This study assessed the risk of depression, anxiety and stress in different segments of the population in Saudi Arabia during the COVID-19 outbreak. The findings show that nearly more than one-third of the respondents in this survey were at risk to develop stress, anxiety, or depression. To be more precise, the risk to experience mild to severe depression, anxiety and stress were 43.5%, 34.9% and 36.5%. The rates of risk to develop depression, anxiety and stress are slightly elevated than a prior study which collected data soon after the outbreak of the pandemic in Saudi Arabia which reported mild to severe levels of depression (40.9%), anxiety (29.9%), and stress (30.4%) . The slight elevation could be attributed to the impact of the prolonged lockdown that was strictly implemented in Saudi Arabia, the increased rates of morbidity and mortality over the passage of time could have increased the risk to experience psychological reactions. The findings are comparable with other cross-sectional studies conducted during the pandemic period in other developed countries such as China, the UK, and Australia. The rates of moderate to severe levels of depression and anxiety in the general populations of these countries were between 37 and 62% [11, 23, 24]. Findings from this study demonstrated the vulnerability of certain sub-groups of the population such as women, young individuals, those who lost jobs, have direct and indirect exposure to the COVID-19 infection and those with chronic health conditions. Keeping in view the COVID-19 pandemic appeared as a global health crisis thus findings are applicable and found comparable with other studies. This study has a significant impact because findings provide insight to develop psycho-social interventions that generate large-scale improvements in health and well-being for at-risk populations and encourage the governing bodies to take measures for improving psychological health during and after the crisis.
The findings from our study demonstrate those female respondents were at increased risk to have anxiety and stress during the COVID-19 pandemic thus validating the prior evidence which showed that females were approximately five times more likely to suffer from posttraumatic stress and approximately two times more likely to have symptoms of depression, anxiety and stress during the pandemic . In general, previous studies have also reported women’s vulnerability to psychological morbidity in comparison to men [25, 26]. Studies from Middle East countries have reported women’s increased vulnerability to common psychological problems such as depression, anxiety, and stress compared to males [27, 28]. There could be certain reasons for the high probability of stress and anxiety among women, such as women of reproductive age are usually more frequent consumers of maternal and child healthcare services and recreational resources in the community. The restricted access during the lockdown might have generated psychological responses. These findings suggest that community mental health programs be adapted to online modes and expanded to provide counselling and support services to at-risk groups of women. Women who are seeking services should be screened for psychological symptoms and provided with appropriate referral services to prevent the prolongation or adverse outcomes on their health. Moreover, mental health is not restricted to the presence or absence of mental disorders but to foster healthy communities it is important to promote mental well-being. The vulnerability to poor mental health in one segment of the population may add risk to another group, for instance, women’s susceptibility to experiencing anxiety and stress not only compromise their well-being but increase the risk for their children and have negative implications on family functioning. The evidence generated from this study has significance to gain public attention and political focus to address the psychosocial needs of at-risk individuals in societies.
Recently, the focus of governing authorities on Saudization and women’s empowerment has allowed more women of this age to enter the KSA job market . Lockdown during the COVID-19 pandemic has restricted women from social and economic activities, which are already meagre in patriarchal societies. Exposure to various factors, such as economic dependence, low social support and poor environmental QOL, may increase the risk of stress and anxiety symptoms during the pandemic for women. Findings imply that women’s health programs should integrate psycho-social guidance and support to enhance their coping strategies and minimize the impact of these difficulties on their psychological health.
Our study findings demonstrate that the risk to experience symptoms of depression was higher in the younger population. These findings are in line with a study which collected data from Middle East countries that indicate an increased rate of stress disorders among youth during the COVID-19 pandemic . The higher risk of stress symptoms in this age group is explainable in the context of Saudi youth culture, as they are more engaged in social, economic and educational activities. The strict and prolonged implementation of lockdowns in various KSA cities affected these activities and was likely a source of stress and anxiety for young adults . The study findings imply the need for more youth support programs to enhance resilience and positive coping among this segment of the population. Findings also showed that non-Saudi residents in Saudi Arabia had a higher risk of depression. This could be due to the fact a large section of residents is living in Saudi Arabia for sake of employment, away from their immediate family, and they have limited access to social and emotional support. The pandemic has influenced the lives of individuals in various regions of the world and the feelings of loneliness and sadness are likely to elevate due to the high rates of morbidity and mortality associated with the pandemic around the globe. Despite, lockdowns and social distancing being effective measures to control the spread of infection, the psychological impacts of such measures on various segments of the community shouldn’t be overlooked.
In addition, the current findings demonstrate the vulnerability of those diagnosed with COVID-19 to stress, anxiety, and depression symptoms. These findings align with previous evidence [32, 33]. Moreover, the levels of stress and anxiety were significantly higher among people who reported living with a family member or friend diagnosed with COVID-19. The feelings of distress, anxiety and stress are likely to be high due to their attachment to loved ones and concerns over their health . These findings imply timely access to psycho-social support for individuals and families who were directly or indirectly exposed to the physical and mental burden of the COVID-19 infection.
Participants diagnosed with chronic health conditions were at significantly higher risk of depression, anxiety and stress. The common chronic health conditions in Saudi Arabia include hypertension, high cholesterol, ischemic heart disease, obesity, kidney disease and diabetes [35, 36]. Other studies have reported that women in Saudi Arabia are potentially at an increased risk of developing obesity, cardiovascular diseases and diabetes mellitus due to sedentary lifestyles and their dietary habits . In our study, more than a quarter of the participants reported suffering from chronic medical conditions, and this rate is higher than the previously reported 18% rate among primary healthcare patients . Among this group, 46–53% reported having symptoms of stress, anxiety or depression. This rate is alarmingly high and signifies the need to provide adequate care and resources to people with chronic health conditions because the risks of physical confinement during quarantine and complete lockdown affect them disproportionately . In the later stages of the lockdown, the Ministry of Health in Saudi Arabia expanded digital solutions to support healthcare services and allowed people to walk and partake in physical activity during the lockdown period .
Some of the limitations of this study should be considered while interpreting findings. Firstly, the cross-sectional descriptive design was employed, and data was collected only once thus it is not possible to demonstrate that risks of depression, anxiety and stress are directly linked with the situation of the pandemic. However, the screening tool assesses the presence of these symptoms in the past week, and the study assessed the relationship of some relevant factors such as loss of job during the pandemic, diagnosis of the COVID-19 infection, having a friend or family member diagnosed with the COVID-19 with the risk to have depression, anxiety and stress. Secondly, the data was collected by employing an online self-report survey form, due to the implementation of social distancing thus, it is important to consider biases inherent in self-report measures while interpreting findings from this study. Thirdly, we recruited focal persons in all regions to reach out target population however, community members who do not use social media tools for communication and those who are not able to read or record their responses on electronic survey forms are excluded systematically. Lastly, the assessment of mental health symptoms was made by using the short form of DASS-21, which is not a replacement for a clinical interview or other diagnostic tools for the assessment of psychopathology. The current finding thus only indicates the risk to experience psychological reactions and should not be interpreted as a disorder or pathological condition.
Overall, the assessment of risk and identification of vulnerable sub-groups through this study provides useful insights to promote community mental health. Community health interventions should focus on mental wellness programs for at-risk populations. Expansion of telehealth services to increase access to healthcare for people with chronic medical conditions. The insights gained from this epidemiological study are helpful to determine the psychological impact of the pandemic on various segments of the population and the need for action. Expansion of existing resources and scaling up of community mental health programs will be effective to reduce the short-term and long-term psycho-social impacts of this crisis. These solutions will also contribute to the attainment of targets set for the 2030 vision for Saudi Arabia, which aims at offering a fulfilling and healthy life to people living in Saudi Arabia . Promoting mental health is essential to develop resilience among individuals, families and communities thus enabling them to effectively deal with challenging situations. Future studies should adopt qualitative methods to gain deeper insight into necessary measures because early and efficient access to psychosocial support is crucial in building healthy and resilient communities.