To our knowledge, this is the first study to report that prevalence and compare the severity of the stress, anxiety and depression among four groups of Iranian society. The main results of the present study indicate that medical students who had worked with COVID-19 patients for at least one week and patients with COVID-19 had the significantly higher score of stress, anxiety and depression compare with medical staff and community population (P<0.05), this suggests that they would be the main targets of psychiatric assessment and care. In overall, the score of anxiety level in male was higher than that in female (P=0.006), and the score of depression in unmarried participants was significantly higher than that in married group (P=0.023). In addition, the score of depression in female medical staff (P=0.011) and community population (P=0.02) was higher than that in male.
Previous studies have shown an association between epidemics and mental disorders during the spread of infections such as SARS and MERS infection [24, 25]. A study of Hawryluck et al. [4] showed that isolation and quarantine during the outbreak are stressful; they found that some subject due to quarantine for SARS in Canada displayed symptoms of PTSD (28.9%) and depression (31.2%). Al-Najjar et al. [26] in a study examining the psychological reactions of adults to the MERS epidemic in western Saudi Arabia, they found that anxiety was significantly increased by increasing susceptibility to infection and social behaviors associated with travel and being in public places. Lee et al. [27] evaluated the psychological impacts of the MERS outbreak and found that PTSD symptoms were very high among hospital staff even many years after the outbreak.
In terms of the psychological impact of COVID-19 pandemic on society, there are not many studies and only a few studies have been conducted in China [28-30]. In a cross-sectional study by Wang et al. [31] psychological impacts, depression, stress, and anxiety was evaluated on 1210 participants from 194 cities in China at the beginning of the COVID-19 outbreak and results showed that 53.8% of these people experienced severe psychological impacts of the outbreak. Moreover, 16.5%, 28.8%, and 8.1% of the respondents reported moderate to severe levels of depression, anxiety, and stress, respectively. Moreover, in a cross-sectional observational study by Xiao et al. [32] on 180 medical staff, levels of anxiety, self-efficacy, stress, sleep quality, and social support were measured and the results showed that medical staff in China who were treating patients with COVID-19 infection had high levels of anxiety, stress, and self-efficacy that were dependent on sleep quality and social support.
The results of this study and all previous studies have shown that the prevalence of psychological trauma due to the prevalence of infectious diseases in society is very significant. Infectious pandemics can cause disruptions on social and individual on many levels [33]. COVID-19 imposes irreversible psychological impacts on all groups of community members, such as general population, health care workers and students due to the commuting restrictions, fear of suffering from the virus, anxiety about closure of schools and businesses, depression following losing friends and family and fear of death [34-36]. Furthermore, the COVID-19 pandemic has become an additional economic and social stress that has made life miserable for the head of the household. As can be seen in the results of the study, the score of anxiety level in men was significantly higher than that in women.
The results of this study revealed that the patients with COVID-19 and medical students who spent time with patients with COVID-19 are the main targets of psychiatric assessment and care. Higher psychological distress in medical students can be related to the physical and emotional exhaustion due to a high-pressure health care system, rapid changes in medical information and procedures, perception of risk to themselves, lifestyle impacted by outbreaks, fear of inadequate medical equipment such as masks and gloves and personal vulnerability due to poor experience compared to fully licensed staff physicians. In patients with COVID-19, these can be related to the fear of severe disease consequences and the contagion, isolation treatment, loss of trust in health services and fear of death. Consequently, they may experience loneliness, denial, anxiety, depression, insomnia, and despair, which may lower treatment adherence. Some of these cases may even have increased risk of aggression and suicide. In addition, the limited knowledge of the COVID-19 and the overwhelming news may cause anxiety and fear in the public. The general public may also experience boredom, frustration, and irritability under the isolation measures [29]. Therefore, during this time of a global pandemic, interventions to promote mental well-being for all community need to be implemented, with particular attention to patients with COVID-19 and first-line of health professional.
To our knowledge, this is the first report of psychological distress among Iranian population during pandemic of COVID-19. The main strengths of the present investigation were the comparison the severity of this psychological distress among four groups of society and the large sample size in each group is of great importance. However, further researches are needed to determine the psychological impact of the pandemic on Iran's population and worldwide.