mental health crisis. Fear of the virus leads to anxiety, depression and stress in humans.

Depression manifests as a state of disinterest in daily activities. The World Health Organization has recommended mental health and anxiety management protocols due to the widespread concerns around mental health globally. Studies have shown that 25% of parents and their children experienced post-traumatic stress during quarantine. Wang et al. reported an increase in anxiety, stress and depression among Chinese individuals, while Jeung's study during the Meres disease outbreak revealed anxiety symptoms in 76% of 1656 patients. A Korean study found that 16% of the population presented symptoms of anxiety and anger (Fountoulakis KN, 2021).

Similar findings were observed in Canada. In a cross-sectional study by Lai et al. that examined the mental health of healthcare providers in China, one participant disclosed depression, while three out of five individuals reported symptoms of anxiety and insomnia. It appears that stress, anxiety and depression can also be influenced by factors such as gender, occupation, socioeconomic status and place of residence. While most research on the psychological well-being of hospital staff and patients has been undertaken, there is a paucity of studies on the mental health of the general population in Iran. Maro and Rodrigo et al. conducted a study in May and June 1999 to examine the psychological characteristics, such as depression, anxiety and stress, of individuals and the relationship between education and news source of individuals during quarantine. The Anxiety, Stress and Depression Scale (DASS) was the measurement tool used in this online survey, which included 529 people with a mean age of 31 years, of whom 70% were employed. Depression, anxiety and stress were reported in 11.7%, 16.9% and 5.6% of the participants, respectively. Women, people with low education, unemployed individuals, villagers and those who had flu-like symptoms reported higher levels of stress, anxiety and depression.

Alzota et al. conducted a study entitled "How the Corona Epidemic Changed Our Lives: A Study of Psychological Characteristics in 59 Countries." A sample of 882.6 individuals was used in this study. The findings of this study suggested that participants experienced moderate to severe levels of depression (25.4%) and anxiety (19.5%), respectively. However, the rate of anxiety and depression was reported to be 21.5% in high-income countries. Factors such as conflict and interpersonal disputes and the difficulty of creating telecommuting opportunities in certain countries increased the rate of depression and anxiety. Countries in the Caribbean and Latin America reported lower rates of depression and anxiety than countries in North America, Europe, Central Asia and sub-Saharan Africa.

A study conducted by Roman ham et al. examined the psychological distress experienced by Tunisian society during the outbreak of coronary artery disease in relation to religious beliefs. Findings indicated that 28.3% of participants reported depression, 24.4% reported anxiety and 19.4% reported severe and very severe stress. Interestingly, no significant relationship was found between depression, anxiety and religious beliefs. Nonetheless, it is recommended that researchers consider religious beliefs as an effective factor in combating diseases (Fawaz M, 2021).

Yildirim et al. conducted a study on the level of anxiety experienced by elderly individuals during quarantine due to the coronavirus pandemic. Results revealed that the level of anxiety and depression in the sample population increased and social isolation was found to be a contributing factor. In fact, all participants displayed at least one symptom of anxiety, stress or depression. Depression and anxiety are common psychiatric issues among the elderly, particularly those with coronary heart disease, who may face difficulty meeting their care needs. The purpose of this study is to explore the psychological characteristics of Iranian society during the COVID-19 quarantine period and to examine how individuals follow news related to the virus.

This cross-sectional study employed an available sampling method, with data collected online using questionnaires shared on various social networks. Data collection began on February 19, 2019, two weeks after the announcement of the first home quarantine in Iran and continued until the end of May. The survey was conducted in Persian and ethical standards were upheld throughout. Participants were over 16 years old, from various walks of life and both genders. No personal information was requested and participants could choose not to answer any questions. Of the 2,476 visitors to the survey link, 936 responded, resulting in a response rate of 54%. The final sample of 936 participants (115 men and 821 women) was selected using available random sampling. The mean age of the sample was 38.36 years, with a standard deviation of 10.16. The youngest participant was 16 years old and the oldest was 75 years old.

Tools

In this study, the participants were requested to provide demographic information, including age, gender, level of education, employment and news sources about Corona. Additionally, the participants were asked about the specific type of news site they accessed, such as the World Health Organization website, social networks, Iran Ministry of Health website and television, in relation to coronary heart disease. The participants' educational levels were as follows: 27 individuals with doctoral studies, 147 individuals with master's degrees, 416 individuals with bachelor's degrees and 345 individuals with diplomas. Interestingly, the majority of participants with a bachelor's degree or lower watched the news on Iranian television.

To assess the psychological characteristics of the participants, the Lovibond Depression, Anxiety and Stress Questionnaire (Dass-21) was utilized. This questionnaire is a 21-item self-report scale, which evaluates negative emotional states in depression, anxiety and stress. Participants were required to indicate the status of their symptoms during the past week. The questionnaire is useful in assessing treatment progress over time, as it provides a comparison of symptom severity across different weeks. Anthony et al. identified three factors of depression, anxiety and stress through analyzing the scale. The results of this study showed that 68% of the total variance of the scale is measured by these three factors.

The eigenvalues of stress, depression and anxiety in the study were 9.07, 2.89, 1.23 and alpha coefficient for these factors were 0.97, 0.92 and 0.95, respectively.

Also, the results of calculating the correlation between factors in the study of Anthony et al. showed a correlation coefficient of 0.48 between the two factors of depression and stress, a correlation coefficient of 0.53 between anxiety and stress and a correlation coefficient of 0.28 between anxiety and depression. The validity and reliability of this questionnaire in Iran have been examined by Samani and Jokar. Validate the test for the depression, anxiety and stress scale of 0.80, 0.76 and 0.77, respectively and the Cronbach's Alpha for the depression, anxiety and stress scale of 0.81, 0.74 and/78, respectively. 0 have reported that in the validity study of this scale, the statistical method of factor analysis of confirmatory type and principal components method was used. The numerical value of KMO index was equal to 0.9012 and also the numerical value of X² index in Bartlett sphericity test was equal to 3092.93 which was significant at the level of 0.0001. And indicated the adequacy of the sample and the variables selected for factor analysis. Based on the factor analysis performed with Varimax rotation on the questionnaire items and based on the eigenvalues and slope of the screen diagram, three sub-scales were extracted: Depression, anxiety and stress, which are in line with the main DASS test factors. Each DASS subscale consists of 7 questions, the final score of each of which is obtained through the sum of the scores of the related questions (Table 1). Each question is scored from zero (does not apply to me at all) to 3 (absolutely does not apply to me). Since DASS-21 is the abbreviated form of the main scale (42 questions), the final score of each these subscales should be doubled. Then, by referring to Table 2, the severity of the symptoms can be determined.

Table 1. Subscales and related questions

Table 2. Intensity of subscale

Data analysis

The present study employed S.P.S.S software, version 23, to scrutinize the data. Invalid data were expunged from the dataset. Descriptive statistics namely mean, standard deviation and frequency were executed. The demographic data of the samples were scrutinized. Using the Lovibond scale, the levels of depression, anxiety and stress were computed for the sample as a whole and for different age, gender and employment cohorts. Furthermore, the association between education level and the source of information pertaining to the pandemic was established.

Based on the findings presented in Table 3 and taking into account the range of symptom severity as measured by the Lavibond questionnaire, it is evident that the sample group experiences an average stress level of 19/36 ± 10/57, indicating a moderate level of stress, while the average depression level is 14/0 ± 11/32, also at a moderate level. Additionally, the average anxiety level is 9/22 ± 8/53, indicating a mild level of anxiety. The study also reveals the age range of the individuals under investigation (Fekih-Romdhane F, 2021).

Table 3. The psychological features and the standard deviation.

The results indicate that the mean stress experienced by the elderly is 28.40 ± 10.13, which is categorized as severe (26-33), whereas the stress level of other groups is at a moderate level (25-19). Furthermore, the mean anxiety level of the elderly group is 13.60 ± 10.52, whereas the people under 25 years old and the youth group experience a moderate level of anxiety (10-14), reporting respective values of 10.60 ± 9.57 and 9.36 ± 8.44. Similarly, the middle-aged group reported a mild level of anxiety (8-9) with a mean value of 36.36. ± 44.9. The mean depression level of the elderly group is 23.60. 18.07, which is classified as severe (27-21), while other groups exhibit a moderate level of depression (14-20). The division of the sample group by gender reveals that the group consisted of 115 men and 821 women. The male group reported a mean stress level of 19.23 ± 11.40, whereas the female group reported a mean stress level of 19.38 ± 10.46. The mean anxiety level in men is reported as 8.97 ± 8.67, whereas in women, it is 9.25 ± 8.51. Moreover, the mean depression level is reported as 14.70 ± 11.95 in men and 13.91 ± 11.24 in women. The data suggests that women are more prone to anxiety, while men are more susceptible to depressive symptoms.

The classification of the sample group based on employment status indicates that the group comprises 403 employed and 533 unemployed individuals. The mean stress level of the employed group is 19.32 ± 10.71, while the unemployed group reports an average stress level of 19.39 ± 10.47. The mean anxiety level of the employed group is 9.03 ± 8.68, whereas that of the unemployed group is 8.41 36 9.36. The mean depression level is reported as 13.97 ± 11.30 in the employed group and 14.04 ± 11.35 in the unemployed group. The findings suggest that employed individuals are more prone to anxiety, while unemployed individuals tend to experience more depressive symptom (Table 4).

Table 4. News database used based on education.

The present study's participants exhibited varying patterns of engagement with news concerning the COVID-19 pandemic. Specifically, 42% of the sample group allocated less than one hour per day to monitoring Corona-related developments in Iran and globally, with 39% dedicating approximately one hour, 13% spending between one and three hours and 6% investing more than three hours to this endeavor. Furthermore, an analysis of the sample group's education levels reveals that the cohort comprised 27 individuals with doctoral degrees, 147 with master's degrees, 416 with bachelor's degrees and 345 with diplomas and undergraduate degrees. As indicated in Table 1, participants with different educational backgrounds tended to source their information from divergent outlets, with the majority of those with master's or doctoral degrees obtaining information from the website of the World Health Organization and the bulk of those with bachelor's degrees or lower following Iranian news broadcasts (Hou WK, 2021).

The current investigation sought to ascertain the pervasiveness of depression, anxiety and stress, as well as to ascertain the relationship between educational level and news source preference among the Iranian populace during the quarantine period imposed in March 1998 and April 1999 due to the coronavirus pandemic. A total of 936 individuals (115 males, 812 females) between 16 to 75 years of age, classified as either employed (n=433) or unemployed (n=533), were included in the sample pool. The participants were subsequently classified based on gender, age and occupation. Age was stratified into four categories: Early youth (under 25 years), youth (25-25 years), middle age (45-65 years) and the elderly (over 65 years); gender was distinguished between males and females; and occupation was dichotomized into employed and unemployed. In addition, educational level was categorized into four groups: 345 individuals had completed undergraduate and postgraduate studies, 416 had completed undergraduate studies, 147 had completed graduate studies and 27 had completed doctoral studies. The response rate was 54%.

The present study initially presents the results in a general manner and subsequently discusses them in a more detailed fashion. The findings indicated that depression-related stress was moderate among the entire sample, while anxiety levels were mild. Nevertheless, based on the Lovebond questionnaire and age groups, the mean stress and depression scores were both moderate, whereas the mean anxiety score was mild. Furthermore, the study demonstrated that stress levels were significantly higher among elderly participants, while the rest of the sample exhibited moderate stress levels. Similarly, the mean anxiety scores were moderate among both the elderly and individuals under 25 years of age, whereas mild anxiety was observed among the youth and middle-aged groups. Additionally, depression levels were found to be severe in the elderly group and moderate in the other age groups.

Another significant finding was that women exhibited higher levels of anxiety than men, while men reported more frequently experiencing depressive symptoms. Furthermore, the sample was divided based on employment status, which revealed that unemployed individuals exhibited higher levels of depression than employed individuals, whereas the employed group demonstrated higher levels of anxiety. The participants in the study followed corona-related news through various means. In terms of duration, 42% of the sample spent less than an hour, 39% spent nearly an hour, 13% spent one to three hours and 6% spent more than three hours following corona-related news in Iran and around the globe. Finally, the results of a separate study based on education level demonstrated that individuals with postgraduate education (master's or doctorate degrees) followed the news more frequently than the World Health Organization, while most individuals with a bachelor's degree or lower followed the news via Iranian television.

The present study examined the levels of stress, anxiety and depression, taking into consideration the findings of several studies, including those of Paulina and Diniz, Alzota et al., Romandham et al., Yildirim et al., Chen, Zao et al., Ozden et al., and Ozamir, Dossil, Piazza, and Idogia, which were found to be consistent with the present study. In addition, the results of the investigations by Fontokius and Aptodis, Chu Hoon and Fawaz and Semerna were generally consistent with the data obtained from this study.

Maro and Rovrigo carried out studies on the mental health of the general population of Portugal and found that depression, anxiety and stress were more prevalent among illiterate and unemployed women and people living in rural areas, as well as those with flu-like symptoms, than in the rest of the population. The prevalence of coronavirus around the world has certainly had an impact on human life. A study conducted in 59 countries found that the population of developed countries with high incomes experienced less pain, anxiety and depression compared to developing countries.

Moreover, the researchers discovered that factors such as interpersonal conflict, disputes and lack of teleworking facilities in some countries increased depression and anxiety. However, the prevalence of depression and anxiety in regions such as the Caribbean and Latin America was lower than in North America, Central Asia, Europe and sub-Saharan Africa.

During the COVID-19 pandemic, the Tunisian populace experienced high levels of depression, anxiety and stress, with rates of 28.3%, 24.4% and 19.4%, respectively. Although no correlation was found between psychological factors and religious beliefs in this particular study, researchers ought to consider the influence of the latter in future investigations. The elderly was among the most vulnerable groups during the outbreak and quarantine measures exacerbated their depression, anxiety and stress levels in Turkey. Moreover, factors such as financial provision further exacerbated their care needs. Studies conducted during the second wave of the pandemic in China revealed that women were more susceptible to anxiety than men, while men who had to quarantine experienced higher levels of anxiety. Financial status and health were also determinant factors in the level of anxiety. Quarantine measures also affected the Greek population, who reported psychological distress, anxiety and suicidal ideation. Another study in China found that levels of anxiety, stress and depression increased during quarantine among the general population, with gender and marriage being further factors that contributed to higher levels of psychological distress. During the coronavirus outbreak in Hong Kong, the level of mental health among the population decreased to 25.4%, with 19% of the population also experiencing depression. Due to the pandemic's widespread effects, education was conducted online, which led to depression and anxiety disorders in undergraduate students in Lebanon. There was a direct relationship between depression, anxiety and stress with the online education system.

The onset of the Corona virus outbreak has resulted in an increase of anxiety, depression and stress among the young population in Spain, according to Experian’s research findings. Furthermore, the study revealed that women were more prone to mental health issues during quarantine due to heightened anxiety, depression and health concerns. Reports indicate that women were three times more likely to experience psychological problems such as post-traumatic stress disorder during the henna epidemic.

Overall, research findings suggest that the COVID-19 outbreak and subsequent home quarantine measures have led to increased anxiety, stress and depression in various populations worldwide. Although results vary among countries, most studies indicate that women experience more anxiety than men, while depression is more prevalent among men. For example, in northern Spain, the rate of depression and anxiety in the young population was higher than in other areas. It is worth noting that the Corona virus not only affects people's physical health but also their mental well-being. Although religious beliefs do not directly impact mental health factors, they may predict new coronavirus mutations and multiple COVID-19 epidemics. Additionally, slow vaccination rates and people's reluctance to be vaccinated can exacerbate anxiety, stress and depression in the general population. Therefore, identifying individuals who are prone to psychological disorders is essential to maintain effective mental health in the community by implementing effective strategies. Despite the high speed of vaccination and decreasing death rates in developed countries, many Middle Eastern countries continue to face economic, psychological and social consequences of the COVID-19 virus.

The primary goal of this study was to examine the psychological characteristics of the Iranian population during the quarantine period of the Corona virus. To achieve this, the DAS questionnaire was administered to participants via an online platform. A total of 936 individuals were selected for this study using the accessible pain sampling method. The findings indicated that women experienced higher levels of anxiety than men, while men demonstrated a greater tendency towards depression symptoms. Employed individuals exhibited greater anxiety, whereas unemployed individuals were more likely to experience depression. Additionally, it was discovered that the majority of participants with master's and doctorate degrees obtained their information from the World Health Organization website, while those with bachelor's degrees or lower primarily relied on Iranian TV.

By considering the psychological characteristics of the general population during periods of crises such as the Corona virus and through proper training and intervention, it is possible to prevent a multitude of social, economic and psychological harms. Therefore, it is recommended that future researchers incorporate environmental and economic factors into their studies and conduct statistical sampling manually to improve the validity of their results.

It should be noted that one limitation of this study was the collection of questionnaire data online. Furthermore, the results only pertain to the population of Iran and cannot be generalized to other countries.

I would like to express my gratitude to my mother for her support in conducting this research, to Dr. Hashemi for his Valuable guidance and to all the participants. I sincerely wish all health.

As mentioned, the questionnaire was shared online on platforms (Instagram Link in, etc.) so that the candidates could Complete it. I will send you the raw data file.

There is no conflict of interest in research.

1. Alzueta, E., Perrin, P., Baker, F.C., Caffarra, S., Ramos-Usuga, D., Yuksel, D., et al. (2021) How the COVID-19 pandemic has changed our lives: A study of psychological correlates across 59 countries. J Clin Psychol. 77(3):556-70.

   [Crossref] [Google Scholar] [PubMed]

2. Alexander, J.L., Dennerstein, L., Kotz, K., Richardson, G (2007) Women, anxiety and mood: A review of nomenclature, comorbidity and epidemiology. Expert Rev Neurother. 7(11 Suppl):S45–S58.

   [Crossref] [Google Scholar] [PubMed]

3. Chew, Q.H., Wei, K.C., Vasoo, S., Chua, H.C., Sim, K (2020) Narrative synthesis of psychological and coping responses towards emerging infectious disease outbreaks in the general population: Practical considerations for the COVID-19 pandemic. Singapore Med J. 61(7):350.

   [Crossref] [Google Scholar] [PubMed]

4. Chen, L., Zhao, H., Razin, D., Song, T., Wu, Y (2021) Anxiety levels during a second local COVID-19 pandemic breakout among quarantined people: A cross sectional survey in China. J Psychiatr Res. 135:37-46.

   [Crossref] [Google Scholar] [PubMed]

5. Etxebarria, N.O., Santamaria, M.D., Gorrochategui, M.P., Mondragon, N.I (2020) Stress, anxiety and depression levels in the initial stage of the COVID-19 outbreak in a population sample in the northern Spain, Cad. Cad Saude Publica. 36:30.

   [Crossref] [Google Scholar] [PubMed]

6. Fountoulakis, K.N., Apostolidou, M.K., Atsiova, M.B., Filippidou, A.K., Florou, A.K (2021) Self-reported changes in anxiety, depression and suicidality during the COVID-19 lockdown in Greece. J Affect Disord. 279:624-629.

   [Crossref] [Google Scholar] [PubMed]

7. Fawaz, M., Samaha, A (2021) E‐learning: Depression, anxiety and stress symptomatology among Lebanese university students during COVID‐19 quarantine. Nurs Forum. 56(1):52-7.

   [Crossref] [Google Scholar] [PubMed]

8. Fekih-Romdhane, F., Cheour, M (2021) Psychological distress among a Tunisian community sample during the COVID-19 pandemic: Correlations with religious coping. J Relig Health. 60(3):1446-61.

   [Crossref] [Google Scholar] [PubMed]

9. Hou, W.K., Lee, T.M.C., Liang, L., Li, T.W., Liu, H (2021) Civil unrest, COVID-19 stressors, anxiety and depression in the acute phase of the pandemic: A population-based study in Hong Kong. Soc Psychiatry Psychiatr Epidemiol. 56(8):1499-508.

   [Crossref] [Google Scholar] [PubMed]