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\begin{document}

\title{The prevalence of depressive symptoms among adults living in the UAE
during the COVID-19 pandemic}



\author[1]{Loay Ismail Ghalyoun}%
\author[1]{Mutaz Mohsin Abualhab}%
\author[1]{Alia Ihab Yousef Mohammed}%
\author[1]{Maryam Ali Naji Almasaabi}%
\author[1]{Fatma Mohammed Alsumaiti}%
\author[1]{Hamda Mohammed Alshehhi}%
\author[1]{Asima Karim}%
\affil[1]{University of Sharjah College of Medicine}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Aim:} To investigate the prevalence of depressive symptoms among
adults living in the UAE during the COVID-19 pandemic.~\textbf{Methods:}
This cross-sectional study used a self-administered anonymous online
questionnaire distributed in both Arabic and English via social media
platforms. A total of 261 adults living in the UAE were included in the
study. Patients clinically diagnosed with depression were excluded from
this study.~\textbf{Results:} Overall, the prevalence of depression
among our studied population was 63\%. Several parameters were
correlated with depression to assess their associations. A lower
household income was found to be linked to a greater likelihood of
developing depression, as 74.6\% of depressed subjects had an income
lower than 20,000 Dhs (p=0.003). Age also had a significant
correlation(95\% CI, p=0.003) with depression, and those in the younger
age group (18-25 years) had a greater prevalence of depression than did
those in the older age group. Difficulty performing daily activities,
restless sleep, feeling lonely, feeling sad, feeling inadequate, and
losing hope were the most commonly reported symptoms in depressed
subjects. A total of 78.21\% of our participants did not know about
hotlines when they were depressed; however, this difference was not
statistically significant (95\% CI, p=0.178).~\textbf{Conclusions:}
Depression was prevalent in 63\% of our participants. A lower household
income and younger age were associated with a greater risk of
depression. We believe that our findings will encourage institutions and
government authorities to implement awareness programs about depression
awareness and screening for depression.%
\end{abstract}%



\sloppy


\textbf{1. Introduction}

COVID-19 is an infectious disease with symptoms ranging from flu-like
symptoms to severe respiratory distress. It is caused by a mutating
virus known as severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2). Most infected people will experience mild to moderate
symptoms and recover shortly afterward. Unfortunately, those who suffer
a serious form of the disease are more at risk of dying due to
complications from the disease. Notably, all age groups can contract
coronavirus disease 2019 (COVID-19) and face severe consequences, such
as death. Hence, it is important to follow the precautionary guidelines
to protect us from contracting the disease. Some countries enforced a
lockdown to further prevent the spread of the virus .

The worldwide crisis that occurred due to the COVID-19 pandemic led to
hospitalization and increased death rates , and several regulations were
imposed, such as social distancing measures, self-quarantine, and
isolation, which led to negative consequences for mental health and the
appearance of depressive symptoms.

According to the Diagnostic and Statistical Manual of Mental Disorders,
fifth edition (DSM-V), major depressive disorder is a mood disorder
characterized by symptoms of either depressed mood throughout the day or
loss of interest in routine activities. Either one of these two symptoms
must be present along with the other 4 symptoms for a minimum of 2 weeks
to clinically diagnose an individual with major depressive disorder.
Other symptoms include changes in appetite, sleep disturbance, suicidal
ideation, and poor concentration. These symptoms must be present nearly
every day to qualify for a diagnosis . Several studies across the UAE
aimed to identify the prevalence of depression before the COVID-19
pandemic, including two in Sharjah , two in Al Ain and one in Dubai ,
with a prevalence rate ranging from 12.5-28.6\%. Accordingly, research
exploring the impact of the COVID-19 pandemic on mental health commenced
with several views supporting the deleterious effect this pandemic
created, from the anxiety of testing positive to the grief of losing
someone due to infection . According to a meta-analysis conducted in
China that investigated the prevalence of mental health problems during
the COVID-19 pandemic, the overall prevalences of depression, anxiety,
distress, and insomnia were 31.4\%, 31.9\%, 41.1\%, and 37.9\%,
respectively . These studies reflect the consequences of this pandemic
on the mental health of people worldwide.

There are few studies discussing the prevalence of depression in the UAE
population, and we have barely managed to find a study that had a
similar aim; however, they utilized different tools and methods to
analyze their data

Several factors contribute to the need for such a study in the UAE.
Mental health is an important aspect of public health; for that reason,
identifying mental health prevalence can help healthcare providers
allocate appropriate resources to address mental health needs.
Additionally, each country may experience different effects of the
pandemic according to government responses and healthcare
infrastructure; thus, the prevalence of depression can also reflect how
the pandemic has uniquely impacted the adult population of the UAE.
Essentially, appropriate mental health measures and interventions must
be tailored to the needs of the UAE population .

We aimed to investigate the prevalence of depressive symptoms among
adults living in the UAE during the COVID-19 pandemic.

\textbf{2. Methods}

\textbf{2.1 Study design and sampling}

A cross-sectional study was conducted over two months starting in
February 2021. The target population was adults living in the UAE who
had access to social media platforms. Adults who were clinically
diagnosed with depression were excluded from the study. English or
Arabic proficiency was also necessary to ensure proper comprehension of
the questionnaire. Nonprobability volunteer sampling was employed to
ensure complete autonomy on the self-administered
questionnaire.\textbf{2.2 Study tool}

The scale utilized for this study was the Center for Epidemiological
Studies Depression (CES-D; CESD, 2021), which measures depressive
symptoms among participants. The instrument contained 20 items that
rated the frequency of experiencing symptoms associated with depression
over the past week, namely, decreased appetite, loss of interest, and
disordered sleep. For each item, the response could range from 0 to 3 (0
= rarely or none of the time, 1 = some or little of the time, 2 =
moderately or much of the time, 3 = most or almost all the time). The
final score was a continuous scale that could span from 0 to 60, with
higher scores indicating frequent depressive symptoms. The CES-D also
provided cutoff scores that aided in identifying individuals at risk for
clinical depression. The tool has already been validated in several
studies and was reliably used in this study to diagnose depressive
symptoms .

\textbf{2.3 Data collection}

The questionnaire was divided into 3 sections, namely, demographic,
scale, and COVID-19-related questions, for a total of 36 questions. To
mitigate self-selection bias, the survey was self-administered through
web platforms. However, we acknowledge the limited options available to
control such bias. As a result, we believe that most of our participants
were motivated to participate due to their depressed state. The
questionnaire was digitized on Google Forms and distributed online via
hyperlinks, considering the social distancing measures imposed during
the COVID-19 pandemic, which restricted in-person interactions for data
collection purposes. Both Arabic and English versions of the
questionnaire were provided. The raw data collected from the
questionnaire were transferred to Excel for initial processing, followed
by secondary processing using SPSS software to obtain meaningful
information through precise data revision.

\textbf{2.4 Data analysis}

We performed univariate and bivariate analyses of the acquired data. In
univariate analysis, frequency tables, bar graphs, and pie charts were
generated by SPSS, which reflects the distribution of observations based
on several options for a variable. Bivariate analysis was performed to
compare two variables using statistical tests depending on the nature of
the data. The chi-square test was the statistical test of choice in the
comparison of two categorical variables coupled with close inspection of
the p value to the proposed 5\% type 1 error to determine the
significance of the variables compared. Several tests were conducted as
part of the statistical inferences to determine the most reasonable
direction of the suggested hypothesis at the start of the research.
Moreover, descriptive statistics were calculated to emphasize the
distribution, location, and spread of the data. The data were found to
be skewed to the right because of outliers. Therefore, the median was
reported as a measure of central tendency. Furthermore, the
interquartile range was delineated to describe the variability of the
data.

When calculating the most common depressive symptoms among our study
participants, the frequencies of symptoms 1-4 were obtained by adding
the ``most'' and ``occasionally'' responses, whereas the frequencies of
symptoms 5-6 were calculated by adding the ``rarely'' and ``sometimes''
responses. It is important to note that the total for the occupation
demographic was lower because only employed participants who chose to
specify their occupation were counted, and the total for the openness
about mental health was lower because it is an optional question since
only those who had mental illness could choose to answer this question.

\textbf{3. Results}

\textbf{3.1 Characteristics of the study population}

Of the 383 participants who completed the online questionnaire, only 257
met the inclusion criteria and were included in this study. Table 1
illustrates the demographic characteristics of the study participants,
where 156 (60.70\%) of the participants were in the 18-25 years age
group (p=0.003, \textbf{Table 1} ). Females (70.43\%) represented
two-thirds of the entire sample. There was a minor discrepancy in the
participants' ethnic backgrounds; 50.97\% of them were not Middle
Eastern, while those of Middle Eastern origin made up 49.03\% of the
participants. Regarding employment status, most of the participants were
students (50.97\%), and most were not students; most of them worked in
the engineering sector (31.15\%). A total of 42.41\% of the participants
were residents of Sharjah, and most of the participants were not living
alone (93.77\%). Those who obtained higher education accounted for
57.59\% of the total sample population. A total of 34.63\% of the study
participants fell into the second highest income range, which was
between 21,000 and 50,000 Dhs (p= 0.003, \textbf{Table 1} ).

\textbf{3.2 COVID-19 impact: prevalence, household infections, and
personal connections to fatalities}

Regarding COVID-19-related questions in the questionnaire, 14.4\% of our
participants were diagnosed with COVID-19 at some point in time.
Additionally, 42.41\% admitted that they had members of their household
who were infected with COVID-19. A considerable proportion of
participants (62.26\%) knew that they had died from COVID-19. The vast
majority (78.21\%) of participants did not know the designated hotlines
when feeling depressed; however, the differences were not statistically
significant \textbf{(Table 1).}

\textbf{3.3 Scoring based on the CES-D tool}

After calculating the total CES-D score for the sample population of 257
adults, a histogram was created \textbf{(Figure 1).} The median central
tendency score was 20. To describe our measure of variability around our
median, the interquartile range was 17, Q1 was 12, and Q3 was 28.50.
After removing the outliers from our existing data, our population
number decreased to 253. When bivariate analysis was repeated on the
edited data, we noted no change in the already significant parameters,
which were age and household income. Hence, the data presented and
discussed in this research paper include outliers.

\textbf{Figure 2} displays a boxplot with a wide range of scores,
indicating significant variability. The data appear to be positively
skewed, despite having an interquartile range equal to the difference
between the first and second quartiles. Four outliers were identified by
SPSS based on the upper fence value of 53. No outliers were observed on
the negative side due to the nature of the CES-D scores, which cannot be
below 0. The five-point summary is as follows: Q0 = 0, Q1 = 12, Q2 = 20,
Q3 = 28.5, and Q4 = 51.

\textbf{3.4 The prevalence of depression among adults in the UAE}

Our study revealed a 63\% prevalence of depression among the
participants. Specifically, individuals within the age range of 18 to 25
years exhibited a notably greater prevalence of depression, at 69.2\%
(n=108), than did older individuals (p= 0.003, \textbf{Table 1} ).
Moreover, 74.6\% of participants with low household incomes
(\textless{}20,000 Dhs) experienced depression, whereas 53.9\% and
53.7\% of participants with higher incomes experienced depression for
the 21-50 k Dhs and \textgreater{}50 k Dhs, respectively
(p=0.003,\textbf{Table 1} ). We next investigated the awareness and
openness of mental health in our studied population by asking related
questions. A total of 78.21\% of our study participants were unaware of
any hotlines in the UAE that they could contact if they were feeling
down. More than half (63.19\%) of our participants felt uncomfortable
talking about their mental illness/es, while 36.81\% felt comfortable
talking about this subject to their loved ones. According to the
bivariate analysis, students (69.5\%) and those who were unemployed
before COVID-19 (62.5\%) had a high prevalence of depression (p= 0.140,
\textbf{Table 1} ).

The most reported symptoms among depressed adults were feeling not good
enough (96 out of 162), being sad (95), having trouble keeping their
mind on what they were doing (91), feeling lonely (91), and feeling
hopelessness (85) and restless sleep (75), as shown in \textbf{Figure 3}
.

\textbf{4. Discussion}

In this study, we aimed to identify the prevalence of depression among
adults in the UAE during the quarantine period of the COVID-19 pandemic.
The overall prevalence of depression was 63\%. The rate of depression
was greater among females than among males, although this difference was
not significant; perhaps females scored higher because our participants
were mostly females. The prevalence of depression was also greater among
younger adults aged 18-25 years than among older adults aged 36 years
and older. This finding was expected, as adolescents are more prone to
stress and are not accustomed to staying indoors during lockdown, which
might have been affected by difficulties in remote learning due to
COVID-19 pandemic regulations . The prevalence of depression was greater
among people in the low-income category than among those in the other
income categories, possibly because of psychological pressure due to the
strain that the COVID-19 pandemic inflicted on work stability, and the
fear of losing their jobs during these times might have added to their
stress . Our results were consistent with those of other published
papers that revealed a sharp increase in the prevalence of not only
depressive symptoms but also other mood disorders during this pandemic
period . The analysis focused on the most common depressive symptoms,
emphasizing the necessity of enhanced physician awareness of individuals
exhibiting indications such as feelings of inadequacy, sadness,
cognitive distraction, and loneliness. Most participants did not know
any hotlines to call when depressed, which could suggest the lack of
awareness of the community about this matter and the need to further
advertise hotlines in social media, public places, and schools.

In UAE society, mental health is often a topic that is mostly avoided
and difficult to discuss, making it easier to ignore the psychological
health of individuals, which affects their well-being and daily life .
According to a previous study, 38\% of Sharjah's undergraduate students
suffer from clinical depression . A different study within the MENA
region explored the mental health impact of the COVID-19 pandemic on the
prevalence of depression among university students in Saudi Arabia and
revealed that 48.8\% of the participants were diagnosed with depression.
Therefore, a fair number of people living in the UAE are suffering from
depression, but this number might be higher; however, due to the limited
epidemiological data available concerning depression in the UAE, it is
much harder to grasp the real prevalence of depression in the
population. There is a paucity of literature concerning the prevalence
of depressive symptoms in the context of the COVID-19 pandemic in the
UAE as measured with the CES-D; however, similar studies have explored
the prevalence of depressive symptoms among UAE residents using the
PHQ-8, with a prevalence of 58.4\%, compared to 63\% in our study . The
CES-D tool was chosen as a tool for measuring depression in this study
due to its successful use among people of a wide range of ages, as well
as its use of a cutoff score that helps to identify individuals at risk
for clinical depression, with good sensitivity, specificity, and high
internal consistency .

When the COVID-19 pandemic occurred, the quarantine period significantly
increased distress among individuals. A lack of human interaction,
loneliness, and physical inactivity due to quarantine can be influencing
factors . A study conducted in 2011 revealed that the prevalence of
depression among male immigrants who resided in labor camps was greater
than that in the general UAE population. According to this study, most
of these laborers live alone and are separated from their hometowns and
families. Coupled with the stress and sense of social deprivation that
they are already suffering from, it increases their chances of being
depressed . This study revealed a striking similarity in the prevalence
of depression among male immigrants residing in labor camps secondary to
the social isolation experienced due to separation from their hometowns
and families, with the prevalence of depression among individuals
subjected to quarantine measures and curfews during the COVID-19
pandemic. Thus, both studies revealed that precipitating social
isolation is a risk factor for depression.

We conducted this study in the UAE due to the limited epidemiological
data about the prevalence of depressive symptoms during the COVID-19
pandemic. As this research adds to our knowledge, it will also help to
establish a better understanding of the prevalence of depression among
residents of the UAE and improve protocols for mental health during
pandemics, which do not produce the desired effect .

\textbf{5. Conclusion}

To conclude, our study reported the prevalence of depressive symptoms
during the COVID-19 pandemic among UAE adults. A substantial finding was
that depression was markedly prevalent in our participants. A lower
household income and younger age were significantly associated with a
greater risk of depression. We believe that our findings will encourage
UAE institutions and government authorities to implement awareness
programs regarding depression and regular screening for depression in
academic facilities and workplaces where the majority of younger people
are prevalent.

\textbf{6. Limitations}

A major limitation is the utilization of web-based methods for data
collection, thus resorting to nonprobability volunteer sampling, which
is subject to selection bias. Furthermore, one crucial limitation was
that we could not reach out to all the Emirates due to our restricted
pool of connections on social media. Hence, most of our participants
were from the Emirate of Sharjah, which compromises our ability to
generalize our results. Moreover, most participants were females;
accordingly, a fair comparison between the two genders was not possible.
Another limiting factor was that the overall sample size was smaller
than our anticipated sample size.

\textbf{Recommendations}

We strongly encourage other researchers to delve further into this
subject for the purpose of supplementing the literature with needed
data, as well as to undertake various campaigns to raise awareness, as
our community lacks understanding about coping with mental health and
seeking help.

\textbf{Funding}

No funding was obtained from any source for this study.

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