Assessment of Mental Health and Various Coping Strategies among general population living Under Imposed COVID-Lockdown Across world: A Cross-Sectional Study.

The 2019 corona virus disease (COVID-19) which outbreak in December 2019, in the Chinese city of Wuhan has became a global threat and is currently the largest known outbreak of atypical pneumonia affecting every continent of the world with about 6,416,828 cases and 382,867 deaths. Disease enforced lockdowns are known to cause heightened levels of depression, anxiety, and stress. Our study aimed to investigate the immediate impact of the COVID-19 pandemic enforced lockdown on mental health and quality of life among general population aged 18 years and to identify various coping strategies used under lockdown. An online survey was conducted between 1st of April-10th of May, 2020; using a validated questionnaire based on DASS-42, employing a snowball sampling technique. A total of 418 responses from 16 different countries were received. The respondents had a high level of depression and anxiety scores, which were significantly different among genders. Also, participants from developing countries-India and Pakistan had severe depression while as participants from India, Pakistan and Kingdom of Saudi Arabia had severe anxiety. We also found that among the various coping strategies, (a) watching television for entertainment, (b) social networking, (c) listening to music, (d) sleeping, (e) doing mundane house chores like cleaning, washing, etc. (f) eating well, and (g) clearing/finishing thepiled-up work were ranked among the most utilized coping strategies by all participants. This study identifies the need to provide the free professional and psychological services to help cope with stress during the disease-enforced lockdown.

Introduction

The 2019 corona virus disease (COVID-19) started in December 2019, as a novel viral outbreak in seafood market in the Chinese city of Wuhan located in central Hubei province [1], [2], [3]. This novel virus quickly became a global threat by spreading across the globe within three months and is currently the largest known outbreak of atypical pneumonia since the severe acute respiratory syndrome (SARS) outbreak in 2003 affecting every continent of the world with about 6,416,828 cases and 382,867 deaths [4].

In order to prevent the spread and burden of disease, governments all over the world were forced to enforce the complete lockdown of their economies and life as we knew it came to a grinding halt [5], and several countries were forced to implement the community mitigation strategies during this pandemic for the survival and management of distress [6], [7]. Currently, an unprecedented lockdown is being enforced around the globe, in both developed as well as developing countries encompassing all continents [8]. Life under current circumstance of COVID pandemic lockdown is very challenging especially for the professionals like students, office workers and academicians and does constitute huge amounts of numerous varieties of stress [7], [9]. During these unprecedented conditions, a person (especially a health care worker) is subjected to various sources of stress emanating from numerous pressures, peer pressures, personal, emotional, work or social issues, boredom, infection fear, loss of usual routine, and reduced social and physical contact, environmental factors, financial and family issues, etc. [10], [11], [12].

The current lockdown and quarantine model of fighting the COVID-19 does clearly have major social and psychological impact on the whole population. The lockdown has multi-faceted affects like unemployment, family separations, domestic violence, deaths of loved ones, failure of closure, social stigmatization, increased loneliness, work stress, the overabundance of (mis)information on social media and various other related factors. All of these serve as the major psychological risk factors for stress, anxiety, depression, and self-harm [7], [11], [12], [13]. Most prevalent psychological disorders are depression and anxiety categorized as: “neurotic, stress-related and somatoform disorders” and “mood disorders”. Importance of psychological and behavioral disorders in community health is well established, as they are the most significant basis of morbidity in general care settings leading to extensive disability [14], [15].

There are numerous important factors causing emotional distress which have been described in the explanatory models of persons suffering from common psychological disorder. Several rating scales purporting to assess the clinical construct of depression are developed of which DASS-42 is one of the best scales to assess the levels of stress, anxiety and depression [16], [17], [18], [19]. Several techniques and strategies have been identified by psychologists to master, reduce, tolerate, or minimize the effects of stressors. All these are referred to as coping strategies and usually include mindfulness-based stress reduction classes, wellness electives, informal support groups and mentoring programs [20]. Coping methods often used include, effective time management, social support, positive reappraisal, and engagement in leisurely [9], [21], [22].

Therefore, we designed this study to measure the mental stress of general populations and to assess their perceptions towards various stress factors, their sources, and their severity under the COVID lockdown.

The main aim of the study was:

to assess the severity of depression, anxiety, and stress in general population ;

to identify various coping strategies used under lockdown.

Methodology

This study is a descriptive type of research using survey approach. The study was carried in between 10th of April–10th of May, 2020. The online questionnaire was distributed through social media (Facebook, Twitter, WhatsApp and Official emails) by the PI and CoIs to their contacts. All participants were randomly selected, and snowball sampling method was used for the inclusion. The participants were also encouraged to send the survey to their own contacts as much as possible. Participants of age equal or more than 18 years, who were able to understand English and provided their informed consent were included. The study was approved by institutional Ethic and Research Board (IRB) of King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) & King Abdullah International Medical Research Center (KAIMRC).

The study was conducted among general population living in the identified lockdown cities around the world especially in countries–Kingdom of Saudi Arabia (KSA), India, Pakistan, United Kingdom (UK) and United States of America (USA). An informed consent from all the participants was duly taken followed by the implementation of a pre-designed questionnaire based on two tools to obtain a data set composed of socio-demographic and physical characteristics.

Tool 1 was DASS-42 (Depression Anxiety Stress Scale), which is a freely available, standardized questionnaire to assess depression, stress, and anxiety. The DASS questionnaire is freely available in public domain and hence requires no permission for its use [18], [19]. For this study we adopted 42-item questionnaire, which constitutes three subscales including depression, anxiety, and stress—each of which is based upon fourteen items of the DASS questionnaire. The participants respond to each item of DASS on a 4-point Likert scale (0 = Did not apply to me, 1 = Applied to me to some degree or some of the time, 2 = Applied to me to a considerable degree or for a good part of time and 3 = Applied to me very much or most of the time). According to the DASS-42 scoring algorithm, higher scores indicated higher depression, anxiety, and stress. Total score is calculated by summing the scores for each subscale. Moreover, DASS scoring manual also does provide a cut-off scores for defining the severity of depression, stress and anxiety, as provided: Normal (0–9 for depression, 0–7 for anxiety and 0–14 for stress), Mild (10–13 for depression, 8–9 for anxiety and 15–18 for stress), Moderate (14–20 for depression, 10–14 for anxiety and 19–25 for stress), Severe (21–27 for depression, 15–19 for anxiety and 26–33 for stress) and Extremely severe (> 28 for depression, > 20 for anxiety, > 34 for stress).

Tool 2 was a validated questionnaire to assess various strategies used by participants for coping the stress on a 5-point Likert scale developed from the previous published studies [22], [23] (0 = Strongly Disagree, 1 = Disagree, 2 = Unsure, 3 = Agree, 4 = Strongly Agree).

The data from the participants was collected via online survey using Google Forms platform. The questionnaire comprised of three sections: Section A contained questions about the demographics. Section B contained DASS 42 statements and Section C contained statements about various coping strategies. The data collected were tabulated and analysis was performed using IBM SPSS Statistics for Windows, version 20.0. Appropriate statistical tools were employed in the data analysis and variables were summarized as frequency and percentage. P-values less than 0.05 were accepted as statistically significant.

Results

A total of 418 participants responded voluntary to the dispensed survey, of them, 244 (58.4%) were males, while 174 (41.6%) were females. The median age of the respondents was 33.5. The average weeks spent by the participants in the lockdown was 3.65. Furthermore, 192 (45.9%) of the respondents were single and 226 (54.1%) were married. Of the respondents, 98 (23.4%) were students, 92 (22.0%) academicians, 70 (16.7%) Research Scientists, 38 (9.1%) doctors, 36 (8.6%) banking professionals, 22 (5.3%) engineers etc, 22 (5.3%) office Administrators and 10 (2.4%) house wives, 8 (1.9%) were nursing professionals. Also, participants were from 16 different countries which were under the lockdown measure during the months of March till May 2020. Major chunk of the participants was from five countries: India (269, 64.4%), Pakistan (54, 12.9%), Saudi Arabia (27, 6.5%), United Kingdom (26, 6.2%) and United States of America (14, 3.3%). Demographic characteristics of the participants are presented in Table 1, Table 2 .

Table 1

Description of participants of survey.

Description des participants à l’étude.

	Median	Interquartile range
Age	33.5	13
How many weeks have you spent in Lock-down?	3.0	1
Depression Score	16.0	22
Anxiety Score	16.0	24
Stress Score	14.0	21

Table 2

Demographic characteristics of participants.

Caractéristiques démographiques des participants.

	n	%
Gender
Male	244	58.4
Female	174	41.6
Marital status
Single	192	45.9
Married	226	54.1
Occupation
Student	98	23.4
Academician (Faculty, Teachers, etc.)	92	22.0
Research scientist	70	16.7
Doctor	38	9.1
Banking professionals	36	8.6
Engineers and allied professionals (IT, Civil, etc.)	22	5.3
Office administrators/Managers, etc.	22	5.3
Housewife/Home maker	10	2.4
Nursing & allied professionals	8	1.9
Self-employed/business owners	6	1.4
Marketer	6	1.4
Media professionals (Print & TV)	4	1.0
Designer	2	.5
Unemployed	2	.5
Hotel industry professional	2	0.5
Current country residence
India	269	64.4
Pakistan	54	12.9
Saudi Arabia	27	6.5
United Kingdom	26	6.2
United States of America	14	3.3
Canada	6	1.4
United Arab Emirates	4	1.0
Estonia	2	0.5
Holland	2	0.5
Germany	2	0.5
Bangladesh	2	0.5
Chile	2	0.5
Korea	2	0.5
Japan	2	0.5
Malaysia	2	0.5
Switzerland	2	0.5
Total	418	100

Analysis of DASS-42 scores (Tool 1) revealed that male and female participants differed significantly in their overall scores for depression and anxiety (P-value < 0.05) while their stress scores were almost comparable (Table 3 ). Furthermore, based on the severity, among male participants 54 (22.1%) had moderate, 24 (9.8%) has severe and 56 (23.0%) had extremely severe depression; while as among female participants 30 (17.2%) had moderate, 18 (10.3%) has severe and 58 (33.0%) suffered from extremely severe depression. For anxiety, among male participants 86 (35.2%) were normal but 28 (11.5%) had moderate, 26 (10.7%) has severe and 90 (36.9%) had extremely severe anxiety; while as among female participants 48 (27.6%) were normal, 08 (4.6%) had moderate, 14 (8.0%) has severe and 94 (54.0%) suffered from extremely severe anxiety. Lastly for stress, among male participants 144 (59.0%) had normal levels of stress but 30 (12.3%) had moderate, 28 (11.5%) has severe and 22 (9.0%) had extremely severe stress; while as among female participants almost half i.e., 86 (49.4%) had normal stress levels but 20 (11.5%) had moderate, 22 (12.6%) has severe and only 24 (13.8%) suffered from extremely severe stress (Table 4, Table 5 ).

Table 3

Participants perceptions of depression, anxiety, and stress on the DASS-42 scale.

Perception des participants concernant la dépression, anxiété et stress sur l’échelle DASS-42.

Item in DASS-42	Questions	Did not apply to me at all	Applied to me to some degree or some of the time	Applied to me to a considerable degree or a good part of time	Applied to me very much, or most of the time
	n = 418	n of n (%)
	Depression Scale
3	I couldn’t seem to experience any positive feelings at all	204 (48.8)	128 (30.6)	50 (12.0)	36 (8.6)
5	I just couldn’t seem to get going these days	186 (44.5)	146 (34.9)	56 (13.4)	30 (7.2)
10	I feel that I have nothing to look forward to	262 (62.7)	96 (23)	24 (5.7)	36 (8.6)
13	I feel sad and depressed	176 (42.1)	152 (36.4)	52 (12.4)	38 (9.1)
16	I feel that I have lost interest in just about everything	236 (56.5)	124 (29.7)	34 (8.1)	24 (5.7)
17	I feel I am not worth much as a person	278 (66.5)	80 (19.1)	36 (8.6)	24 (5.7)
21	I feel that life Isn’t worthwhile (these days)	248 (59.3)	98 (23.4)	46 (11.0)	26 (6.2)
24	I can’t seem to get any enjoyment out of the things I did	180 (43.1)	174 (41.6)	40 (9.6)	24 (5.7)
26	I feel down-hearted and blue	272 (65.1)	96 (23.0)	28 (6.7)	22 (5.3)
31	I am unable to become enthusiastic about anything	220 (52.6)	132 (31.6)	34 (8.1)	32 (7.7)
34	I feel that I am worthless	296 (70.8)	68 (16.3)	30 (7.2)	24 (5.7)
37	I can see nothing in the future to be hopeful about	290 (69.4)	88 (21.1)	30 (7.2)	10 (2.4)
38	I feel that life was meaningless	312 (74.6)	68 (16.3)	18 (4.3)	20 (4.8)
42	I find it difficult to work up the initiative to do things	192 (45.9)	132 (31.6)	52 (12.4)	42 (10.0)
	Anxiety Scale
2	I am aware of dryness of my mouth	188 (45.0)	108 (25.8)	84 (20.1)	38 (9.1)
4	I experienced breathing difficulty (e.g. breathlessness or excessively rapid breathing in the absence of physical exertion)	320 (76.6)	70 (16.7)	22 (5.3)	6 (1.4)
7	I have a feeling of shakiness (e.g. legs going to give way)	334 (79.9)	66 (15.8)	8 (1.9)	10 (2.4)
9	I find myself in situations that make me so anxious, i will be relieved when it ends	124 (29.7)	160 (38.3)	88 (21.1)	46 (11.0)
15	I have a feeling of faintness	328 (78.5)	62 (14.8)	14 (3.3)	14 (3.3)
19	I perspire noticeably (e.g. hands sweaty) in the absence of high temperatures or physical exertion	332 (79.4)	62 (14.8)	14 (3.3)	10 (2.4)
20	I feel scared (without any good reason in current time)	250 (59.8)	118 (28.2)	24 (5.7)	26 (6.2)
23	I have difficulty in swallowing	358 (85.6)	42 (10.0)	12 (2.9)	6 (1.4)
25	I am aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat)	228 (54.5)	110 (26.3)	50 (12.0)	30 (7.2)
28	I feel I am close to panic	268 (64.1)	104 (24.9)	26 (6.2)	20 (4.8)
30	I fear that I would be “thrown” by some trivial but unfamiliar task	270 (64.6)	102 (24.4)	24 (5.7)	22 (5.3)
36	I feel terrified in current times	216 (51.7)	134 (32.1)	42 (10.0)	26 (6.2)
40	I am worried about situations in which I might panic and make a fool of myself	226 (54.1)	116 (27.8)	44 (10.5)	32 (7.7)
41	I experience trembling (e.g., in the hands)	340 (81.3)	46 (11.0)	18 (4.3)	14 (3.3)
	Stress Scale
1	I find myself getting upset by quite trivial things	122 (29.2)	180 (43.1)	74 (17.7)	42 (10.0)
6	I tend to over-react to situations	198 (47.4)	140 (33.5)	48 (11.5)	32 (7.7)
8	I find it difficult to relax	186 (44.5)	148 (35.4)	50 (12.0)	34 (8.1)
11	I find myself getting upset rather easily	176 (42.1)	158 (37.8)	44 (10.5)	40 (9.6)
12	I feel that I am using a lot of nervous energy	180 (43.1)	140 (33.5)	74 (17.7)	24 (5.7)
14	I find myself getting impatient when I am delayed in any way in simple chores (e.g. lifts, being kept waiting)	204 (48.8)	116 (27.8)	66 (15.8)	32 (7.7)
18	I feel that I am rather touchy (these days)	210 (50.2)	138 (33.0)	38 (9.1)	32 (7.7)
22	I find it hard to relax and wind down	176 (42.1)	158 (37.8)	54 (12.9)	30 (7.2)
27	I find that I am very irritable	202 (48.3)	132 (31.6)	44 (10.5)	40 (9.6)
29	I find it hard to calm down after something upsets me	194 (46.4)	136 (32.5)	46 (11.0)	42 (10.0)
32	I find it difficult to tolerate interruptions to what I am/was doing	204 (48.8)	122 (29.2)	48 (11.5)	44 (10.5)
33	I am in a state of nervous tension	228 (54.5)	132 (31.6)	32 (7.7)	26 (6.2)
35	I am intolerant of anything that kept me from getting on with what I was doing	228 (54.5)	132 (31.6)	26 (6.2)	32 (7.7)
39	I find myself getting agitated (these days)	232 (55.5)	114 (27.3)	42 (10.0)	30 (7.2)

Table 4

Participants perceptions on the DASS-42 scale based on gender with respect to severity ratings of depression, anxiety, and stress.

Perceptions des participants sur l’échelle DASS-42 basée sur le sexe en ce qui concerne les cotes de gravité de la dépression, de l’anxiété et du stress.

Severity ratings	Depression category, n (%)		Anxiety category, n (%)		Stress category, n (%)
	Male	Female	Male	Female	Male	Female
Normal	92 (37.7)	48 (27.6)	86 (35.2)	48 (27.6)	144 (59.0)	86 (49.4)
Mild	18 (7.4)	20 (11.5)	14 (5.7)	10 (5.7)	20 (8.2)	22 (12.6)
Moderate	54 (22.1)	30 (17.2)	28 (11.5)	8 (4.6)	30 (12.3)	20 (11.5)
Severe	24 (9.8)	18 (10.3)	26 (10.7)	14 (8.0)	28 (11.5)	22 (12.6)
Extremely severe	56 (23.0)	58 (33.3)	90 (36.9)	94 (54.0)	22 (9.0)	24 (13.8)

Table 5

Participants overall scores on the DASS-42 scale based on gender.

Notes globales des participants sur l’échelle DASS-42 en fonction du sexe.

	n	Mean Rank	Mann-Whitney U	Z-value	P-value
Depression score
Male	244	197.54	18,310	−2.398	.016
Female	174	226.27
Anxiety score
Male	244	195.34	17,772	−2.840	.005
Female	174	229.36
Stress score
Male	244	201.12	19,184	−1.680	.093
Female	174	221.25
Total	418

Country wise, we found that there was a significant difference in the depression and stress scores (P  < 0.05), with India having a higher mean rank and United Kingdom having lowest. Also, scores for Pakistan and Saudi Arabia were almost comparable for all three categories. Mean ranks for depression and stress for USA was second to India (Table 6, Table 7 ). Of all the participants, 84 (31.2%) of 269 Indians were extremely depressed, 2 (7.4%) of 27 Saudis, 14 (25.9%) of 54 Pakistanis, 4 (28.6%) of 14 of USA while as only 4 (15.4%) of 26 Britishers were extremely depressed. For anxiety, 48.3% of Indians, 37.0% of Saudis, 37.0% of Pakistanis, 28.6% of USA while as only 23.1% of 26 Britishers had extreme anxiety. For stress, 11.9% of Indians and only 3.7% of Pakistanis had extreme stress (Table 7).

Table 6

Participants overall scores on the DASS-42 scale based on country of residence.

Notes globales des participants sur l’échelle DASS-42 en fonction du pays de résidence.

Country	n	Mean Rank	Chi2	df	P-value
Depression score
India	269	222.71	11.61	5	0.041
Saudi Arabia	27	168.35
United Kingdom	26	197.58
Pakistan	54	172.91
United States of America	14	205.79
Others	28	205.79
Anxiety score
India	269	222.49	10.33	5	0.066
Saudi Arabia	27	178.20
United Kingdom	26	188.88
Pakistan	54	174.46
United States of America	14	200.21
Others	28	206.21
Stress score
India	269	225.02	15.45	5	0.009
Saudi Arabia	27	188.57
United Kingdom	26	156.81
Pakistan	54	174.02
United States of America	14	185.07
Others	28	210.14
Total	418

Table 7

Participants overall scores on the DASS-42 scale based on country of residence and severity of depression, anxiety, and stress.

Score global des participants sur l’échelle DASS-42 en fonction du pays de résidence et de la gravité de la dépression, de l’anxiété et du stress.

Severity rating	Current country residence, n (%)
	India	Saudi Arabia	United Kingdom	United States of America	Pakistan	Others
Depression category
Normal	77 (28.6)	13 (48.1)	8 (30.8)	6 (42.6)	26 (48.1)	10 (35.7)
Mild	26 (9.7)	0 (0.0)	8 (30.8)	0 (0.0)	4 (7.4)	0 (0.0)
Moderate	48 (17.8)	10 (37.0)	6 (23.1)	4 (28.6)	6 (11.1)	10 (35.7)
Severe	34 (12.6)	2 (7.4)	0 (0.0)	0 (0.0)	4 (7.4)	2 (7.1)
Extremely severe	84 (31.2)	2 (7.4)	4 (15.4)	4 (28.6)	14 (25.9)	6 (21.4)
Anxiety category
Normal	75 (27.9)	11 (40.7)	10 (38.5)	8 (28.6)	24 (44.4)	8 (28.6)
Mild	14 (5.2)	2 (7.4)	2 (7.7)	2 (7.1)	4 (7.4)	2 (7.1)
Moderate	24 (8.9)	2 (7.4)	2 (7.7)	4 (14.3)	2 (3.7)	4 (14.3)
Severe	26 (9.7)	2 (7.4)	6 (23.1)	0 (0.0)	4 (7.4)	0 (0.0)
Extremely severe	130 (48.3)	10 (37.0)	6 (23.1)	4 (28.6)	20 (37.0)	14 (50.0)
Stress category
Normal	133 (49.4)	15 (55.6)	22 (84.6)	10 (71.4)	34 (63.0)	2 (100.0)
Mild	28 (10.4)	6 (22.2)	2 (7.7)	0 (0.0)	4 (7.4)	0 (0.0)
Moderate	40 (14.9)	4 (14.8)	0 (0.0)	0 (0.0)	4 (7.4)	0 (0.0)
Severe	36 (13.4)	2 (7.4)	0 (0.0)	0 (0.0)	10 (18.5)	0 (0.0)
Extremely severe	32 (11.9)	0 (0.0)	2 (7.7)	4 (28.6)	2 (3.7)	0 (0.0)
Total	269	27	26	14	54	28

Analysis of Tool 2 questionnaire revealed that there were no marked differences in using the different coping strategies by the participants in dealing with the lockdown with males and females utilizing all strategies almost comparably; however there was slight difference on the basis of professions. All the participants used the range of strategies to manage their time in quarantine in a varying degree (Table 8 ). Seven coping strategies (a) watching television for entertainment, (b) social networking, (c) listening to music, (d) sleeping, (e) doing mundane house chores like cleaning, washing, etc. (f) eating well, and (g) clearing/finishing my piled-up work were ranked among the most utilized coping strategies by all participants (received highest agreement) in contrast to (a) gardening/landscaping, etc., (b) watching television for news exclusively, (c) taking up new hobby, (d) participating in online classes, etc. as the non-utilized or less useful coping strategy. Taking solace in offering prayers and participating/playing indoor sports were chosen preferentially by 38.95 of banking professional and 36.7% students to be as strongly agreeable coping strategy. Also, 53.1% of students and 31.4% of research scientists strongly agreed to use sleeping in their lockdown quarantine hours. 27.3% of Office managers and 20.4% of students strongly agreed to identifying themselves with other role models who prioritize their quality of life while 40.8% of students, 28.6% of research scientists and 26.3% of doctors strongly agreed to use respecting ones physical limits & avoiding spending many hours without sleeping. Cooking as coping strategy was strongly agreeable to 63.6% of office administrators and 44.9% students. 22.9% of doctors, 26.1% of academicians and 28.6% of students were in strong agreement to participate in online courses during the lockdown. The replies to various coping strategies by participants on the basis of 5 point Likert scale are provided in the Table 8 and Table 9. Also, Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10, Figure 11, Figure 12, Figure 13, Figure 14, Figure 15, Figure 16, Figure 17, Figure 18 provide the graphical representation of the Likert scale scoring for various coping strategies employed by various professionals during their lockdown.

Table 8

Participants overall perception of the coping strategies on a five-point Likert scale.

Perception générale des participants concernant les stratégies d’adaptation sur une échelle de Likert en cinq points.

n = 418	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
Coping Strategies, n (%)
Identifying yourself with other role models who prioritize their quality of life	122 (29.2)	48 (11.5)	78 (18.7)	98 (23.4)	72 (17.2)
Respecting my physical limits, avoiding spending many hours without sleeping	90 (21.5)	60 (14.4)	44 (10.5)	110 (26.3)	114 (27.3)
Cooking	86 (20.6)	48 (11.5)	60 (14.4)	124 (29.7)	100 (23.9)
Eating well	56 (13.4)	18 (4.3)	54 (12.9)	158 (37.8)	132 (31.6)
Reading non-medical literature/novels, etc.	100 (23.9)	50 (12.0)	54 (12.9)	120 (28.7)	94 (22.5)
Listening to Music, etc.	82 (19.6)	42 (10.0)	58 (13.9)	120 (28.7)	116 (27.8)
Watching television for Movies/Dramas/Sports/Religious, etc.	88 (21.1)	32 (7.7)	46 (11.0)	108 (25.8)	144 (34.4)
Social networking — Facebook, Instagram, Twitter	74 (17.7)	30 (7.2)	44 (10.5)	122 (29.2)	148 (35.4)
Taking solace in offering Prayers	76 (18.2)	32 (7.7)	60 (14.4)	130 (31.1)	120 (28.7)
Participating/Playing Indoor Sports	112 (26.8)	50 (12.0)	74 (17.7)	86 (20.6)	96 (23.0)
Sleeping	58 (13.9)	54 (12.9)	60 (14.4)	118 (28.2)	128 (30.6)
Listening to Religious Videos	106 (25.4)	54 (12.9)	78 (18.7)	106 (25.4)	74 (17.7)
Doing mundane house chores like cleaning, washing, etc.	86 (20.6)	54 (12.9)	72 (17.2)	110 (26.3)	96 (23.0)
Clearing/Finishing my piled up work	86 (20.6)	42 (10.0)	68 (16.3)	106 (25.4)	116 (27.8)
Participating in Online courses	132 (31.6)	46 (11.0)	58 (13.9)	96 (23.0)	86 (20.6)
Taking up a new Hobby	138 (33.0)	56 (13.4)	74 (17.7)	80 (19.1)	70 (16.7)
Gardening, Landscaping, etc.	186 (44.5)	62 (14.8)	76 (18.2)	50 (12.0)	44 (10.5)
Watching television for News Exclusively	154 (36.8)	62 (14.8)	60 (14.4)	64 (15.3)	78 (18.7)

Figure 1

Identifying yourself with other role models who prioritize their quality of life.

S’identifier à d’autres modèles qui donnent la priorité à leur qualité de vie.

Figure 2

Respecting my physical limits, avoiding spending many hours without sleeping.

Respecter mes limites physiques, éviter de passer de nombreuses heures sans dormir.

Figure 3

Cooking.

Cuisiner.

Figure 4

Eating well.

Bien manger.

Figure 5

Reading non-medical literature, novels…

Lire de la littérature non médicale, romans….

Figure 6

Watching television for Movies/Dramas/Sports/Religious…

Regarder la télévision pour des films, des pièces de théâtre, du sport, des émissions religieuses….

Figure 7

Listening to music.

Écouter de la musique.

Figure 8

Social networking — Facebook, Instagram, Twitter

Réseaux sociaux — Facebook, Instagram, Twitter.

Figure 9

Taking solace in offering Prayers.

Se consoler en priant.

Figure 10

Participating/Playing Indoor Sports.

Participer et jouer à des sports en intérieur.

Figure 11

Sleeping.

Dormir.

Figure 12

Listening to religious videos.

Regarder des videos religieuses.

Figure 13

Doing mundane house chores like cleaning, washing…

Accomplir des tâches ménagères de base comme nettoyer, laver…

Figure 14

Taking up a new hobby.

S’adonner à un nouveau passe-temps.

Figure 15

Clearing/Finishing my piled up work.

Déblayer/finir mon travail accumulé.

Figure 16

Gardening-landscaping.

Jardiner-faire de l’aménagement paysager.

Figure 17

Participating in Online courses.

Participer à des cours en ligne.

Figure 18

Watching television for News Exclusively.

Regarder uniquement les Nouvelles à la télévision.

Discussion

COVID-19 is defined as the alterative form of severe acute respiratory syndrome (SARS), caused by coronavirus 2 (SARS-CoV-2) with a high possibility of transmission from animals to humans which has been associated with contact with a local seafood vendor in Wuhan that illegally sold some wildlife animals including bats [24], [25]. The initial transmission from the reservoir (usually bats) to humans involves a zoonotic jump and then transmission between people occurs during close contact, mostly via small droplets produced by coughing, sneezing, and talking [26]. Coronaviruses, belong to the family of RNA viruses called Coronaviridae, which possess a well-developed spherical protein envelope protecting the genetic material inside it. The envelope resembles the crown (‘corona’ in Latin), in its structure and hence their name and the RNA contained in them is the largest known positive-sense RNA genome in viruses [26], [27].

Since the declaration of COVID-19 as the pandemic by WHO, on 11 March 2020 the disease has presented itself as an unprecedented public health crisis because of its rapid spread and higher lethality than previous pandemic/epidemics which is compounded further by the increased international travel density and immune naivety of the worldwide population [28]. This has resulted in the huge psychological impact on the mental health of the individuals living across the globe under lockdown for limiting its spread and for their own survival [6], [11], [12].

As all pandemics are characterized by their unique set of conditions and control measures which affect the general population variedly on many factors like causality, progression of disease, casualties caused, mitigation strategies and control measures. With each day passing under lockdown the effects of quarantine and isolation become often intense and do adversely affect the mental well-being of a given population and in turn influencing their community behavior negatively [9]. As reported, epidemics have already been associated with a wide range of psychiatric comorbidities including anxiety, panic, depression, and trauma-related disorders [29] and this psychosocial impact has been found to be even higher during quarantine/lockdown measures [7]. Lockdown and quarantine have also been associated with high stress levels, depression, irritability, and insomnia [9], [30], [31], [32].

Hence, to answer these burning questions we designed this study to attempt to evaluate the depression, anxiety and stress of the general people living under the COVID enforced lockdown in various cities of the world and also to understand how they are utilizing their lockdown time to cope with such an unprecedented isolation and quarantine. To the best of our knowledge, this study was among one of the first multicentric collaborative studies to investigate the immediate impact of the COVID-19 Lockdown on the mental health and coping strategies of the general public across the world in five main cities lockdown cities.

In our current study, we found that there was a significant level of depression and anxiety in our participants and it differed in between male and females (P-value < 0.05). The results were in concordance with the earlier reports from China, India and Italy [9], [11], [24]. Rossi et al., in their study in Italian general population reported that depression, anxiety, insomnia, high perceived stress and adjustment disorder were 37%, 17.3%, 20.8%, 7.3%, 21.8% and 22.9%, respectively among the 18,147 respondents of the survey [30]. In connection with the COVID-19 pandemic enforced lockdown, a study by Wang et al. [33], in China, with 1210 respondents found rates of 30% of anxiety and 17% of depression among participants. In another survey-based study by Qiu et al. [34], with more than 50,000 Chinese participants 35% of the participants reported trauma-related distress symptoms, with women and young adults showing significantly higher psychological distress.

In their study, Zhang et al. [25] reported that nearly 85% of respondents reported their worries about COVID-19, and over 20% reported at least one form of mental distress in line with previous acute emergencies. Also, COVID-19 outbreak significantly reduced the young adults’ sleep quality and thereby increased their global negative emotions, especially stress and anxiety. Our results also tell the similar story of increased DASS scores reflecting increased mental distress among the participants especially Indians and Pakistanis. Also, in our study majority of the participates strongly agreed to using sleep as one of the best coping strategy in the current lockdown time, which was consistent with a previous study revealing that individuals with better sleep quality showed reduced morbidity rates of post-traumatic stress disorder [25], [34], [35].

Furthermore, we also found that the participants used the range of strategies to manage their time in quarantine with a varying degree of agreement depending upon their personal choices and likings. Among the top coping strategies that were used for spending time and coping the stress during the lockdown with highest levels of agreements were: (a) watching television for entertainment, (b) social networking, (c) listening to music, (d) sleeping, (e) doing mundane house chores like cleaning, washing, etc. (f) eating well, and (g) clearing/finishing my piled-up work. And among the lowest ranked coping strategies with highest levels of disagreements were: (a) Gardening & Landscaping, (b) Taking up a new Hobby, (c) Participating in Online courses, (d) Identifying yourself with other role models who prioritize their quality of life, (e) Participating/Playing Indoor Sports, and (f) Listening to Religious Videos. Ours is the first kind of study to report on the coping strategies. Please see the Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10, Figure 11, Figure 12, Figure 13, Figure 14, Figure 15, Figure 16, Figure 17, Figure 18 and Table 8 (Supplementary Tables Also) for more in-depth information. Sleeping and eating well was utilized by most of the professionals as the strategy to cope with the stress. 63.6% of office administrators 44.9% of students, and 36.4% of engineers, etc. strongly agreed with utilizing eating well as the strategy to be used in lockdown. Also, 53.1% of students, and 31.4% of academicians strongly agreed with proper sleeping as strategy to cope with stress. These results are in tune with the study by Zang et al. [25], in Chinese population. Also, taking solace in prayers was also regraded as coping strategy by students (40.8% = strongly agreed) and banking professionals (38.9% = strongly agreed).

Conclusion

The depression and stress scoring of the participants was very high especially among Indian and Pakistani nationals. Therefore, we recommend that during the lockdown and quarantine period it is imperative for the government to provide the free professional and psychological services to help cope with stress during the disease enforced lockdown and to make general people aware about the coping strategies which can be utilized to relive the stress and make effective use of spare time.

Limitations

This is the first study that has evaluated the mental health of respondents during COVID lockdown using DASS-42 across general population. However, this study has an important limitation in sample collection as we included only the well-educated and smart phone savvy participants who are well versed with the use of social media. Also, the sample from different countries were not equal and stratified which might skew the results. Also, this was a self-reported and voluntary study that could introduce a systematic bias as well.

Ethical clearance

This study was retrospectively approved by the Institutional Review Board of King Abdullah International Medical Research Centre (KAIMRC), a research wing of KSAU-HS, Jeddah (Reference No. RJ20/067/J; Dated: 22/04/2020).

Author contributions

S.S.A. conceptualized the project, designed the study questionnaire in its final form, analyzed the collected data and wrote the entire manuscript.

M.A.K. helped in the data collection and did the statistical analysis of the collected data and made sense of it.

S.S.N. helped in data collection, proof reading, revising, and drafting of tables & figures of the final version of manuscript.

M.Z.B. helped in data collection, proof reading, revising of the final version of manuscript.

Disclosure of interest

The authors declare that they have no competing interest.