Discussion

The prevalence of depressive 3326 (83.4%) and anxiety 2777 (69.6%) symptoms among Syrians was significantly higher compared with the prevalence of anxiety in 17 studies (31.9%) and the prevalence of depression in 14 studies (33.7%).^{Reference Salari, Hosseinian-Far, Jalali, Vaisi-Raygani, Rasoulpoor and Mohammadi1} The high prevalence of depressive and anxiety symptoms found in our study surpasses World Health Organization prevalence estimations (of 3.9% and 4.3% respectively).⁹ A potential explanation for this disparity is that exposure to multiple stressors, including war and pandemic, may have triggered mental disorders among Syrians.

Literature has revealed that Syria's lack of mental healthcare services provided by psychologists and psychiatrists results in limited access to mental healthcare for many distressed individuals. Scarcity of online and social media support in the form of publications, resources, posts, guidelines, videos and online group chats is likely to exacerbate the problem.^{Reference Hedar2,Reference Abou-Saleh and Mobayed3} Such support can alleviate mental health problems caused by risk factors such as exposure to COVID-19.

All participants presenting with mild (1150; 28.8%) and moderate (1006; 25.2%) depression and mild (1293; 32.4%) and moderate (805; 20.2%) anxiety require clinical assessment for symptom duration and functional disability to determine the necessity of treatment. As over half the population (54% for depression and 52.6% for anxiety) requires a scheduled clinical assessment, with a total population of 18 284 423, this means that over 9 million people require mental health services. The lack of psychiatrists, hospitals, medical capacity and clinics projects ominous outcomes for Syrians’ mental health.

Participants with moderately severe (684; 17.2%) and severe (486; 12.2%) depression and severe (679; 17.0%) anxiety may require further assessment and active treatment with psychotherapy and/or medications. In 2005, the health expenditure per capita in Syria was US$58, which is extremely low in comparison with the UK (US$2900).^{Reference Assalman, Alkhalil and Curtice10} As the country is drowning in debts from the effects of the rampant war, the health expenditure per capita is likely to be significantly lower in the coming years. In 2013, the World Federation for Mental Health (WFMH) declared a call for action on the mental health consequences of the manifold emergency in Syria. One of WFMH's concerns is the neglect of trauma created by the violence and disruption.

Multivariable logistic regression analyses found strong associations with depressive and anxiety symptoms for: female gender; the 18–25 age group; careers in private, business and ‘other’ sectors, as well as students; poor, moderate and good economic status; and having chronic disease(s). This last may be attributed to the higher incidence of depression and anxiety among chronically ill people than others.^{Reference Gerontoukou, Michaelidoy, Rekleiti, Saridi and Souliotis11} The COVID-19 pandemic is likely to add to the problem, given that people with chronic disease(s) are at increased risk of COVID-19 infection, which can be more severe, with increased rates of complications and mortality.^{Reference Zhou, Yu, Du, Fan, Liu and Liu12} The findings regarding young adults may be related to the fact that this age group, who were children when this war started, have grown up witnessing destruction and displacement and grave violations of children's rights – abductions, rape, killing and maiming continue unabated. Approximately 6 million Syrian children have been born since the crisis began, growing up knowing nothing but war, terror and displacement.¹³ Prolonged lockdowns that have harmed society, left many people unemployed, schools and universities closed and resulted in hyperinflation could explain the spread of mental disorders among younger generations. The findings related to females reflect the literature, which reports an increased prevalence of depression in women associated in part with female sex hormones and with factors such as life circumstances and culture.^{Reference Albert14} Also, this conflict has rendered Syrian women and girls particularly vulnerable to physical, sexual, economic and psychological violence.^{Reference Hedar2}

For the estimated high burden of depressive and anxiety symptoms encountered in this study, we must adopt the epidemiological modelling outputs for targeted mental health planning to calculate the required resources needed to guide optimal mental health service delivery.^{Reference Charlson, Lee, Diminic and Whiteford15}