Prelude

As the world is facing a recent exacerbation of new COVID-19 cases and deaths, the shadow of a new lockdown looms over the populations, carrying the fears and worries of a dark future for many people [22,23,24]. Yet, the psychological sequelae of the first lockdown are not completely healed since the return to the normal life is long in coming while the damage is severe. The major findings of the present study provide strong indications regarding the psychological impact of the COVID-19 crisis and the associated restrictive lockdown measures in a society where psychiatric and psychological care is not common and where the religious and social conventions endorse resilience and reliance on God as the main coping strategies, both with everyday life stressors and sudden changes in well-being [25,26,27].

Increased psychological distress after the lifting of COVID-19 lockdown in the Saudi population

Both IES-R and DASS scales performed well in the study population. These scales showed a high prevalence of PTSD 1 week after lifting the first COVID-19 lockdown, which was significantly associated with high levels of stress, anxiety, and depression disorders. On the other hand, there was no disparity of PTSD or stress, anxiety, and depression disorders across the different sociodemographic factors. The major observation is that PTSD and depression figures found in the present study were higher than those found during the lockdown period. A study by Alshehri et al. found a prevalence of PTSD of approximately 25% using the PTSD checklist (PCL-5) for Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) criteria. Additionally, the study showed significant associations of the prevalence of PTSD with sociodemographic factors as it was higher in females, single participants, and low-income classes [15]. Likewise, Alkhamees et al. observed lower rates of PTSD (23.6%), and severe or extremely severe stress (13.7%), anxiety (13.9%), and depression (17.4%) using IES-R and DASS-21. Furthermore, Alkhamees et al. observed significantly higher scores among females and younger age categories in all disorders [16]. Another study by Alghamdi et al. used DASS-21 to assess psychological distress during the 5th week of the complete curfew among the public, healthcare workers, and security force personnel in Saudi Arabia. Authors found comparable prevalence rates of severe or extremely severe depression (13% to 17%) and anxiety (22.5% to 25%) between the three subpopulations, whereas security force personnel had relatively lower levels of stress (~7%) compared to the two other categories (14.5%-18%) respectively [14]. Overall, the levels of PTSD and depression reported in the present study are higher than those reported in other Saudi studies conducted during the curfew period. Several factors may contribute to the rise of psychological distress indices found in the present study. We propose four main theories that may competitively explain these figures. These theories are the following:

  1. 1.

    Overestimation due to inappropriateness of the scales

  2. 2.

    The hugeness of the epidemiological picture and or severity of the restrictive measures

  3. 3.

    The snowballing proportion of vulnerable individuals

  4. 4.

    Increase in risk perception among the population after the lifting of the curfew and the recognition of the extent of the pandemic

The following sections discuss these theories and provide directions toward their practical implications in light of the literature and the present study findings.

Overestimation: Are the used PTSD scales appropriate in COVID-19?

By focusing on PTSD, the first theory to explain the high levels consists of questioning the validity of the assessment tools and their appropriateness in the context of COVID-19. Internationally, the prevalence of clinically significant PTSD during the COVID-19 crisis was variable and did not seem to be consistent with the epidemiological figures. For example, in Italy, where the crisis was remarkably severe, a national online study, using the PCL-5 scale, found 20% of cases with significant PTSD symptoms among 1321 participants, which was positively associated with anxiety and depression symptoms. In contrast to our study, the Italian study found a statistically significant association of PTSD with gender, educational level, and positive COVID-19 contacts [28]. On the other hand, significantly higher figures were reported from other countries. A Lebanese study that used the PTSD Checklist–Civilian Version (PCL-C) to screen for PTSD symptoms among Lebanese citizens found a very high prevalence of symptoms, 2 weeks after the start date of the lockdown, notably numbing symptoms characterized by avoidance and passivity (up to 43.4%) and active symptoms (up to 33.2%). The same study showed a remarkable increase in the prevalence of symptoms in the 4th week of lockdown, exceeding 60% [29]. In Portugal, a recent study showed similarly high rates of severe PTSD (42.3%), which is comparable to findings of our study; however, significantly lower rates of severe or extremely severe depression (1.1%), anxiety (6.2%), and stress (0.0) were reported [30]. Similar to our study, the Portuguese study used IES-R and DASS-21 scales.

The PTSD figures found in the present study and other studies may be overestimated due to a potential inappropriateness of the screening tools to the case of an ongoing crisis. By looking into the 22 IES-R items, at least 10 of them may be misinterpreted and result in false-positive responses. For example, a positive answer to items 1 (any reminder brought back feelings about it), 5 (I avoided letting myself get upset when I thought about it or was reminded of it), or 21 (I felt watchful and on-guard) may be confounded with the effect of the continuous flow of breaking news on the pandemic, an actual socioeconomic impact such as income decrease, or the fear of being infected, respectively. It is interesting to note that an Italian team developed a COVID-19-specific tool to screen for PTSD, which found a prevalence of PTSD symptomatology as high as 27.5% that correlated with other indicators of psychological health, including general distress (r = 0.77) and sleep disturbance (r = 0.53). On the other hand, the Italian COVID-19-PTSD scale correlated well with the IES-R overall scale (r = 0.70) and subscales (r = 0.39 to 0.66) [31]. Furthermore, the risk mentioned above of overestimation and false positivity should be considered, especially in online-based studies. It would be of considerable interest to study the sensitivity and specificity of the scales used to assess psychological distress during COVID-19 by reference to clinical diagnosis by a psychiatrist.

The hugeness of the epidemiological picture or severity of the restrictive measure?

Remarkably, the highest rates of PTSD were observed in the Eastern Province and Al Madinah, both having been subject to stricter lockdown measures inducing more prolonged and more stringent movement restrictions due to the higher number of COVID-19 cases in the first mass screening data [32]. By contrast, the lowest prevalence of PTSD was found in regions with the lowest prevalence of COVID-19, notably the southern regions. Another national study confirmed this, which showed a significantly higher prevalence of PTSD in the Eastern province (32.2%), while the lowest rates were reported in the Southern region (18.7%) [15]. This difference between the regions may be explained by the severity of lockdown and curfew measures. According to community mobility reports, the most substantial decline in the population mobility in the Eastern Province and Al Madinah was in April-May 2020 and reached down to −91% from baseline [33]. This suggestion is supported by a study from the USA, which showed higher levels of psychological distress in populations from states that implemented more restrictive lockdown and curfew policies [34]. This constitutes a critical public health indicator of interest for policymakers, health care providers, and individuals, directing the need for preventive actions and psychological support solutions to be implemented in the regions with the highest risk of stricter lockdown.

To this day, nearly 1 year after the start of the pandemic, both the Eastern and Al Madinah Provinces show the highest cumulative prevalence rates, with more than 18k and 14k cases per 1 million people, respectively [35]. Updated data (31 January 2021) from community mobility reports per region show a −29% and −32% decline in park visits in the two provinces versus a national average of −23% [36]. In the meantime, other regions are witnessing an even more substantial decline in mobility, such as Al Jowf, Hail, and Jazan, despite their relatively lower prevalence rates [35, 36]. Such persistence of reduced mobility despite lifting the restrictions may indicate an overall shift in the lifestyle. Yet, the possibility of this being due to the crisis’ socioeconomic and psychological adverse effects or denoting an alienation to social distancing should be raised. Alienation is defined as the loss of personal and social connections in the context of recurrent negative emotions, leading to feelings of powerlessness, meaninglessness, normlessness, isolation, and self-estrangement [17, 37]. There is a strong association of alienation with the occurrence of PTSD symptoms, and this was notably observed in response to the social distancing during the COVID-19 [38]. Furthermore, it was suggested that persistent stress and PTSD are part of a vicious cycle inducing immunosuppression, which may increase susceptibility to COVID-19 infection [39]. Consequently, monitoring the population’s psychological and social well-being is highly recommended, especially in regions subject to more stringent mobility-restricting measures.

The snowballing proportion of vulnerable individuals

In the present study, psychiatric comorbidity was reported by 11.4% of the participants and was independently associated with an 87% increase in the risk of PTSD. In their study on the Saudi population, Alshehri et al. found that having a psychiatric condition was independently associated with an even higher risk (OR > 3) of developing PTSD during the COVID-19 pandemic, as demonstrated in their stepwise multivariate regression [15]. Comparably, Alkhamees et al. evidenced a positive correlation between a positive psychiatric history and IES-R, DASS-stress, anxiety, and depression scores [16]. Several authors have probed into the hypothesis of whether individuals with psychological and psychiatric disorders are experiencing more psychological distress during the COVID-19 crisis and lockdown. A case-control study that used the IES-R and DASS-21 scales, like our study, showed a higher prevalence of PTSD (31.6% vs 13.8%) and severe or extremely severe anxiety (14.4%% vs 0.9%), depression (13.2% vs 0.9%), and stress (7.8% vs 0.0%) among individuals with psychiatric history compared with their counterparts, respectively. Additionally, the study found a higher prevalence of moderately severe (19.7% vs 1.8%) and severe (7.9% vs 0.9%) clinical insomnia using the insomnia severity index (ISI) [40]. Another case-control study compared individuals with a previous history of depression or suicidal attempts versus those without in terms of the development of depressive disorders, distress, and change in suicidal thoughts during the COVID-19 crisis. Findings showed higher levels of distress and depressive symptoms among both participants with a history of depression (16.5% and 23.3% vs 8.7% and 9.0%) and those with a history of suicidal attempts (16.9% and 38.7% vs 1.9% and 12.0%), compared to their respective controls. Additionally, a significant increase in suicidal thoughts was observed among controls, although lesser than in cases [41]. This denotes the higher vulnerability of psychiatric patients to the COVID-19 crisis and lockdown, which has a significant clinical implication in the management of psychiatric patients. Nevertheless, these observations primarily raise another important public health concern: the rising incidence of psychiatric disorders among the healthy subpopulation, thus snowballing the proportion of vulnerable individuals toward the persisting effects of an enduring crisis. Pressing actions should be undertaken by the health authorities and policymakers to assess the levels of vulnerability and resilience among the subpopulations with low coping capacity and implement preventive strategies against psychological distress among the whole population. As the case may be, with regards to the persistence of the COVID-19 crisis, drastic rearrangements of daily life could be planned to mediate the transformation of coping capacity into adaptive capacity. Such strategies could inspire environmental studies that explored the factors that may enhance the adaptive capacity to climate change among vulnerable and most exposed subpopulations [42].

Increased risk perception

Findings from the present study suggest that the perceived risk of being infected with COVID-19 could be a major factor of psychological distress. This is demonstrated via three parameters, including the number of alarming symptoms experienced by the participant, COVID-19-related death or ICU admission in the acquaintances, and being tested for COVID-19; besides the previously discussed prevalence of COVID-19 in the residential locality.

There was a higher risk of PTSD among participants who experienced COVID-19-like symptoms, notably +94% odd risk among those who reported three or more out of the six symptoms designated as highly alarming for the population. The association between the occurrence of symptoms that may evocate COVID-19 and the psychological distress was demonstrated in other populations; such as in Portugal, where the number of flu-like symptoms experienced in the last 14 days was associated with a substantial increase in the odd risk of developing depression (OR = 1.90), anxiety (OR = 2.71), and stress (OR = 2.69) [30].

Similarly, having a COVID-19-related death or ICU admission in the acquaintances was independently associated with a 54% increase in the odd risk of PTSD. On the other hand, direct or indirect contact with a confirmed or suspect COVID-19 case showed no effect on developing PTSD. This dimension may be equally related to grief due to the loss of a close relative or to the perceived risk of infection. In line with our findings, Alshehri et al. demonstrated a higher prevalence of PTSD among participants who had a family member die due to COVID-19 (OR ~2) and those who were either confirmed or suspected to have been infected. Remarkably, levels of PTSD were higher among participants who were suspected than those who were confirmed to have been infected [15]. The latter observation supports the hypothesis that risk perception and fear of COVID-19 may constitute the major factor of psychological distress during the pandemic, and, on the other hand, a confirmed infected status may help acquire better resilience and adaptation [43, 44].

This is supported by the third parameter, including whether the participant has undergone COVID-19 screening in the past 14 days. Although not statistically significant, the prevalence of PTSD was lower among participants who declared having been tested for COVID-19 in the past 14 days (36.5%) compared to those who were not tested (42.1%). A similar finding was observed in a German study, which showed a likelihood of a decrease in COVID-19-related anxiety and fear of COVID-19 consequences on owns life among individuals who have been tested [43]. Contrariwise, another study from the UK demonstrated a higher propensity to be tested among individuals with a psychiatric history, probably related to higher levels of anxiety leading to more frequent voluntary testing than those without a psychiatric history. However, by excluding participants with a psychiatric history, the incidence rates of self-harming behaviors were significantly increased among the tested individuals versus non-tested ones (24.1% vs 19.3%, respectively). In contrast, the rates of anxiety and depression were comparable between the two groups [45]. We conclude that anxiety may prompt the willingness for COVID-19 testing, while undergoing the test may reduce the anxiety related to the fear of being infected.

Overall, there seems to be a strong correlation of psychological distress with the perceived risk of COVID-19 infection. In the case of our study, the absence of correlation with objective epidemiological factors, such as direct contact with a confirmed case, may be suggestive of a low level of education regarding the actual risks and preventive measures. This suggests that the perceived risk of infection that generates psychological distress is subjective and, most of the time, based on irrational factors.

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