Discussion

Current times are extremely tough as the COVID-19 pandemic is flaring everywhere in the world. We provided some evidence through the results of our survey of increased levels of distress, depression, anxiety and somatisation symptoms among the Saudi public during the time of the COVID-19 pandemic. This provides grounds for genuine concern regarding the pandemic-associated psychosocial effects in Saudi Arabia. Our findings are consistent with the results of a recent systematic review of the psychological effects of the COVID-19 pandemic, which estimated a prevalence of 33% for depression and 28% for anxiety.^{Reference Luo, Guo, Yu and Wang14} A recent Italian study found increased levels of distress among the public, which, in turn, influenced the perceived negative effects of the COVID-19 crisis.^{Reference Cerami, Santi, Galandra, Dodich, Cappa and Vecchi15} Many factors have affected distress levels among the public during the current crisis. Lockdown measures and curfews have negative effects on people, particularly those unable to sustain themselves with such measures in place, leading to increased levels of anxiety and depression.^{Reference Rehman, Shahnawaz, Khan, Kharshiing, Khursheed and Gupta16} Worst, the evidence suggests that such high levels of distress, anxiety and poverty lead to a high risk of contracting COVID-19 and a higher risk of complications.^{Reference Batty, Deary, Luciano, Altschul, Kivimaki and Gale17} It has been theorised that COVID-19 infection activates the same immune–inflammatory pathways that are associated with a range of mental health difficulties.^{Reference Debnath, Berk and Maes18}

One other factor that has been proposed to increase the psychological effects of COVID-19 is a lack of satisfaction with health information.^{Reference Cortés-Álvarez and Piñeiro-Lamas19} Although social media may spread enormous amounts of misleading and anxiety-provoking material about COVID-19, some countries have managed to use social media effectively to promote accurate public health advice and hence to limit feelings of depression and anxiety among the public.^{Reference Teufel, Schweda, Dörrie, Musche, Hetkamp and Weismüller20}

One striking finding in our survey was the substantial negative effect of getting informal information from friends and relatives on all dimensions of psychological experiences. Word of mouth is quite influential in the cohesive tribal Saudi community, and many studies have found that it may form the main source of information about many medical and health-related issues.^{Reference Khan, Ahmed, Aldarmahi, Zaidi, Subahi and Shaikh21,Reference Alyami, Alswat, Omer, Ahmed, Alshammari and Alsaggaf22} Information about COVID-19 evolves by the hour, given its novel mechanisms. Hence, harmful rumours tend to spread widely via informal channels of information.^{Reference Tasnim, Hossain and Mazumder23}

We identified females to be at increased risk of distress, depression and somatisation during the current COVID-19 crisis in Saudi Arabia. Many studies have confirmed that women are more susceptible to psychological distress during the current pandemic.^{Reference Stanton, To, Khalesi, Williams, Alley and Thwaite24} Females were also more likely to suffer depressive symptoms, particularly among healthcare workers. Biological factors could explain such differences in emotional susceptibility between men and women.

Our results confirm the high reliability for the scores of the four dimensions of the Arabic version of the 4DSQ scale. This corroborates good psychometric properties for the 4DSQ in primary care facilities.^{Reference Sitnikova, Dijkstra-Kersten, Mokkink, Terluin, van Marwijk and Leone25} Some authors went on to use the 4DSQ as a gold standard against which other psychometric tools could be compared.^{Reference Braam, van Oostrom, Terluin, Vasse, de Vet and Anema26} The Cronbach's alpha values for the four dimensions of the 4DSQ tool in its Arabic format indicated its high reliability and high internal consistency. Thus, the Arabic 4DSQ could be used reliably in various research and clinical settings to evaluate the presence and extent of symptoms of distress, depression, anxiety and somatisation among Arabic speakers.

We also demonstrated that for the Arabic 4DSQ to conform to the underlying four-factor structure, three items require removal. It is hard to explain why those three questions do not conform to the overall four-factor structure. One potential explanation is the repetition of their concepts in other items. For instance, item 20 ‘During the past week, did you suffer from disturbed sleep?’ and item 39 ‘During the past week, did you have difficulty in getting to sleep?’ seem to measure the same construct, although they belong to different dimensions. Moreover, death wishes are explored using both item 46 ‘During the past week, did you ever think I wish I was dead?’ and item 33 ‘During the past week, did you feel that you would be better off if you were dead?’. A clearer explanation could be found should the factor analysis be carried out in a large-scale face-to-face investigation. Of note, many studies have confirmed the factor structure in different languages, including Polish,^{Reference Czachowski, Terluin, Izdebski and Izdebski27} Russian^{Reference Iakhno, Smulevich, Terluin, Reĭkhart, Zakharova and Andriushchenko28} and Turkish.^{Reference Terluin, Unalan, Turfaner Sipahioğlu, Arslan Özkul and van Marwijk29} However, as we examined the Arabic version of 4DSQ, we concluded that three items need revision before it can effectively measure the underlying four constructs in Arabic-speaking populations.

The current investigation, to the best of our knowledge, was the first validation of the Arabic version of the 4DQS. We presented the results of a study with many strengths. We used an established and well-validated tool. Our sample included a wide range of participants that could represent the Saudi public at large. We used robust statistical methods to model our data-set. However, several limitations must be acknowledged. Our survey was cross-sectional and observational and thus would allow for limited generalisability. The online survey was subject to technological availability and computer literacy. It was, however, the only reasonable option during the time of the COVID-19 pandemic. Furthermore, although the questionnaire was online and was theoretically accessible to all Saudi citizens, the recruitment invitation was sent out through social media outlets that were primarily used by local Taif-based people. It would be more accurate to assume that the obtained sample is representative of local Taif residents than of all Saudi Arabia. Moreover, the high education level observed in our survey was not representative of the wider Saudi population. It can be attributed to our respondents being those who had access to social media and were more willing to complete the online survey. Similarly, the nature of the online survey may have left out older and retired respondents. The low participation by females could well be related to unique Saudi cultural, social and religious restrictions. However, substantial changes are underway in Saudi Arabia; hence, future surveys should suffer less from this gender difference in participation. Moreover, we did not use a completely matched control from Saudi Arabia for our normative data. The normative data we used were different in terms of geographical localisation, method of interview and recruitment practicality.

We need to be cautious before directly attributing detrimental effects on mental health to the COVID-19 pandemic or the curfew. We must consider the effects of limited access to mental health services during the pandemic.

Future research should include a large number of respondents (preferably thousands) and, as the pandemic eases, should use face-to-face measures. We did not collect data pertaining to the effects of ethnicity on 4DSQ scores. Future research should consider that in more depth.

Psychological sequelae to the COVID-19 pandemic are quite prevalent and should be addressed by public health measures hand in hand with medical sequelae. Furthermore, the provision of accurate information about COVID-19 by the state media and Ministry of Health is an important factor in alleviating psychological distress during the COVID-19 crisis. The Arabic version of the 4DSQ is reliable and valid; however, it requires reconsideration of three repetitive items before it can safely be used in primary and specialist care settings in Saudi Arabia and the Arabic-speaking world.

Based on our results, public health campaigns should clearly advise the public to avoid word-of-mouth information regarding the COVID-19 pandemic and coronavirus. The public should prefer institutional and official communications provided through the Ministry of Health, governmental sites and media outlets.