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Frontiers in Public Health logoLink to Frontiers in Public Health
. 2021 Mar 26;9:585235. doi: 10.3389/fpubh.2021.585235

Mental Distress and Psychological Disorders Related to COVID-19 Mandatory Lockdown

Ameer Kakaje 1,*, Ammar Fadel 1, Leen Makki 2,3, Ayham Ghareeb 1, Ragheed Al Zohbi 2
PMCID: PMC8032968  PMID: 33842416

Abstract

Background: Lockdown restrictions due to COVID-19 have affected many people's lifestyles and ability to earn a living. They add further distress to the lives of people in Syria, who have already endured 9 years of war. This study evaluates distress and the major causes of concerns related to COVID-19 during the full lockdown.

Methods: Online questionnaires were distributed using SPTSS, K10, and MSPSS which were used with other demographic, war- and COVID-19-related questions that were taken from The (CRISIS) V0.1 Adult Self-Report Baseline Form.

Results: Our sample included 5,588 with the mean age of 26.84 ± 7.815 years. Of those, only one case of COVID-19 was confirmed. Over 42.7% had two or more positive PTSD symptoms, 42.6% had moderate or severe mental disorder, but only 14.9% had low social support. Higher PTSD and K10 scores overall were seen in female participants and with most of war variables (P < 0.05). Relationships with the partner being negatively affected and distress from a decline in ability to work and provide food were the most prominent.

Conclusions: The indirect effects of COVID-19 are far more than that of the pathogen itself. A reduced ability to earn and to provide food were the main concerns indicated in this study. Relationships deteriorated in participants with high K10 and PTSD scores who also had more symptoms and used more hypnotics in the last four weeks. Smoking patterns were not related to K10 and PTSD. Social support played a role in reducing stress, but when relationships were affected, lower support was observed.

Keywords: COVID-19, lockdown, psychological distress, posttraumatic stress disorder, mental disorders, conflict, developing country, Syria

Introduction

Further to the ramifications of war which the Syrian population has been experiencing since 2011, the spread of the COVID-19 virus has created additional challenges. With the new restrictions imposed by the government in Syria, the country was in full lockdown despite having few confirmed cases; all non-essential business, schools, universities, parks, mosques, churches, and other areas of common gathering were closed. A forced lockdown was announced from 6 p.m. to 6 a.m. on weekdays and 12 p.m. to 6 a.m. on weekends. This potentially made it even harder for Syrians to cope with the underlying stress caused by years of insecurity, fear, and loss. While institutions and governments around the world designated specific hotlines, projects and support platforms for citizens coping with the stress of changes to their life brought by the pandemic (14), such measures in Syria did not take place. The reason for this could be attributed to the stigma regarding mental health, which is highly prevalent in most developing countries (5) but also to the difficult nine years of war the country had been experiencing, making any mental health programs now appear unreasonably out of context.

Previous literature on outbreaks has focused on the physical health consequences of the disease and less on the mental health sequela that social distancing can generate. However, disasters, whether they are natural, man-made or industrial, have an impact on the social structure of the community and therefore strongly impact the mental health of these communities (5). This impact can cause and aggravate medical conditions such as post-traumatic stress disorder (PTSD), depression, substance abuse, and a broad range of maladaptive and harmful behaviors such as child and domestic abuse (6). For instance, after the hurricane of Maria in Puerto Rico, the country had 25 suicides every month during the three months following the hurricane and 19 suicides per month in the eight following months, which were an increase from the baseline before the hurricane (7). As for PTSD, it was diagnosed in 30–40% of people surviving a disaster compared to the 8% prevalence in the general population (7).

Studies have tried to understand the impact of disease outbreaks on the mental health of those affected, proving that survivors of diseases, like SARS, can suffer from elevated stress and worry, even one year after the disease outbreak (8). While it is very important to understand the ramifications of disease outbreaks on the mental health of the community affected directly by the disease, the impact of the crisis goes beyond those who acquire the disease and affect even the healthiest members of the community (9). Some risk factors that make individuals more prone to have impaired wellbeing and quality of life during COVID-19 have been identified such as fears of infection, being lonely, boredom, frustration, and pervasive anxiety while others have been identified as protective factors including resilience and social support (10). These risk factors may also be related to negative outcomes such as suicide. It is suggested that these aspects might be from neglect and abuse since childhood (11).

Our study aims to understand that impact in the context and background of war and evaluates how disease outbreaks and war have significant consequences on mental health. In this study, we assess mental health during COVID-19 by asking participants direct questions related to the outbreak and its effect on life, and indirectly by measuring post-traumatic stress disorder (PTSD), social support, and mental distress. This study used the same methods adopted by a previous study, conducted one year before to allow comparisons (12). We hypothesize that PTSD symptoms and mental distress from living in war-torn Syria have increased during COVID-19 and that social support minimized it. We also speculated that COVID-19 related variables are similar to the effects of war on mental health.

Methods

Sampling

We conducted a cross-sectional study across Syria from April 6 to April 13, 2020. Online surveys were distributed in Arabic to participants from several Syrian governorates. The study only included participants who were living within Syria. Participants who answered key questions and lived in Syria during COVID-19 lockdown and generally in Syria in the last 9 years were included. The questionnaires were posted online twice each day at 10 a.m. and 10 p.m. in online Social Media groups that were concerned with different topics to cover the widest possible population.

Questionnaires

Socioeconomic Status (SES)

Socioeconomic status (SES) was assessed by asking whether the place where the participants lived was owned, rented, or whether they were living with friends or accommodation provided by the government. We also asked whether the family income was adequate for essentials, or allowed them to buy more items.

Screening for Mental Disorder

An Arabic version of Kessler 10 + LM (K10 + LM) was used to screen and measure the severity of psychological distress (1315). K10 is a self-reported measure that enables the assessment of anxiety and depression in the last 4 weeks, with scores ranging from 10 to 50, and each question has five possible responses. The answers score from one when replying “none of the time” to five when replying “all of the time.” Higher scores are indicative of higher levels of psychological distress. The severity of mental distress is divided into four levels: scores 10–19 will be likely well, scores 20–24 will likely have a mild disorder, scores 25-29 will likely have a moderate disorder, and finally scores 30 and above will likely have a severe disorder.

Social Support

We used the Arabic version of the Multidimensional Scale of Perceived Social Support (MSPSS) (16, 17) to assess the social support from friends, significant others, and family with four questions for each source. We used total mean scores (not means of each individual question) for comparisons with other variables. The norms will likely vary according to culture, nationality, age, and gender. The mean scores for the total or individual subscale are divided into 3 categories: 1 to 2.9 to be considered low support, 3 to 5 to be considered moderate support, and 5.1 to 7 to be considered high support.

PTSD

The Screen for Posttraumatic Stress Symptoms (SPTSS) tool of diagnostic and statistical manual of mental disorders (DSM) IV was used. It contains three clusters of avoidance, arousal, and re-experience. The first two responses of “Not at all” and “1 or 2 times” represent the score 0 and the other responses represent the score 1. When scoring three or more on avoidance, two or more on arousal, and one or more on re-experience, that cluster is considered positive. Although it is based on DSM IV, it is somewhat close to what is used in the International Classification of Disease 11 (ICD-11) criteria and is reliable when screening for PTSD. SPTSS is a brief screening method that is not based on a single trauma model which helps to identify individuals who have high levels of SPSS symptoms and are not linked to a specific event.

COVID-19 Questions

We used questions that involved COVID-19 from The Coronavirus Health Impact Survey (CRISIS) V0.1 Adult Self-Report Baseline Form (18), and we translated them and added extra questions. CRISIS is a self-reported baseline current form, and we only used some of the questions. Questions involved Health/Exposure status in the last 2 weeks, distress from COVID-19, feeling new symptoms that could not be attributed to allergies, distress from different aspects, smoking, relationships, and earning money being affected. These questions with their answers are demonstrated in Table 1.

Table 1.

Characteristics of responders and their responses to COVID-19 questions.

Characteristic Frequency
(Percentage %)
Gender
Male 1696 (30.4)
Female 3892 (69.6)
District
Damascus 2345 (42.1)
Idlib 4 (0.1)
Deir ez-Zur 20 (0.4)
Homs 673 (12.1)
Tartus 442 (7.9)
Latakia 482 (8.6)
Al Hasakah 58 (1.0)
Quneitra 13 (0.2)
Rif-Dimashq 661 (11.9)
Daraa 114 (2.0)
As Suwayda 203 (3.6)
Hama 303 (5.4)
Ar Raqqah 11 (0.2)
Aleppo 246 (4.4)
Change place of living due to war
No 3480 (63.4)
Within the same city 919 (16.7)
To another city 1092 (19.9)
Distress from war noises
No 884 (15.9)
Yes 4679 (84.1)
Being a student
No 2371 (42.6)
In a school 133 (2.4)
In a university of high institute 3059 (55.0)
Education
Elementary 26 (0.5)
Until grade 9 125 (2.2)
High School 784 (14.0)
University, or high institute 4064 (72.7)
Master or higher 589 (10.5)
House that you currently live in
Owned 3566 (64.1)
Rented or given by the government 1433 (25.8)
Living in friends\relatives house 560 (10.1)
Consanguinity between parents
No 3902 (70.2)
Third degree relatives 901 (16.2)
Fourth degree relatives 324 (5.8)
More distant relatives 433 (7.8)
Chronic Medical Condition
No 1602 (66.4)
Hypertension 161 (6.7)
Diabetes 36 (1.5)
Asthma 176 (7.3)
Other 337 (14.0)
Two or more 101 (4.2)
Chronic Condition With Housemates
No 1027 (25.8)
Hypertension 977 (24.5)
Diabetes 251 (6.3)
Asthma 154 (3.9)
Other 408 (10.3)
Two or more 1163 (29.2)
Marital Status
Single 3271 (58.9)
In a relationship 477 (8.6)
Married 1426 (25.7)
Divorced 72 (1.3)
Engaged 274 (4.9)
Widowed 38 (0.7)
Smoking cigarette or shisha
I was not a smoker and did not start 3609 (66.6)
I used to smoke one of them but now I smoke both 73 (1.3)
Yes I am smoking now and before COVID 19 1656 (30.5)
I started smoking cigarettes 32 (0.6)
I started Shisha 52 (1.0)
Smoking Changes From COVID-19
Stopped smoking 94 (6.6)
Almost the same 460 (32.4)
Increased dramatically 322 (22.7)
Decreased dramatically 544 (38.3)
Monthly Income adequacy
It cannot cover buying the essentials 1296 (23.3)
It is only enough for essentials from food and drink 3243 (58.3)
It is enough for essentials and other things 1023 (18.4)
Have you been suspected of having COVID-19
No symptoms or signs 5445 (97.9)
Yes, has some possible symptoms, but no diagnosis 115 (2.1)
Yes, I was diagnosed with COVID-19 by a doctor 1 (>0.1)
Exposed to someone likely to have COVID-19 5306 (95.9)
No
Yes, has some possible symptoms, but no diagnosis by doctor 214 (3.9)
Yes, with someone was diagnosed by a doctor 10 (0.2)
Anyone in your family been diagnosed with COVID-19
No 5528 (99.2)
Yes, non-household member 23 (0.4)
Yes, member of household 23 (0.4)
Happened because of COVID-19:
Fallen ill physically
No 4883 (87.6)
To a family member 417 (7.5)
To a housemate 40 (0.7)
To you 237 (4.2)
Hospitalized
No 5476 (98.2)
To a family member 73 (1.3)
To a housemate 12 (0.2)
To you 16 (0.3)
Self-quarantine with symptoms
No 5549 (99.5)
To a family member 10 (0.2)
To a housemate 10 (0.2)
To you 8 (0.1)
Self-quarantine without symptoms
No 5535 (99.2)
To a family member 16 (0.3)
To a housemate 11 (0.2)
To you 15 (0.3)
Lost Job
No 3853 (69.7)
To a family member 822 (14.9)
To a housemate 78 (1.4)
To you 338 (6.1)
Two of the previous 374 (6.8)
All of the previous 63 (1.1)
Reduced ability to earn money
No 3539 (64.0)
To a family member 973 (17.6)
To a housemate 107 (1.9)
To you 348 (6.3)
Two of the previous 473 (8.6)
All of the previous 88 (1.6)
Passed away
No 5535 (99.3)
To a family member 32 (0.6)
To a housemate 6 (0.1)
How worried have you been from:
Being infected
Not at all 1255 (23.3)
Slightly 2262 (42.0)
Moderately 1170 (21.7)
Very 701 (13.0)
Friends or family being infected
Not at all 318 (6.0)
Slightly 1472 (27.7)
Moderately 1476 (27.8)
Very 2045 (38.5)
Your work will be negatively affected
Not at all 1821 (37.5)
Slightly 1026 (21.2)
Moderately 792 (16.3)
Very 1211 (25.0)
Your studies will be negatively affected
Not at all 1749 (37.9)
Slightly 868 (18.8)
Moderately 846 (18.3)
Very 1153 (25.0)
Providing food will be affected
Not at all 1043 (20.3)
Slightly 1592 (30.9)
Moderately 1225 (23.8)
Very 1290 (25.0)
Are you committed to quarantine
I do not go out at all 1592 (28.6)
Only for essentials 3248 (58.3)
Reduced my going out 662 (11.9)
Have not changed at all 67 (1.2)
Quality of your relationships with your friends
A lot better 78 (1.4)
A little better 368 (6.7)
About the same 3901 (70.7)
A little worse 841 (15.2)
A lot worse 330 (6.0)
Quality of your relationships with your housemates
A lot better 302 (5.5)
A little better 1154 (21.0)
About the same 3067 (55.9)
A little worse 788 (14.4)
A lot worse 177 (3.2)
Quality of the relationships between you and members of your family
A lot better 143 (2.6)
A little better 640 (11.7)
About the same 3867 (70.7)
A little worse 622 (11.4)
A lot worse 196 (3.6)
Quality of your relationships with your Partner
A lot better 196 (6.7)
A little better 403 (13.8)
About the same 1658 (56.7)
A little worse 436 (14.9)
A lot worse 230 (7.9)
Drugs increases after COVID-19
No drugs 3856 (71.6)
Analgesics and NSAIDS 1028 (19.1)
OTC flu medications 197 (3.7)
Hypnotics 32 (0.6)
Antibiotics 58 (1.1)
Other 128 (2.4)
2 drugs 72 (1.3)
3 drugs or more 14 (0.3)
Drugs increases for your family
No drugs 3926 (73.3)
Analgesics and NSAIDS 839 (15.7)
OTC flu medications 237 (4.4)
Hypnotics 17 (0.3)
Antibiotics 85 (1.6)
Other 149 (2.8)
2 drugs 83 (1.5)
3 drugs or more 20 (0.4)

Other Questions

Basic demographic questions were included on gender, age, educational level, whether they were currently a student, the governorate where they lived, and whether they had consanguineous parents. We asked whether they were distressed from war noises or having to change their place of living due to war and the number of these changes experienced.

Definitions

Consanguinity was defined as third-degree consanguinity when the parents were first cousins, and fourth-degree consanguinity when the parents were second cousins, or second cousins once removed. We defined IT work type as engineering around a computer, IT, web design, or communication engineering that required programming. We defined engineering work types as civil, electrical/mechanical engineering, and architecture.

We defined a retail worker as a job selling costumers products, either in stores, or being a salesman. Medical engineering was part of “other health workers.” Working in television, radio, entertainment, or journalism were categorized in the “media” work type. We defined “office” work type as any work in an office either in a company or private practice such as accounting and law. A photographer or any job involving music, painting, or design except for web design was included in the “Art and music” category.

Data Process

Data were processed using IBM SPSS software version 26 for Windows (SPSS Inc., IL, USA). Chi-square, one-way analysis of variance (ANOVA), linear regression, and independent t-tests were performed to determine the statistical significance between the groups. Pearson correlation was also calculated. Through the same software, odds ratios (ORs) and the 95% confidence intervals for the groups were calculated using Mantel–Haenszel test. Values of <0.05 for the two-tailed P values were considered statistically significant.

Results

Our sample comprised 5,588 participants from all across Syria with 3,892 (69.6%) female participants. The mean age was 26.84 ± 7.815 years. In the sample, 37.8% were well according to K10, but 27.6% had a probable severe mental disorder. Approximately, 37% did not report positive SPTSS items, and 23.3% met the criteria for probable PTSD. Characteristics of subjects, their responses to COVID-19 questions, war variables, and other nominal variables are demonstrated in Table 1. Age, PTSD, MSPSS, K10 scores, and results on other war and numeral variables are demonstrated in Table 2. COVID-19 questions, war, and other variables associated with SPTSS items and total scores are demonstrated in Table 3 with each social support and total MSPSS support scores demonstrated in Table 4, and K10 + LM scores and days demonstrated in Table 5. PTSD, and K10 scores distributions in governorates by gender and according to the type of work are demonstrated in Figure 1. The associations between PTSD clusters, K10 scores, and social support are demonstrated in Table 6.

Table 2.

Age, PTSD, social support, and K10 results and scores with other numeric variables.

Characteristic Frequency
(Percentage %)
Characteristic Mean (Std. Deviation)
Positive Avoidance Prevalence 1891 (35.6) Age 26.84 (7.815)
Positive Arousal Prevalence 2558 (48.7) Changing place of living due to war 0.45 (0.752)
Positive Re-experience Prevalence 2305 (44.3) Number of people living in the house 2.59 (0.605)
Positive PTSD Number prevalence How many rooms of your current house 3.837 (1.6269)
No PTSD 1909 (36.8) Number of children under 18 living in the house 1.22 (1.666)
One positive subscale 1061 (20.5) Avoidance score 1.98 (1.748)
Two positive subscales 1005 (19.4) Arousal score 1.70 (1.504)
Three positive subscales 1209 (23.3) Re-experience score 1.03 (1.458)
Significant Other Support Total PTSD score 4.74 (4.051)
Low Support 1038 (19.3) Significant other score 19.257 (7.3549)
Moderate Support 1365 (25.4) Family score 19.155 (6.5910)
High Support 2968 (55.3) Friends score 16.082 (7.2203)
Family Support Total support score 54.46 (17.041)
Low Support 908 (16.9) K10 score 23.8473 (9.10760)
Moderate Support 1590 (29.6) Days unable to carry normal activities and work due to negative feelings 6.91 (7.662)
High Support 2865 (53.4) Days had to reduce normal activities and work due to negative feelings 9.53 (8.903)
Friends Support
Low Support 1690 (31.7)
Moderate Support 1697 (31.8)
High Support 1950 (36.5)
Total Support
Low Support 796 (14.9)
Moderate Support 2449 (45.9)
High Support 2087 (39.1)
K10Result
Well 2039 (37.8)
Mild Mental Disorder 1056 (19.6)
Moderate Mental Disorder 812 (15.0)
Severe Mental Disorder 1489 (27.6)

Table 3.

SPTSS items and total mean scores and correlations with COVID-19 and war variables along with other variables.

Characteristic Avoidance Arousal Re-experience Total SPSS Score
Mean Std.
Dev.
P value Mean Std.
Dev.
P value Mean Std.
Dev.
P value Mean Std.
Dev.
P value
Gender
Male 1.8 1.8 <0.001 1.5 1.4 <0.001 0.8 1.3 <0.001 4.1 3.9 <0.001
Female 2.1 1.7 1.8 1.5 1.1 1.5 5 4.1
Change place of living due to war
No 1.9 1.7 <0.001 1.6 1.5 <0.001 1 1.4 0.001 4.5 4 <0.001
Within the same city 2.1 1.8 1.8 1.5 1.1 1.5 5 4.1
To another city 2.2 1.8 1.9 1.5 1.2 1.5 5.2 4.1
Distress from war noises
No 1.8 1.7 0.002 1.4 1.4 <0.001 0.8 1.3 <0.001 4.1 3.8 <0.001
Yes 2 1.7 1.8 1.5 1.1 1.5 4.9 4.1
Being a student
No 1.8 1.7 <0.001 1.6 1.5 <0.001 0.9 1.4 <0.001 4.4 4 <0.001
In a school 2.2 1.6 1.7 1.5 1.3 1.5 5.1 3.9
In a university of high institute 2.1 1.8 1.8 1.5 1.1 1.5 5 4.1
Education
Elementary 1.5 1.8 0.006 1.4 1.6 <0.001 0.9 1.5 0.002 4 4.6 <0.001
Until grade 9 1.9 1.7 1.5 1.5 1.2 1.4 4.7 4
High School 2.1 1.7 1.7 1.5 1.1 1.5 5 4
University, or high institute 2 1.8 1.7 1.5 1 1.5 4.8 4.1
Master or higher 1.8 1.7 1.4 1.4 0.8 1.3 4 3.8
House that you currently live in
Owned 1.9 1.7 <0.001 1.6 1.5 0.001 1 1.5 0.089 4.6 4 0.001
Rented or given by the government 2.1 1.8 1.8 1.5 1.1 1.5 5 4.1
Living in friends\relatives house 2.1 1.8 1.8 1.5 1.1 1.5 5.1 4
Chronic Medical Condition
No 1.9 1.7 <0.001 1.6 1.5 <0.001 0.9 1.4 <0.001 4.4 3.9 <0.001
Hypertension 1.9 1.9 1.6 1.6 1.1 1.6 4.7 4.5
Diabetes 1.5 1.8 1.6 1.6 1 1.4 4.4 4.3
Asthma 2.6 1.8 2.2 1.6 1.5 1.6 6.3 4.3
Other 2.5 1.8 2.2 1.6 1.5 1.6 6.2 4.3
Two or more 2.3 1.8 2 1.6 1.4 1.7 5.8 4.4
Chronic Condition With Housemates
No 1.8 1.7 <0.001 1.6 1.5 <0.001 0.9 1.4 <0.001 4.3 3.8 <0.001
Hypertension 2 1.7 1.6 1.5 1 1.4 4.6 4
Diabetes 1.9 1.7 1.6 1.5 0.9 1.4 4.4 3.9
Asthma 2.2 1.8 1.9 1.5 1.5 1.6 5.7 4.1
Other 2.2 1.9 2 1.6 1.3 1.6 5.6 4.4
Two or more 2.2 1.8 1.9 1.5 1.1 1.5 5.2 4.2
Marital Status
Single 2.1 1.7 <0.001 1.7 1.5 0.002 1.1 1.5 0.009 4.8 4 <0.001
In a relationship 2.1 1.8 2 1.5 1.2 1.5 5.2 4.1
Married 1.7 1.7 1.6 1.5 0.9 1.4 4.3 3.9
Divorced 1.8 1.9 1.5 1.4 1.1 1.5 4.3 4.3
Engaged 2.2 1.9 1.7 1.5 1.1 1.6 5 4.3
Widowed 2.6 2.2 1.8 1.5 1.4 1.5 5.8 4.5
Smoking cigarette or shisha
I was not a smoker and did not start 2 1.7 0.001 1.7 1.5 0.001 1 1.4 <0.001 4.7 3.9 <0.001
I used to smoke one of them but now I smoke both 2.8 2 2.4 1.6 1.7 1.7 6.9 4.5
Yes I am smoking now and before COVID 19 2 1.8 1.7 1.5 1.1 1.5 4.8 4.2
I started smoking cigarettes 2.2 2.3 1.3 1.5 1 1.5 4.6 5
I started Shisha 2.4 2.1 1.8 1.7 1.4 1.8 5.6 5
Smoking Changes From COVID-19
Stopped smoking 1.9 1.6 <0.001 1.7 1.5 <0.001 0.8 1.3 <0.001 4.5 4 <0.001
Almost the same 1.8 1.7 1.5 1.5 0.9 1.4 4.2 4
Increased dramatically 2.5 2 2.2 1.6 1.5 1.7 6.2 4.6
Decreased dramatically 2 1.7 1.7 1.5 1 1.4 4.8 3.9
Monthly Income adequacy
It cannot cover buying the essentials 2.3 1.8 <0.001 1.9 1.6 <0.001 1.3 1.6 <0.001 5.6 4.3 <0.001
It is only enough for essentials from food and drink 1.9 1.7 1.7 1.5 1 1.4 4.6 3.9
It is enough for essentials and other things 1.7 1.7 1.5 1.5 0.9 1.4 4.1 3.9
Have you been suspected of having COVID-19
No symptoms or signs 2 1.7 0.005 1.7 1.5 0.002 1 1.5 0.034 4.7 4 0.001
Yes, has some possible symptoms, but no diagnosis 2.5 1.9 2.2 1.6 1.4 1.7 6.2 4.4
Yes, I was diagnosed with COVID-19 by a doctor 1 . 3 . 1 . 5 .
Exposed to someone likely to have COVID-19
No 2 1.7 <0.001 1.7 1.5 <0.001 1 1.4 <0.001 4.7 4 <0.001
Yes, has some possible symptoms, but no diagnosis by doctor 2.5 1.8 2.2 1.6 1.3 1.6 6 4.3
Yes, with someone was diagnosed by a doctor 3.3 2.2 2.5 1.4 2.4 2 8.2 4.2
Anyone in your family been diagnosed with COVID-19
No 2 1.7 0.339 1.7 1.5 0.252 1 1.5 0.111 4.7 4 0.141
Yes, non-household member 2.4 1.9 2.2 1.5 1.7 1.9 6.4 4.9
Yes, member of household 2.3 1.6 1.7 1.5 1.1 1.3 5.1 3.3
Happened because of COVID-19:
Fallen ill physically
No 1.9 1.7 <0.001 1.6 1.5 <0.001 1 1.4 <0.001 4.5 4 <0.001
To a family member 2.4 1.9 2.1 1.5 1.4 1.6 6 4.3
To a housemate 2.4 1.9 2 1.7 1.3 1.6 5.8 4.4
To you 2.5 1.8 2.2 1.6 1.6 1.7 6.5 4.3
Hospitalized
No 2 1.7 0.117 1.7 1.5 0.274 1 1.5 0.053 4.7 4 0.064
To a family member 2.4 2 2 1.6 1.4 1.7 5.8 4.7
To a housemate 2.6 2 2 1.8 1.6 1.9 6.2 5.1
To you 2.3 2.3 1.7 1.4 1.4 1.7 5.5 4.7
Self-quarantine with symptoms
No 2 1.7 <0.001 1.7 1.5 0.025 1 1.5 0.001 4.7 4 <0.001
To a family member 4 2.2 3 1.4 2.7 1.3 9.7 4.6
To a housemate 3.2 1.9 2.1 1.7 1.9 1.8 7.3 4.9
To you 3.3 2.1 2.3 1.6 1.6 2.1 7.1 4.6
Self-quarantine without symptoms
No 2 1.7 0.013 1.7 1.5 0.025 1 1.5 0.001 4.7 4 0.004
To a family member 2.6 1.8 2.7 1.3 1.5 1.6 6.8 4.4
To a housemate 3.5 1.8 1.9 1.7 2 1.7 7.4 4.3
To you 2.5 1.4 2.4 1.8 2.4 1.8 7.3 4.5
Lost Job
No 1.8 1.7 <0.001 1.6 1.5 <0.001 1 1.4 <0.001 4.4 4 <0.001
To a family member 2.2 1.7 1.9 1.5 1.2 1.5 5.4 4
To a housemate 2 1.7 2.1 1.6 1.5 1.7 5.8 4.4
To you 2.1 1.8 1.9 1.5 1 1.4 5.1 4.1
Two of the previous 2.4 1.7 1.8 1.5 1.1 1.5 5.4 3.9
All of the previous 2.9 1.7 2.1 1.6 1.5 1.7 6.4 4.5
Reduced ability to earn money
No 1.8 1.7 <0.001 1.5 1.5 <0.001 0.9 1.4 <0.001 4.3 4 <0.001
To a family member 2.3 1.7 2 1.5 1.2 1.5 5.4 4
To a housemate 2.1 1.8 2.2 1.6 1.5 1.6 5.9 4.4
To you 2.1 1.8 1.9 1.6 1.1 1.4 5.1 4.1
Two of the previous 2.4 1.7 1.9 1.5 1.2 1.5 5.5 4
All of the previous 2.7 1.7 2.2 1.6 1.6 1.7 6.4 4.4
Passed away
No 2 1.7 <0.001 1.7 1.5 <0.001 1 1.5 <0.001 4.7 4 <0.001
To a family member 3.3 2 2.9 1.6 2.1 1.9 8.3 4.9
To a housemate 3.8 1.7 2.2 1.9 2 2.1 8 5.1
How worried have you been from:
Being infected
Not at all 1.8 1.8 <0.001 1.4 1.4 <0.001 0.9 1.4 <0.001 4.1 4 <0.001
Slightly 1.8 1.6 1.5 1.4 0.9 1.3 4.2 3.7
Moderately 2.1 1.7 1.8 1.5 1.1 1.4 5 3.9
Very 2.9 1.8 2.6 1.5 1.8 1.8 7.3 4.3
Friends or family being infected
Not at all 1.5 1.8 <0.001 1.3 1.3 <0.001 0.7 1.3 <0.001 3.5 3.8 <0.001
Slightly 1.7 1.7 1.3 1.4 0.8 1.3 3.8 3.7
Moderately 1.9 1.7 1.6 1.4 0.9 1.4 4.5 3.8
Very 2.4 1.8 2.1 1.5 1.4 1.6 5.9 4.2
Your work will be negatively affected
Not at all 1.7 1.7 <0.001 1.5 1.4 <0.001 0.9 1.4 <0.001 4.1 3.8 <0.001
Slightly 1.8 1.7 1.5 1.4 0.9 1.4 4.3 3.8
Moderately 2 1.8 1.6 1.4 0.9 1.4 4.5 3.9
Very 2.5 1.8 2.1 1.6 1.4 1.6 6.1 4.4
Your studies will be negatively affected
Not at all 1.8 1.7 <0.001 1.6 1.5 <0.001 0.9 1.4 <0.001 4.3 3.8 <0.001
Slightly 1.8 1.6 1.5 1.4 0.9 1.4 4.1 3.8
Moderately 2 1.7 1.6 1.5 1 1.4 4.6 3.9
Very 2.6 1.8 2.2 1.6 1.5 1.6 6.2 4.3
Providing food will be affected
Not at all 1.5 1.6 <0.001 1.3 1.4 <0.001 0.8 1.3 <0.001 3.6 3.6 <0.001
Slightly 1.7 1.6 1.5 1.4 0.8 1.3 4 3.6
Moderately 2.1 1.8 1.7 1.5 1 1.4 4.9 3.9
Very 2.7 1.8 2.3 1.6 1.6 1.7 6.5 4.3
Are you committed to quarantine
I do not go out at all 2.2 1.8 <0.001 1.8 1.5 <0.001 1.2 1.5 <0.001 5.2 4.2 <0.001
Only for essentials 1.9 1.7 1.7 1.5 1 1.4 4.6 4
Reduced my going out 1.8 1.7 1.6 1.5 1 1.4 4.4 4
Have not changed at all 2 2 1.7 1.6 1.1 1.5 4.9 4.4
Quality of your relationships with your friends
A lot better 1.7 1.4 <0.001 1.6 1.5 <0.001 0.8 1.4 <0.001 4 3.4 <0.001
A little better 2 1.7 1.8 1.6 1.1 1.5 4.8 4.2
About the same 1.8 1.7 1.6 1.5 0.9 1.4 4.3 3.8
A little worse 2.5 1.8 2.1 1.6 1.4 1.6 6.1 4.3
A lot worse 2.8 1.9 2.2 1.6 1.7 1.8 6.7 4.6
Quality of your relationships with your housemates
A lot better 1.6 1.5 <0.001 1.5 1.4 <0.001 0.8 1.3 <0.001 3.9 3.5 <0.001
A little better 1.9 1.7 1.6 1.5 1 1.4 4.6 3.9
About the same 1.8 1.7 1.5 1.5 0.9 1.3 4.2 3.9
A little worse 2.7 1.7 2.4 1.5 1.5 1.6 6.6 4.1
A lot worse 3.5 1.7 3.1 1.4 2.3 1.8 8.9 4.3
Quality of the relationships between you and members of your family
A lot better 1.5 1.4 <0.001 1.5 1.4 <0.001 0.8 1.2 <0.001 3.8 3.3 <0.001
A little better 1.9 1.7 1.6 1.4 1 1.4 4.5 3.8
About the same 1.9 1.7 1.6 1.5 0.9 1.4 4.4 3.9
A little worse 2.6 1.8 2.2 1.5 1.5 1.7 6.3 4.2
A lot worse 3 1.8 2.6 1.7 2 1.8 7.6 4.6
Quality of your relationships with your Partner
A lot better 1.6 1.7 <0.001 1.6 1.5 <0.001 0.9 1.4 <0.001 4.1 3.9 <0.001
A little better 1.9 1.7 1.8 1.5 1.1 1.5 4.8 4.1
About the same 1.6 1.7 1.5 1.5 0.8 1.3 4 3.8
A little worse 2.6 1.8 2.2 1.5 1.4 1.6 6.2 4.1
A lot worse 3.3 1.8 2.8 1.6 2.3 1.8 8.5 4.4
Drugs increases after COVID-19
No drugs 1.8 1.7 <0.001 1.5 1.4 <0.001 0.8 1.3 <0.001 4.2 3.8 <0.001
Analgesics and NSAIDS 2.4 1.9 2.1 1.6 1.5 1.7 6 4.4
OTC flu medications 1.9 1.7 1.8 1.5 1.2 1.5 4.9 4.1
Hypnotics 3.3 1.7 3.1 1.5 2.7 1.9 9.2 4
Antibiotics 2.3 1.6 2.1 1.5 1.3 1.7 5.8 4
Other 2.3 2 2.1 1.5 1.2 1.5 5.6 4.2
2 drugs 2.4 1.8 2.2 1.6 1.7 1.7 6.3 4.4
3 drugs or more 1.9 2 2.5 1.7 1.5 1.8 5.9 5.1
Drugs increases for your family
No drugs 1.9 1.7 <0.001 1.6 1.5 <0.001 0.9 1.4 <0.001 4.4 3.9 <0.001
Analgesics and NSAIDS 2.3 1.8 2 1.6 1.3 1.6 5.6 4.2
OTC flu medications 2 1.7 1.8 1.4 1 1.4 4.9 3.9
Hypnotics 2.4 1.4 2.5 1.3 1.5 1.3 6.5 2.9
Antibiotics 2.7 1.7 2.4 1.5 1.8 1.7 6.8 4.2
Other 2.2 1.9 2 1.5 1.3 1.5 5.5 4.1
2 drugs 2.1 1.6 1.8 1.5 1.2 1.4 5.1 4.1
3 drugs or more 2.5 1.3 2.3 1.8 1.5 1.9 6.3 4

Table 4.

MSPSS items and total scores mean scores and correlations with COVID-19 and war variables along with other variables.

Characteristic Significant Other Support Family Support Friends Support Total MSPSS Score
Mean Std.
Dev.
P value Mean Std.
Dev.
P value Mean Std.
Dev.
P value Mean Std.
Dev.
P value
Gender
Male 18.4 7.6 <0.001 18.7 6.6 0.002 16.3 7.1 0.096 53.4 17.7 0.004
Female 19.6 7.2 19.3 6.6 16 7.3 54.9 16.7
Change place of living due to war
No 19.4 7.4 0.04 19.4 6.6 <0.001 16.3 7.2 0.023 55.1 17.1 0.001
Within the same city 18.8 7.2 18.7 6.5 15.9 7.2 53.3 16.8
To another city 19.2 7.4 18.6 6.6 15.6 7.2 53.4 17
Distress from war noises
No 18.3 7.6 <0.001 18.2 6.9 <0.001 15.8 7.4 0.227 52.3 17.8 <0.001
Yes 19.4 7.3 19.3 6.5 16.1 7.2 54.9 16.9
Being a student
No 20.3 7 <0.001 19.8 6.5 <0.001 16.2 7.2 0.459 56.3 16.9 <0.001
In a school 18.2 7.5 18.6 6.7 15.6 7.8 52.2 17.8
In a university of high institute 18.5 7.5 18.7 6.6 16 7.2 53.2 17
Education
Elementary 22.7 5.6 <0.001 18.7 6.6 <0.001 14.7 7.7 <0.001 56.1 16.5 <0.001
Until grade 9 18.2 7.6 17.7 7.1 13.9 7.7 49.7 18.2
High School 18.4 7.3 18.2 6.7 15.6 7.3 52.2 17.4
University, or high institute 19.3 7.3 19.1 6.6 16.1 7.2 54.4 17
Master or higher 20.4 7.3 20.9 6.2 17.3 7 58.7 16.1
House that you currently live in
Owned 19.4 7.3 0.184 19.5 6.5 <0.001 16.3 7.1 0.004 55.1 17 0.001
Rented or given by the government 19.2 7.3 18.7 6.7 15.6 7.3 53.5 17.2
Living in friends\relatives house 18.8 7.6 18.3 6.6 15.6 7.3 52.8 16.8
Chronic Medical Condition
No 20.6 7.4 0.001 20.3 6.5 <0.001 17 7.2 0.002 57.9 16.8 <0.001
Hypertension 19.2 7.3 18.4 6.8 16.1 7.2 53.7 17.8
Diabetes 20.1 8.1 19.5 7 14.9 8 54.4 19.8
Asthma 18.8 8.2 18.9 7.3 15.1 7.7 52.8 18.9
Other 19.1 7.8 18.2 7 15.9 7.4 53.2 17.6
Two or more 18.7 7.9 17.6 6.9 15.7 7.4 52.1 19.1
Chronic Condition With Housemates
No 20.9 7.3 <0.001 20.4 6.7 <0.001 16.8 7.3 0.204 58 16.8 <0.001
Hypertension 18.8 7.3 19 6.4 16.3 7.1 54.1 16.6
Diabetes 19.9 7.5 18.9 7 16.7 7.7 55.4 18.6
Asthma 19 7.7 18.6 7.1 15.8 7.2 53.3 17.9
Other 19.5 7.4 18.8 6.6 15.8 7.4 54 17.4
Two or more 18.9 7.5 18.7 6.7 16.2 7.2 53.8 17
Marital Status
Single 17.3 7.4 <0.001 18.7 6.6 <0.001 16.2 7.2 0.611 52.1 17.3 <0.001
In a relationship 23.2 5.4 18.4 6.6 16.4 7.3 57.9 14.9
Married 21.8 6.3 20.5 6.3 15.8 7.2 58 16.5
Divorced 18.3 7.8 18.1 7 16 7.5 52 18.2
Engaged 23.7 5.4 19.9 6.4 16.1 7.4 59.7 14.9
Widowed 17.8 7.3 17.9 6 14.9 6.4 50 15.2
Smoking cigarette or shisha
I was not a smoker and did not start 19.3 7.3 0.413 19.4 6.5 0.001 16.1 7.2 0.211 54.7 16.9 0.049
I used to smoke one of them but now I smoke both 17.6 7.8 17.1 7.1 14.2 7.3 48.9 16.6
Yes I am smoking now and before COVID 19 19.3 7.4 18.9 6.7 16.2 7.2 54.4 17.4
I started smoking cigarettes 19.5 7.5 18.5 7.6 16.7 7.4 54.6 17.2
I started Shisha 18.8 7.8 17.1 7 15.6 7.2 51.6 17.8
SmokingChangesFromCOVID19
Stopped smoking 20.2 6.9 0.049 19.8 6.2 0.001 17.1 7.3 0.001 57.1 16.5 <0.001
Almost the same 19.8 7.2 19.5 6.5 16.2 7.2 55.4 16.9
Increased dramatically 18.4 7.5 17.6 7 14.8 7.1 50.7 17.5
Decreased dramatically 19.5 7.3 18.8 6.8 16.9 7.2 55.2 17.3
Monthly Income Adequacy
It cannot cover buying the essentials 18.6 7.8 <0.001 17.9 7.2 <0.001 14.6 7.3 <0.001 51 18.1 <0.001
It is only enough for essentials from food and drink 19.2 7.2 19.3 6.4 16.3 7.1 54.8 16.6
It is enough for essentials and other things 20.2 7.1 20.3 6.2 17.3 7.2 57.8 16.4
Have you been suspected of having COVID-19
No symptoms or signs 19.3 7.3 0.381 19.2 6.6 0.002 16.1 7.2 0.059 54.6 17 0.014
Yes, has some possible symptoms, but no diagnosis 18.4 8 17 6.9 14.9 7.4 50 18.2
Yes, I was diagnosed with COVID-19 by a doctor 14.5 . 19 . 4 . 37.5 .
Exposed to someone likely to have COVID-19
No 19.3 7.3 0.075 19.2 6.6 0.354 16.1 7.2 0.751 54.6 17 0.17
Yes, has some possible symptoms, but no diagnosis by doctor 18.2 7.8 18.5 6.6 15.8 7 52.4 17
Yes, with someone was diagnosed by a doctor 17.3 7.1 18.7 7.9 15.3 8.6 51.3 22
Anyone in your family been diagnosed with COVID-19
No 19.3 7.3 0.03 19.2 6.6 0.026 16.1 7.2 0.023 54.5 17 0.005
Yes, non-household member 17.6 7.6 18.9 6.8 15.4 6.8 52.4 15.9
Yes, member of household 15.5 7.5 15.4 7.3 11.9 6.8 42.8 18.4
Happened because of COVID-19:
Fallen ill physically
No 19.4 7.3 <0.001 19.3 6.5 <0.001 16.2 7.2 0.007 54.9 17 <0.001
To a family member 18.2 7.5 17.8 7 15.2 7.3 51.2 17.3
To a housemate 18.6 6.9 17.2 7.9 15.1 6.6 51.1 18.2
To you 17.9 7.7 18.1 6.7 15.1 7.4 51 17.2
Hospitalized
No 19.3 7.4 0.933 19.2 6.6 0.134 16.1 7.2 0.582 54.5 17 0.41
To a family member 19 7.6 17.6 6.9 14.9 7.4 51.3 17.8
To a housemate 18.8 7.6 17.3 8.9 15.3 6.7 51.3 22.2
To you 20.2 7.6 17.9 8.6 16.1 6.3 54.2 17.8
Self-quarantine with symptoms
No 19.3 7.4 0.06 19.2 6.6 <0.001 16.1 7.2 0.071 54.5 17 0.002
To a family member 19.8 6.7 21.1 6.9 16.3 7.5 57.2 17.9
To a housemate 13.5 6.9 10 8.1 11.5 5.8 35 19.9
To you 22 6.1 19 6.9 20.5 5.3 61.5 14.8
Self-quarantine without symptoms
No 19.3 7.3 0.117 19.2 6.6 <0.001 16.1 7.2 0.031 54.5 17 0.001
To a family member 18.4 7.6 16.2 7.1 14.8 6.5 49.4 16.2
To a housemate 14.1 7.6 10 8.2 10 4.4 34.1 18.7
To you 20.2 8 19.3 6.8 17.4 7.5 56.9 18.4
Lost Job
No 19.4 7.3 0.03 19.5 6.6 <0.001 16.4 7.2 <0.001 55.3 17 <0.001
To a family member 18.6 7.6 18.7 6.3 15.5 7.2 52.7 17
To a housemate 20.5 6.4 18.6 6.5 13.8 7.2 52.9 15.6
To you 18.8 7.5 18 6.9 15.6 7.4 52.5 17.4
Two of the previous 19.2 7.5 18.4 6.7 15.5 7.3 53.1 16.8
All of the previous 19 7.2 18.1 6.9 14.4 7.1 51 18
Reduced ability to earn money
No 19.5 7.3 <0.001 19.6 6.5 <0.001 16.4 7.2 <0.001 55.6 17 <0.001
To a family member 18.6 7.5 18.6 6.5 15.7 7.2 52.9 17
To a housemate 20.5 6.8 19.4 6.6 14.9 7.6 54.7 17.2
To you 18.4 7.7 18.1 6.8 15.2 7.2 51.7 17.6
Two of the previous 18.7 7.4 18.2 6.6 15.6 7.1 52.4 16.5
All of the previous 19.7 7.2 17.9 6.6 14.1 7.4 51.5 17.9
Passed away
No 19.3 7.3 0.02 19.2 6.6 0.002 16.1 7.2 0.007 54.5 17 <0.001
To a family member 16.6 8.5 17.4 7.1 13.5 6.8 47.5 19.1
To a housemate 13 6.2 11 8 10 5.2 34 18
How worried have you been from:
Being infected
Not at all 19 7.7 0.328 18.8 6.8 0.016 15.9 7.6 <0.001 53.7 18.1 0.009
Slightly 19.3 7.2 19.3 6.4 16.3 7 54.9 16.7
Moderately 19.5 7.2 19.5 6.4 16.6 7.2 55.4 16.8
Very 19.1 7.3 18.7 7 15.2 7.2 53 16.3
Friends or family being infected
Not at all 19.5 7.7 0.606 18.7 7.3 0.263 15.8 7.6 0.286 54.1 18.7 0.715
Slightly 19.5 7.1 19.1 6.6 16.4 7.1 55 17.1
Moderately 19.2 7.4 19.1 6.4 16.2 7.2 54.4 16.9
Very 19.2 7.4 19.4 6.6 16 7.2 54.6 16.6
Your work will be negatively affected
Not at all 19.7 7.4 0.034 19.6 6.6 <0.001 16.4 7.3 0.001 55.8 17.3 <0.001
Slightly 19.4 7.1 19.6 6.3 16.6 7.1 55.5 16.9
Moderately 19.2 7.1 18.9 6.4 16.3 6.9 54.3 16.6
Very 19 7.6 18.7 6.8 15.5 7.2 53.2 16.9
Your studies will be negatively affected
Not at all 19.9 7.5 <0.001 19.4 6.7 0.016 16.2 7.3 0.101 55.5 17.5 0.001
Slightly 19.2 7.1 19.2 6.3 16.5 7.1 54.9 16.5
Moderately 18.6 7.4 19.1 6.5 16.4 7 53.9 16.9
Very 18.4 7.5 18.6 6.7 15.8 7.4 52.8 16.8
Providing food will be affected
Not at all 20.2 7.3 <0.001 19.5 6.8 0.032 16.7 7.4 <0.001 56.4 17.5 <0.001
Slightly 19 7.1 19.3 6.3 16.2 7 54.6 16.7
Moderately 19.2 7.4 19.2 6.5 16.3 7.2 54.7 17.1
Very 18.9 7.6 18.7 6.8 15.5 7.2 53.1 16.8
Are you committed to quarantine
I do not go out at all 19 7.5 0.164 19.1 6.7 0.774 15.6 7.5 0.005 53.6 17.4 0.145
Only for essentials 19.5 7.3 19.2 6.5 16.2 7.1 54.8 16.8
Reduced my going out 19.1 7.6 19.1 6.6 16.7 7.2 54.8 17.4
Have not changed at all 18.8 6.9 18.4 7.1 16.4 7.2 53.8 17.3
Quality of your relationships with your friends
A lot better 22.8 6.4 <0.001 20.1 7.2 <0.001 21 6.1 <0.001 63.6 15.3 <0.001
A little better 19.4 7 19 6.5 17.3 6.7 55.6 16.3
About the same 19.7 7.2 19.5 6.4 16.6 7.1 55.8 16.6
A little worse 17.7 7.7 18.1 6.7 14.3 7 50.1 16.9
A lot worse 17.5 8.2 17.4 7.6 12.4 7.4 47.4 18.7
Quality of your relationships with your housemates
A lot better 23 6.4 <0.001 23.5 5.1 <0.001 17.9 7.2 <0.001 64.5 14 <0.001
A little better 19.8 7 19.9 5.8 16.7 7 56.4 15.8
About the same 19.4 7.3 19.6 6.4 16.3 7.2 55.3 16.8
A little worse 17.5 7.5 16.2 6.6 14.7 7.2 48.4 16.6
A lot worse 15 8.3 12.8 7.3 12.1 6.9 40 18
Quality of the relationships between you and members of your family
A lot better 22.9 6.8 <0.001 23.2 5.2 <0.001 17.6 7.7 <0.001 63.6 14.8 <0.001
A little better 19.9 6.8 19.8 6 16.3 7.1 56.1 15.8
About the same 19.4 7.3 19.4 6.5 16.4 7.1 55.1 16.7
A little worse 17.8 7.8 17.5 6.9 14.6 7.4 50 18.1
A lot worse 16.6 8.2 15.9 7.8 13.6 7.5 46 18.5
Quality of your relationships with your Partner
A lot better 25.7 3.9 <0.001 22.3 5.9 <0.001 17.2 7.6 <0.001 65.3 13.1 <0.001
A little better 22.2 5.6 19.4 6 16.1 7.3 57.8 15.1
About the same 21.6 6.5 20.1 6.4 16.7 7.2 58.4 16.3
A little worse 19.6 7 17.8 6.5 14.5 7.3 51.9 16.4
A lot worse 15.6 7.7 15.9 7.1 13.3 7.5 44.8 18.1
Drugs increases after COVID-19
No drugs 19.3 7.4 0.655 19.3 6.6 0.317 16.3 7.2 0.046 54.9 17.1 0.126
Analgesics and NSAIDS 19 7.1 18.8 6.4 15.5 7.2 53.2 16.6
OTC flu medications 19.2 7.3 19.1 6.5 15.9 6.7 54 17.1
Hypnotics 18.4 9 19.4 7.5 15.1 8.2 52.4 20.2
Antibiotics 19.1 6.2 17.7 7 15.1 7.4 51.6 16.4
Other 20.2 7.8 19.4 6.6 16.5 7.3 56.2 17.8
2 drugs 20.1 7.6 18.9 7 15.7 7.4 54.9 17.3
3 drugs or more 20.2 8.7 20.8 6.7 15.4 8.8 56.4 17.3
Drugs increases for your family
No drugs 19.3 7.4 0.079 19.3 6.6 0.047 16.3 7.2 0.148 54.9 17.1 0.029
Analgesics and NSAIDS 18.9 7.4 19 6.5 15.6 7.2 53.5 16.7
OTC flu medications 19.7 6.4 18.5 6.3 16.2 7.2 54.3 16.3
Hypnotics 20.7 6.4 17.6 7.9 15.9 6.4 54.2 18.1
Antibiotics 18.2 6.8 18.2 6.7 15.3 7.5 51.5 16.8
Other 20 7 19.4 6.4 16.5 7.2 55.9 16.4
2 drugs 18.6 7.6 19.2 5.9 15 7.3 52.5 16.2
3 drugs or more 15.6 6.9 15.4 6.2 13.8 4.7 44.7 13.2

Table 5.

K10 scores, days unable to work and days of reduced work and correlations with COVID-19 and war variables along with other variables.

Characteristic K10 Days unable to work
Mean Std.
Dev.
P value Mean Std.
Dev.
P value
Gender
Male 22 9.1 <0.001 5.9 7.7 <0.001
Female 24.6 9 7.3 7.6
Change place of living due to war
No 23.4 9.1 <0.001 6.8 7.7 0.381
Within the same city 24.4 9 7.2 7.6
To another city 24.8 9.2 7.1 7.6
Distress from war noises
No 22.5 9.2 <0.001 6.2 7.8 0.005
Yes 24.1 9.1 7.1 7.6
Being a student
No 23 9.1 <0.001 5.1 6.8 <0.001
In a school 25.3 9.5 8.4 7.3
In a university of high institute 24.5 9 8.2 8.1
Education
Elementary 24.5 10 0.001 4.9 7.2 <0.001
Until grade 9 23.4 9.4 4.5 5.9
High School 24.4 9.3 8 8.3
University, or high institute 24 9.1 7 7.7
Master or higher 22.4 8.7 5.3 6.4
House that you currently live in
Owned 23.6 9.1 0.002 6.8 7.5 0.194
Rented or given by the government 24.1 9 7.1 8
Living in friends\relatives house 25 9.5 7.3 8
Chronic Medical Condition
No 23.3 9.3 <0.001 6.5 7.5 0.005
Hypertension 24.6 10.1 6.5 8.2
Diabetes 22.1 9.6 5.1 6.6
Asthma 26.3 9.2 8.3 8.4
Other 26.6 9.3 8 8.1
Two or more 25.1 10.1 8 8.7
Chronic Condition With Housemates
No 23 9.5 <0.001 6.3 7.4 0.004
Hypertension 23.7 8.8 7 7.7
Diabetes 23.7 8.8 8.2 8.5
Asthma 25.2 9.2 7.1 7.6
Other 25.8 8.8 7.7 8.2
Two or more 25.3 9.3 7.5 7.9
Marital Status
Single 24.2 9 <0.001 7.5 7.8 <0.001
In a relationship 25.2 9.5 8.5 8.5
Married 22.6 9 4.9 6.5
Divorced 21.6 8.9 5.7 8
Engaged 25 9.6 7.5 8
Widowed 22.8 8.6 4.9 6.8
Smoking cigarette or shisha
I was not a smoker and did not start 23.7 8.9 <0.001 6.9 7.5 0.431
I used to smoke one of them but now I smoke both 26.8 9.2 8.6 9
Yes I am smoking now and before COVID 19 24.2 9.5 7 8
I started smoking cigarettes 25.5 12.3 8.4 8.3
I started Shisha 27.8 10.9 7 8.2
SmokingChangesFromCOVID19
Stopped smoking 22.7 9.1 <0.001 6.8 8.7 0.006
Almost the same 22.7 9.2 6.1 7.8
Increased dramatically 27.4 10.1 8.5 8.7
Decreased dramatically 23.9 9 6.9 8.2
Monthly Income
It cannot cover buying the essentials 25.4 9.8 <0.001 7.9 8.4 <0.001
It is only enough for essentials from food and drink 23.6 8.8 6.8 7.4
It is enough for essentials and other things 22.6 8.8 6.2 7.2
Have you been suspected of having COVID-19
No symptoms or signs 23.8 9.1 0.002 6.9 7.7 0.686
Yes, has some possible symptoms, but no diagnosis 26.9 9.1 7.6 7.3
Yes, I was diagnosed with COVID-19 by a doctor 17 . 7 .
Exposed to someone likely to have COVID-19
No 23.7 9.1 <0.001 6.9 7.6 0.007
Yes, has some possible symptoms, but no diagnosis by doctor 26.7 8.9 7.6 7.8
Yes, with someone was diagnosed by a doctor 26.3 9.7 15.4 10.3
Anyone in your family been diagnosed with COVID-19
No 23.8 9.1 0.96 6.9 7.7 0.329
Yes, non-household member 23.3 8.4 7.7 7.5
Yes, member of household 23.9 8.1 9.4 9.3
Happened because of COVID-19:
Fallen ill physically
No 23.5 9.1 <0.001 6.7 7.5 <0.001
To a family member 26.3 8.9 8.9 8.7
To a housemate 26.5 8.8 6.5 7.1
To you 26.4 8.5 8.3 7.7
Hospitalized
No 23.8 9.1 0.009 6.9 7.7 0.821
To a family member 26.3 9.3 7.8 7.7
To a housemate 25.8 10 7.5 6
To you 29.3 9.6 7.4 8.6
Self-quarantine with symptoms
No 23.8 9.1 0.28 6.9 7.7 0.382
To a family member 27.4 8.8 7.6 6.1
To a housemate 27.1 5.6 11.9 7.2
To you 27.6 6.8 7.6 8.2
Self-quarantine without symptoms
No 23.8 9.1 0.054 6.9 7.7 0.496
To a family member 27.8 8.9 9.3 9.8
To a housemate 30.1 5.4 9.8 7.4
To you 25.3 8.6 6.9 7.1
Lost Job
No 23.2 8.9 <0.001 6.6 7.5 <0.001
To a family member 25.5 9 8.1 8
To a housemate 25.4 9.9 6 7
To you 24.1 9.3 6.6 7.5
Two of the previous 25.4 9.4 7.3 8.1
All of the previous 26.9 10.3 8.6 8.5
Reduced ability to earn money
No 22.9 8.9 <0.001 6.3 7.3 <0.001
To a family member 25.5 9 8.3 8.1
To a housemate 26.1 9.2 6.2 6.8
To you 24.1 9.4 6.5 7.6
Two of the previous 25.8 9.2 7.9 8.4
All of the previous 27.8 10.1 9.2 8.9
Passed away
No 23.8 9.1 0.003 6.9 7.7 0.242
To a family member 29.5 9.9 9.6 7.7
To a housemate 29.3 6.2 10 4.1
How worried have you been from:
Being infected 22.1 9.6 <0.001 6.9 8.3 <0.001
Not at all 22.8 8.5 6.4 7.3
Slightly 24.9 8.6 7.1 7.5
Moderately 28.9 9.2 8.5 8.3
Very
Friends or family being infected
Not at all 19.9 9.4 <0.001 5.1 7.6 <0.001
Slightly 21.8 8.5 6.1 7.4
Moderately 23.3 8.4 6.8 7.3
Very 26.5 9.3 8 8
Your work will be negatively affected
Not at all 22.5 8.7 <0.001 6.8 7.8 0.006
Slightly 23.1 8.6 6.3 7.1
Moderately 23.4 8.9 6.8 7.4
Very 26.7 9.5 7.5 7.9
Your studies will be negatively affected
Not at all 22.8 8.9 <0.001 5.8 7.5 <0.001
Slightly 22.9 8.4 6.7 7.4
Moderately 23.5 8.4 7.7 7.3
Very 27.1 9.6 9.4 8.4
Providing food will be affected
Not at all 21.4 8.6 <0.001 6 7.4 <0.001
Slightly 22.5 8.3 6.4 7.2
Moderately 24.2 8.6 7.3 7.9
Very 27.4 9.7 8.2 8.1
Are you committed to quarantine
I do not go out at all 24.4 9.1 0.009 7.9 7.9 <0.001
Only for essentials 23.5 9.1 6.6 7.5
Reduced my going out 24 9.2 6.2 7.4
Have not changed at all 25.1 10.2 5.4 7.7
Quality of your relationships with your friends
A lot better 24.3 9.1 <0.001 6.5 6.2 <0.001
A little better 24.3 9.2 7.2 7.1
About the same 23 8.9 6.4 7.5
A little worse 26.3 9 8.2 7.9
A lot worse 27 10.1 9.6 8.8
Quality of your relationships with your housemates
A lot better 21.7 8.7 <0.001 5.3 6.4 <0.001
A little better 23.4 8.6 6.4 7
About the same 22.4 8.6 6.3 7.5
A little worse 28.7 8.5 9.3 8
A lot worse 34.2 9.1 12.9 9.1
Quality of the relationships between you and members of your family
A lot better 21.9 8.3 <0.001 5.8 7.2 <0.001
A little better 23.4 8.8 6.7 7.5
About the same 23.1 8.8 6.5 7.5
A little worse 27.3 9.1 8.5 7.9
A lot worse 29.2 10.9 11 9.2
Quality of your relationships with your Partner
A lot better 22.1 9.6 <0.001 5.1 6.7 <0.001
A little better 23.6 8.7 5.9 6.8
About the same 22 8.7 5.4 6.8
A little worse 28 8.7 9 8.5
A lot worse 32 9.5 10.8 8.5
Drugs increases after COVID-19
No drugs 22.6 8.7 <0.001 6.5 7.5 0.002
Analgesics and NSAIDS 26.8 9.1 7.7 7.8
OTC flu medications 23.8 8.3 6.5 7.3
Hypnotics 32.8 9.8 9.5 8.9
Antibiotics 24.7 9.3 7.6 7.5
Other 26.1 9.6 6.6 8
2 drugs 27.9 9.9 6.8 7.5
3 drugs or more 27.7 10.2 9 8.1
Drugs increases for your family
No drugs 22.9 9 <0.001 6.5 7.6 <0.001
Analgesics and NSAIDS 25.9 8.9 7.6 7.6
OTC flu medications 25.1 8.4 6.9 7.3
Hypnotics 27.6 9 12.2 7.7
Antibiotics 27.7 8.7 9.3 8.1
Other 26 9.5 7.4 8.7
2 drugs 24.1 8.6 8.6 8.9
3 drugs or more 27.3 8.1 9.2 9.6

Figure 1.

Figure 1

SPTSS and K10 scores by gender distribution according to the type of work and governorates.

Table 6.

Correlations between each cluster of MSPSS, SPTSS, and K10.

Significant other support Family Support Friends support Total MSPSS Score
Avoidance r = −0.213 r = −0.242 r = −0.195 r = −0.269
Arousal r = −0.137 r = −0.190 r = −0.157 r = −0.199
Re-experience r = −0.171 r = −0.215 r = −0.175 r = −0.231
Total SPTSS score r = −0.207 r = −0.256 r = −0.209 r = −0.278
K10 total score r = −0.164 r = −0.230 r = −0.166 r = −0.229
Days unable to work r = −0.169 r = −0.212 r = −0.147 r = −0.220
Age r = 0.124 r = 0.080 r = 0.033* r = 0.100
Avoidance Arousal Re-experience Total SPTSS score
K10 total score r = 0.600 r = 0.594 r = 0.553 r = 0.683
Days unable to work r = 0.400 r = 0.327 r = 0.330 r = 415
Age r = −0.113 r = −0.079 r = −0.073 r = −0.104

All correlations were significant at P < 0.001.

*

P = 0.016.

Correlation between K10 total score and days of unable to work was not significant (r = 0.021 and P = 0.159).

PTSD

Avoidance, arousal, and total PTSD scores differed according to governorate (P = 0.009, P = 0.060, and P = 0.020, respectively). These PTSD scores differences are demonstrated in Figure 1. All PTSD items did not correlate with consanguinity (P > 0.05). PTSD items and total scores differed according to governorate and type of work or being unemployed (P < 0.05), with total PTSD score differences having (P < 0.001) and demonstrated in Figure 1.

Regressing gender, educational level, rented housing, type of work, having a chronic medical condition, marital status, monthly income adequacy, distress from war noises, and changing place of living due to war on PTSD scores using forward linear regression was significant (P < 0.001) with having a chronic condition (R2 = 3.2%), gender (R2 = 1.4%), monthly income adequacy (R2 = 1.3%), marital status (R2 = 0.3%), changing place of living due to war and educational level (R2 = 0.2%) contributing to the variance. SPTSS item score correlations are demonstrated in Table 3.

MSPSS

Family, friends, significant other, and total support were significantly correlated with the type of work and governorate (P < 0.001), but with consanguinity (P > 0.05).

Regressing gender, educational level, rented accommodation, type of work, having a chronic medical condition, marital status, monthly income adequacy, distress from war noises, and changing place of living due to war on total MSPSS score using forward linear regression was significant (P < 0.001), with social status (R2 = 2.4%), monthly income adequacy (R2 = 1.8%), having a chronic medical condition (R2 = 1.3%), and educational level (R2 = 1%) while living in rented accommodation, type of work, and distress from war noises (R2 = 0.2%) and (P < 0.05) contributing to the variance.

K10

K10 had no association with consanguinity (P > 0.05). K10 total score was different according to governorate and type of work or being unemployed (P < 0.05), with total PTSD score differences having (P < 0.001) and demonstrated in Figure 1.

When Regressing gender, educational level, rented accommodation, type of work, having a chronic medical condition, marital status, monthly income adequacy, distress from war noises, and changing place of living due to war on total K10 score by using forward linear regression, (P < 0.001) for gender (R2 = 2.2%), and having a chronic condition (1.7%), monthly income adequacy (R2 = 0.8%), and social (R2 = 0.6%) while change place of living due to war (R2 = 0.4%) and educational level (R2 = 0.3%) for (P < 0.05). When using forward linear regression on total days of not being able to work with the same previous variables, (P < 0.001) for the type of work (R2 = 1.5%), gender (R2 = 0.8%), marital status (R2 = 1%), having a chronic medical condition (R2 = 0.8%), and monthly income adequacy (R2 = 0.6%).

COVID-19 Variables

When regressing gender, educational level, rented accommodation, type of work, having a chronic medical condition, marital status, monthly income adequacy, distress from war noises, changing place of living due to war, along with other COVID-19 variables of distress from losing the job, decreased income, passing away, the distress of being infected or a family member, distress of the job, studies, and food being affected on total SPTSS score by using forward linear regression, (P < 0.001) for the distress that the ability to provide food will be affected (R2 = 8%), distress from friend or family being infected (R2 = 2.6%), having a chronic condition (R2 = 1.9%), studies being affected (R2 = 1.6%), gender (R2 = 1.4%), job being affected (R2 = 1%), and passing away (R2 = 0.6%) while losing their job, being infected (R2 = 0.4%), and educational level [R2 = 0.2%, P < 0.05].

When regressing the same previous variables on total MSPSS score, (P < 0.001) for social status (R2 = 3.3%), monthly income adequacy (R2 = 1.6%), having a chronic condition (R2 = 1%), passing away (R2 = 0.8%), and educational level (R2 = 0.7%) while decreased income, type of work, and distress from work noise [R2 = 0.3%, P < 0.05]. When regressing the same previous variables on total K10 score with the same previous variables, (P < 0.001) for the distress that the ability to provide food is affected (R2 = 6.6%), gender (R2 = 2.5%), studies being affected (R2 = 1.7%), a friend or family being infected (R2 = 1.3%), having a chronic medical condition (R2 = 1%), and losing their job (R2 = 0.7%) while job being affected (R2 = 0.3%), educational level, distress being infected and passing away [R2 = 0.2, P < 0.05). When regressing the same previous variables on total days of not being able to work with the same previous variables, (P < 0.001) for the distress that studies will be affected (R2 = 3%), gender (R2 = 1%), the distress of food provision being affected (R2 = 0.9%), and type of work (R2 = 0.8%), while having a chronic medical condition (R2 = 0.6%), marital status (R2 = 0.3%), and decreased income (R2 = 0.4%), and educational level (R2 = 0.3%) for (P < 0.05).

No significant difference between gender and smoking changes in lockdown (P > 0.05). However, female participants felt more distress from war noises, more symptoms in the last two weeks, worried more than a friend or member of their family might have it, worried less that job will be affected or the ability to provide food will be affected, committed more to lockdown, their relationships worsened less with friends but more with family in the house and other family members, and took more medication than male participants (P < 0.05). No significant difference between gender in the relationship with partner or studies being affected (P > 0.05).

Being single was correlated with decreasing amount smoked in lockdown more (P < 0.011) and was correlated with less distress from war (P < 0.001). Being married was correlated with less distress of family or friend having COVID-19 when compared to being single (P < 0.001), but with more distress of job being affected (P = 0.009). There was no significant difference in distress about not being able to provide food during the COVID-19 pandemic and being single or married (P > 0.05).

Younger ages were insignificantly correlated with being distressed from acquiring COVID-19 (P = 0.082), significantly correlated with being distressed that a family may have it, a job affected, studies, and providing food being affected from COVID-19 (P < 0.05). Relationships with friends was more stable in older ages as in the younger ages they tended to improve or deteriorate (P < 0.001) while the relationship with housemates was not affected dramatically Younger participants overall their relationship deteriorate more frequently (P < 0.001). Moreover, the relationship with other family members and partners improved more frequently in the older ages (P < 0.001).

Discussion

Our study found that 1,891 (35.6%) participants had avoidance symptoms, 2,558 (48.7%) had arousal symptoms, 2,305 (44.3%) had re-experience symptoms, 1,005 (19.4%) had two PTSD symptoms, 2,301 (42.6%) had moderate to severe mental disorder, and 706 (14.9%) had low social support. Furthermore, female participants were found to have higher avoidance, arousal, re-experience, and mental disorder (K10) scores despite having higher social support scores. Moreover, being distressed from war noises, changing their place of living due to war, being a university or school student, not having an adequate monthly income, and most COVID-19 worries were associated with increased SPTSS and K10 scores and a decreased social support score. However, when regressing to determine the most significant contributing factors, we found that distress about providing food was the main contributing factor to the high SPTSS and K10 scores followed by distress from friends or family being infected, studies being affected from COVID-19, their job being affected from COVID-19, and gender. Social status and monthly income adequacy were the highest contributing factors to having low social support. Interestingly, no factors related to war were found to be significant when using the regression model.

COVID-19

This study assessed the psychological distress caused by the lockdown, and the new social and financial challenges caused by the pandemic, rather than by the illness itself, as <10 cases were confirmed in Syria at the time of the study. Our results show that psychological distress and PTSD symptoms are more common in participants with weak social support, problems at work, and who face challenges in the provision of food. Although our study showed a decrease in the overall frequency of smoking in both genders, there was no significant change in smoking habits among genders This can be explained by an increase in the cost of tobacco during the lockdown or could because of warnings of the effects of smoking on COVID-19.

Regular habits and war exposure in Syria were found to be related to unusual exposures to different substances (19). This exposure has led to an increase in different medical conditions compared to other countries such as allergic rhinitis (20) and laryngopharyngeal reflux disease (21), and both were related to distress from war noises.

Regarding familial relationships, almost half of the participants reported a difference in the relationship with their housemates but over 70% did not report a change in the relationship with other family members and friends.

PTSD, MSPSS, and K10 With COVID-19

Our Study

The provision of food during the lockdown was a big stressor identified by the participants, associated with higher SPTSS and K10 scores. Higher PTSD and mental disorder scores were observed in subjects with a deteriorated relationship with their family, housemates, and friends. This could be from the impact of reduced supports for mental health or from participants with higher PTSD and mental disorder scores suffering from more fragile relationships.

Although participants who tested positive for COVID-19 were few, higher PTSD and mental disorder scores were seen amongst them and their family members. A quarter of the participants did not report having flu-like symptoms but those who had symptoms had not been diagnosed. Higher scores of PTSD and mental distress were also observed in subjects who were self-isolated when asymptomatic compared to an asymptomatic family member who had not. Higher scores were seen when a housemate's ability to earn money was affected, more than when a family member's ability to earn money was affected. This could be explained by the fact that female participants comprised over two-thirds of our sample, and in Syria, a large number of women rely on their housemates to earn money.

Lower PTSD and mental disorder scores were observed in those that ignored lockdown instructions and were able to go out and buy household essentials. Patients with higher scores reported using hypnotics more frequently. Interestingly, social support decreased in participants who did not smoke or used to smoke and commenced using shisha which could be from this habit affecting housemates or the irritability from ceasing cigarette smoking. Higher social support was found in participants with relationships not being affected or improved in the lockdown while higher PTSD scores were seen in participants whose relationships deteriorated with their partners.

Fewer working hours being affected from mental distress were observed in married participants which could be explained by schools being closed and parents having to stay home to look after their children. Higher mental disorder scores and fewer working days being affected from mental distress were observed in participants who increased their smoking habits. Furthermore, the higher the K10 score, the more symptomatic the participants became. Interestingly, subjects with decreased working hours had higher social support and therefore a better relationship status. Higher PTSD scores were observed with higher mental disorder scores, and more days of being unable to work with correlations of (r = 0.682), and (r = 0.415), respectively. Interestingly, mental disorders scores and days of being unable to work had an insignificant correlation (P = 0.159).

Other Studies

The nature of COVID-19 required new methods to collect data as it can be expensive to safely collect data from a large population. The impact that the pandemic has is still uncertain, which could cause anxiety, worry, and even despair (22). Internet-based questionnaires proved to be very effective during the pandemic in many countries where specific questionnaires were developed for this purpose, for example in Italy (23).

Many studies have also found that COVID-19 had severe effects on mental health. Studies from Italy indicated that COVID-19 was linked to anxiety, distress, and symptoms of PTSD (24, 25). The lockdown also affected sleep quality (24). An association was found with general anxiety, and depression in Ireland (26). Another study from Hong Kong found that around a quarter of the population declared that their mental health got worse during the pandemic. Most of the worries were from being infected, not having sufficient masks, and being bothered when not being able to work from home. Interestingly, an association with a previous event was established as participants who did not have experience with the previous SARS outbreak had a worse mental health status (27).

One study among adults in the USA found that COVID-19-related experience was associated with an odds ratio higher than 3 of having probable anxiety and depression and the stress from COVID-19 could predict a variance of (R2 ≥ 30) with anxiety and depression (28). However, a study in Spain demonstrated that the levels of symptoms of depression, anxiety, and stress were low at the beginning, but these levels rose after staying at home (29). Nevertheless, a study in the UK found that the early stages of the pandemic were associated with a modest increase of mental health problems including anxiety, depression, and trauma symptoms (30).

PTSD, MSPSS, and K10 With Other Variables

As PTSD needs at least 4 weeks to develop, we used the SPTSS score as a probable indicator rather than cut-off points. Having certain medical conditions was associated with higher scores in SPTSS and K10, especially when having a family member with chronic medical conditions like asthma. This may indicate the need to address the psychological effect of chronic medical conditions, not only on the affected person but on other members of their household. Participants who did not own the house they lived in and had an inadequate monthly income had higher SPTSS and K10 scores which indicates the role of financial burden. Avoidance scores were higher when losing a housemate while other PTSD symptoms scores increased more when participants had lost a family member. This could be explained by the stereotype brought to the widowed woman in the community that makes her feel isolated. Another theory could be that the morale of the widowed dropped, as losing a partner is considered a major trauma and the possibility of losing the social and financial support of the partner is also significant.

Mental distress and PTSD have been identified in many studies to be more common in female participants, particularly from war noises (12). Distress was also more common in female schoolchildren aged 15 years and over, but male schoolchildren had more tendency to smoke (31), which was similar to adults in Syria (32). The high prevalence of PTSD and severe mental distress are not novel findings and the prevalence found in our study was lower than a previous study that used the same materials and same scales conducted a year ago (12). The previous study found that 60.8% of the sample had two positive PTSD clusters or more according to DSM IV and 61.2% of the sample had moderate to severe mental disorders according to K10. Our study findings were also lower than those of a study on Syrian schools in Damascus (31) in which PTSD prevalence was found to be 53%. This may indicate that war may have a more severe effect than the pandemic.

Many risk factors for psychological distress were identified that were associated with COVID-19 such as female gender, being younger than 50 years of age, being in direct contact with someone who was infected by COVID-19, having a high risk of acquiring COVID-19, the presence of children at home, low income, having previous medical conditions in them or with others and being uncertain about the risk of contagion (25, 26, 30). However, despite the finding that psychological distress is associated with younger age, being 65 years or older was associated with more severe anxiety related to COVID-19 (26). In Turkey, a neighboring country to Syria, it was found that being female, living in an urban place, and having a previous psychiatric problem were associated with anxiety, compared to depression which was only associated with living in an urban place. However, being female, having a chronic medical condition, and having psychiatric disorders were associated with anxiety (33).

Limitations

As PTSD needs four weeks to develop (according to the strict definition), we used scoring symptoms rather than diagnosing cut-off, which is perhaps more indicative of an acute stress disorder. This study was online and mainly involved participants who had enough free time to fill in the survey which may neglect the truly affected population. Furthermore, the days of fewer productivity questions in K10-LM may not be fully understood for some participants and therefore were not mentioned in the discussion. This study used a questionnaire and is not based on medical diagnosis, which would have been more accurate. No clinical examination by professionals was conducted and therefore determining if the effect of COVID-19 was truly more severe than war is not conclusive.

The sampling method, the use of an online questionnaire, the sample size compared to the population, and the subjectivity of the used method were the main source of biases in our study.

Conclusion

Although full lockdown can be an effective method for preventing the spread of pandemic diseases such as COVID-19, this study indicates that it causes severe distress. This is reflected in mental distress and PTSD symptoms even in countries that were originally affected by wars, as the restrictions of lockdowns can obstruct lifestyle and the ability to earn and provide daily food. Social support has a role and to some extent reduces the amount of stress either on PTSD or distress from COVID-19. Being widowed, low SES, low social support, and living in rented accommodation were associated the most with distress as the ability to earn and to provide food were the most common stressors. Having high K10 and PTSD scores were associated with having more symptoms of COVID-19 despite not being exposed to it. PTSD and severe mental distress were prevalent in the Syrian community due to the psychological effects of war in the previous 9 years. Positive PTSD clusters in this study were less prevalent compared to previous studies in Syria which may suggest that the first weeks of lockdown might reduce the stress. However, this study suggests that COVID-19 stress, mainly from the effect on the economy, might be more distressing than experiencing war.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, upon reasonable request.

Ethics Statement

Informed consent was taken before participants completed the survey. Informed consent was also taken for using and publishing the data. Confidentiality was assured by not asking or publishing any data that may refer to the individual identity. The ethical aspects of the study were approved by Damascus University deanship (Damascus, Syria).

Author Contributions

AK: conceptualization, data curation, formal analysis, investigation, methodology, project administration, supervision, resources, validation, original draft, writing, review, and editing. AF: review and editing, original draft, investigation, software, and resources. LM: original draft, writing, review, and editing. AG: conceptualization, project administration, editing, and software. RA: project administration, investigation, and resources. All authors have read and approved the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Glossary

Abbreviations

ANOVA

Analysis of variance

CI

Confidence Interval

COVID-19

Coronavirus disease 2019

CRISIS

The CoRonavIruS Health Impact Survey

DSM

Diagnostic and statistical manual of mental disorders

ICD

International Classification of Disease

K10

Kessler

MSPSS

Multidimensional Scale of Perceived Social Support

NMIH

National Institute of Mental Health

PTSD

post-traumatic stress disorder

SES

Socioeconomic status

SPSS

Statistical Package for the Social Sciences

SPTSS

Screen for Posttraumatic Stress Symptoms.

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Associated Data

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Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, upon reasonable request.


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