Discussion
This study included 180 medical students in Syria and estimated the prevalence of anxiety and OCD during the COVID-19 pandemic. It found that females and interns had higher OCD scores compared with males and more junior students. OCD scores were not associated with social status, work, smoking, residency status before or during university, having chronic diseases themselves or with a housemate. Factors that were associated with higher anxiety scores were female gender and smoking. In contrast, anxiety had no significant association with social status, residence before and during university, academic year, work, chronic disease, and chronic disease of a housemate.
When using multi-variable analysis, only sex and smoking were significant factors in OCD and anxiety. OCD was significantly affected by anxiety when using multi-variable analysis as the R2 was 26.7%, but this does not signify that it might be the vice versa that is true OCD is the one which increases the anxiety or that they are both associated).
Anxiety scores were not correlated with the consumption of tea, coffee, mate, or alcohol. OCD scores were also not correlated with coffee, mate, or alcohol consumption, but they were significantly correlated with tea consumption. A previous study on the general Syrian population reported that shisha smoking was significantly associated with worse mental health (14).
Out study showed that 37 (20.6%) of participant had moderate to severe OCD, while 67 (37.2%) participants needed further assessment for general anxiety and they both were more frequent among females. One study in Iran found OCD prevalence was about 1.8% and was significantly higher in females compared to males (2.8% compared to 0.7%) (3). One study from Iraq during COVID-19 found that 43% of undergraduate medical students had probable OCD symptoms and it was more predominant in female students. Furthermore, 58.5% and 53.5% of participants had symptoms of worry and stress, respectively (15). Moreover, 53.6 of university students in Egypt had anxiety which was more common among females (16). Moreover, another study from the USA found that anxiety rate was 61% higher than anxiety whereas a systematic review found that it was about 28% (8). These differences between these numbers and our study might be from Syrians being exposed to chronic stress from war and the deteriorating economy.
We found a significant correlation between OCD and anxiety. This coincides with the findings reported previously concerning the COVID-19 pandemic (17). An earlier cross-sectional study performed in Saudi Arabia revealed a positive correlation between the new-onset OCD during the COVID-19 pandemic and the high perceived stress (17).
The war and economic factors harmed the mental well-being of the Syrian population before COVID-19. As reported by a previous study, about 60.8% of the adult Syrian population had at least two positive post-traumatic stress disorder (PTSD) symptoms, and 61.2% had a moderate to severe mental disorder (18). So, these factors might have affected the results when evaluating the impact of COVID-19 on mental health. Another study in Syria during the lockdown reported that about 42.7% of the adult Syrian population had at least two PTSD symptoms, and about 42.6% had moderate to severe mental disorders (19). An Indian study reported that people with insufficient supplies during the lockdown were more severely affected by anxiety, stress, and depression than the rest (20).
Several factors contributed to the psychological burden of the COVID-19 pandemic that added to the burden of direct morbidity caused by COVID-19 (14). After the lockdown in Syria, the increased living costs and the reduced capability to ensure income and provide food contributed significantly to the psychological burden of the pandemic (14, 19). Surprisingly, a deteriorating economy from COVID-19 negatively impacted mental health more than war variables and direct COVID-19 damage in Syria (14, 19). During the third week of the first lockdown and before economy deterioration, lockdown had a positive effect on mental health which was probably due to giving people a break from war and life stress in addition to not having any COVID cases at that time (19). However, after a few months as the economy deteriorated and despite lockdown termination and while the cases started to increase, economy was the major stressor surpassing all (14). Our study was conducted one to two months after the previous study while COVID cases number was rapidly increasing, and lockdown was terminated.
Doctors reported to have less stress than the general population and the other healthcare workers (14). However, another study found that being a healthcare worker, young age, difficulty concentration, fear of being infected, and work overload were identified as risk factors for anxiety during the COVID-19 pandemic (21). Students and healthcare professionals were among the most affected workgroups by anxiety, stress, and depression during the COVID-19 pandemic (20).
In a Chinese population, a study found that age, education level, health status, and personnel category (according to the persons’ role in battling COVID-19) significantly affected anxiety scores. Furthermore, higher levels of anxiety were found in immature adults, lower education than junior high school, people with chronic diseases, and frontline medical personnel (22). Zhu et al. 2020 agreed that frontline medical personnel had higher anxiety levels during the COVID-19 pandemic (23). Hu et al. 2020 reported that anxiety scores were not affected by sex, region, marital status, and previously confirmed or suspected COVID-19 affection (22). Interestingly, the type of quarantine applied affected the anxiety scores; the stricter the quarantine was, the higher the anxiety scores were (22). Another study from Germany reported that the COVID-19 mental health burden was more prominent in females and younger people (24).
Previous studies reported contradicted psychological impact for the lockdown duration. Some studies reported a negative effect on mental health when being in longer quarantine duration (25), while others reported no significant impact (22). However, this might be due to the different quarantine measures and durations reported in each study.