Anxiety and Depression in Health Workers and General Population During COVID‐19 in IRAN: A Cross‐Sectional Study

Abstract Background The COVID‐19 outbreak has exerted a great deal of psychological pressure on Iranian health workers and the general population. The aim of this study was to determine the effect of pandemic on anxiety and depression in Iranian population. Methods 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 and univariate and multivariate logistic regression models were conducted. Results 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. 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 = .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 < .001) and (OR = 1.5, 95% CI: 1.154‐2.021, P = .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 = .005). Conclusions Regarding the high prevalence of anxiety and depression symptoms, especially among healthcare workers, appropriate psychological/psychiatric intervention necessitates.


| INTRODUC TI ON
COVID-19 is an acute respiratory illness with unknown causes that began in December 2019 in 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][6] 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. 7 Due to the increase in the virus-related mortalities, both the medical staff and the general public 8 have experienced psychological problems such as anxiety and depression. 9 On average, the medical personnel work for 16 to 22 hours per day, putting their mental health at risk. 10 High-risk positions with constant contact with the infected and 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. 9,11 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. 9 Many of the medical and nursing staff working in Wuhan had mental health disorders. 12 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. 13 Therefore, it is necessary to pay attention to protective factors and the process of successful adaptation to adverse conditions. 14 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.

| Settings and participants
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, online Internet access, 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 in Iran, the time that transfers between provinces was limited, and almost socioeconomic activities were restricted from April 6 to April 15, 2020.

| Informed consent
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 15-80 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.

| Investigation approach
The study was conducted during quarantine, including interprovincial travel ban, prohibition of nonessential business activities, and closure of schools and universities. This was the first quarantine in Iran, and the reason for research in this period was to investigate the effect of the outbreak of COVID-19 and the quarantine to prevent of the spread of this pandemic on people's mental health.
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.

| Investigation tools
The present study made use of online demographic questionnaires and Hospital Anxiety and Depression Scale (HADS) for the general public and healthcare workers. 10

| Demographic 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.

| Statistical analysis
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).

| RE SULTS
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:

| General demographic data
Based on the online survey, 2045 qualified questionnaires were finally obtained. The characteristics of the participants are shown in

| Prevalence of anxiety and depression symptoms in the COVID-19 infected
The results of the analysis of the infected are shown in Table 4

| D ISCUSS I ON
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 were higher than in the noninfected.
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

| Anxiety and depression symptoms in healthcare workers
The physicians showed higher scores of anxiety and depression compared with other medical staff. 4  with the general population, [32][33][34] 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. 35 In a study in Singapore and India, the depression symptoms were reported 10.6% and anxiety symptoms were reported 15.7% in medical workers. 36 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

| CON CLUS I ON S AND RECOMMENDATIONS
The majority of the medical staff and general population in our study experienced anxiety and depression symptoms. To address the con-

| LI M ITATI O N S
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.

ACK N OWLED G M ENTS
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.

CO N FLI C T O F I NTE R E S T
None to declare.

AUTH O R CO NTR I B UTI O N S
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. All of the authors agree to be cooperative for all aspects of the study and approved the manuscript.

FU N D I N G I N FO R M ATI O N
This study was supported by Mazandaran University of Medical Sciences.

I N S TITUTI O N A L R E V I E WER B OA R D
The protocol for this research project has been approved by a suitably constituted Ethics Committee of the institution and it con-

I N FO R M ED CO N S ENT
Electronic informed consent was obtained from all participants.

E TH I C A L CO N S I D ER ATI O N
All procedures were conducted according to the Declaration of Helsinki and were approved by the Ethics Committee of Mazandaran University of Medical Sciences. The participants could leave without any explanation before the research.

DATA AVA I L A B I L I T Y S TAT E M E N T
The raw data belonged to the present study cannot be made publicly available, because the disclosure of personal data was not included in the research protocol of the present study.