Mental distress in ongoing conflict and non-conflict settings during COVID-19: a study on Syrians in different countries

When applying cut-off points, Syrians in Syria comprised of 72 (31 3%) with avoidance symptoms, 106 (46 5%) with arousal symptoms, and 103 (45 4%) with re-experience symptoms, whereas Syrians outside Syria comprised of 96 (41 6%) with avoidance symptoms, 112 (49 6%) with arousal symptoms, and 111 (50 5%) with re-experience symptoms [ ]only avoidance was significantly more frequent in Syria (p = 0 022) K10 scores, days unable to work, social support and PTSD in different countries Characteristic Syria mean (s d ) Outside Syria mean (s d ) p value Nearby country mean (s d ) Canada mean (s d ) Egypt mean (s d ) UAE mean (s d ) Russia mean (s d ) Germany mean (s d ) p valuea Arousal 1 55 (1 427) 1 79 (1 563) 0 089 1 80 (1 560) 1 46 (1 266) 1 69 (1 569) 1 96 (1 641) 2 73 (1 272) 1 56 (1 586) 0 131 Avoidance 1 82 (1 726) 2 17 (1 889) 0 035 2 59 (1 968) 1 69 (1 974) 2 04 (1 605) 2 17 (1 872) 2 00 (2 145) 1 82 (1 820) 0 067 Re-experience 0 93 (1 284) 1 21 (1 600) 0 042 1 38 (1 686) 1 00 (1 206) 0 85 (1 287) 1 27 (1 724) 1 18 (1 471) 1 15 (1 638) 0 307 Total SPTSS 4 30 (3 735) 5 07 (4 422) 0 045 5 71 (4 630) 4 08 (3 796) 4 48 (3 435) 5 27 (4 698) 5 91 (4 571) 4 39 (4 422) 0 158 Friends support 15 620 (7 5494) 15 232 (7 7590) 0 590 15 372 (8 1975) 14 269 (8 9550) 15 115 (6 4750) 16 848 (8 0415) 7 727 (4 5131) 15 481 (7 0557) 0 038 Family support 19 097 (6 9193) 19 613 (6 8274) 0 423 18 633 (6 9157) 19 500 (9 0692) 19 058 (6 5793) 20 924 (6 6533) 20 500 (7 5299) 19 972 (6 2935) 0 632 Significant other support 19 273 (7 6526) 20 226 (7 3404) 0 174 19 880 (6 8556) 19 923 (8 4307) 19 111 (8 1090) 21 340 (7 4324) 18 864 (7 7495) 20 636 (7 3500) 0 653 Total social support 53 85 (18 307) 54 55 (18 263) 0 686 53 68 (17 675) 53 69 (21 092) 52 02 (19 812) 58 31 (19 702) 47 09 (15 152) 55 45 (16 854) 0 567 Total K 10 support 22 5633 (8 74049) 23 4474 (9 63162) 0 305 23 8108 (9 26131) 20 1538 (10 91517) 24 6071 (10 71288) 24 4681 (8 74481) 20 3636 (7 24255) 22 8909 (10 42375) 0 508 Days unable to work in the past 4 weeks 7 81 (11 050) 179 220 15 (2 444 117 919) 0 326 584 802 67 (4 415 106 822) 5 55 (9 048) 5 41 (6 681) 14 82 (58 913) 7 44 (7 502) 7 88 (7 860) 0 493 We used one-way analysis of variance and independent t test in this table a This p value is when comparing Syria with the previous countries [ ]there were no significant differences in the relationship with the partner and housemates, being distressed from war noise, being themselves or family exposed/infected to COVID-19, being hospitalized, self-quarantined with or without symptoms, losing jobs, and worries of work and study being affected [ ]as Syria did not have many active cases and the conflict was relatively less severe at the time of this study, Syrians in Syria were particularly concerned about providing food and a reduced ability to earn


Mental distress in ongoing conflict and non-conflict settings during COVID-19: A study on Syrians in different countries
Dear editor, Syria has suffered for nine years from war which caused more than the half of children and adults to suffer from severe post-traumatic stress disorder (PTSD) and/or mental distress (Kakaje et al., 2020a) (Kakaje et al., 2020b). Even when leaving the country and being refugees, around the quarter of those who left the country has suffered from post-traumatic stress symptoms (PTSS), depression, and/or anxiety (Georgiadou et al., 2018). This study evaluates the mental distress in Syrians who left the country because of war, and those who stayed in the conflict in Syria in the last years.
As self-reporting measures tend to overestimate symptoms, scores were used rather than cutoff points. Only Syrians were included, either living in Syria or those who left Syria due to war regardless of the method and Visa status and they were recruited using Social Media groups via online questionnaires. No participants living in camps were included. For each participant living outside Syria, a matching case living in Syria was randomly chosen. We only matched for age and gender as other variables would vary between the countries such as salaries and the socioeconomic status standards.
Income was assessed based on the income being adequate for needs rather than earned amount (Kakaje et al., 2020a). Nearby countries category involved countries that surround Syria which are Lebanon, Jordan, Turkey, Iraq, and Iran. Data were processed using IBM SPSS software version 26 for Windows.
Due to the short time of data collecting and the urgency of COVID-19, a larger sample size was not achievable. Around 241 participants from outside Syria received the survey, but only 236 agreed to participate. A larger number of people agreed to participate from Syria.
However, only one matching participant was randomly chosen while the others were excluded. This study included 472 participants, of which 214 (45.3%) were males with a mean age of 29.1 ± 7.5 years.
There were no significant differences in SPTSS, K10, and social support scores between different governates within Syria (p>0.05). Living in Syria was associated with a higher level of education, owning houses or apartments rather than tenants, being singles, and having less monthly income adequacy compared to living in other countries (p<0.001). Results of the scales are demonstrated in (Table 1). When applying cut-off points, Syrians in Syria comprised 72 (31.3%) with avoidance symptoms, 106 (46.5%) with arousal symptoms, and Doctors and dentists living in Syria had higher scores than the others compared to living in other countries.
Participants from Syria were more worried from the reduced ability to earn money, being unable to provide food, and their relationship with their deteriorated friends or family (p<0.05), but they were less worried about getting infected (p=0.041) compared with Syrians outside. However, there were no significant differences in the relationship with the partner and housemates, being distressed from war noise, being themselves or family exposed/infected to COVID-19, being hospitalised, self-quarantined with or without symptoms, losing jobs, and worries of work and study being affected. K10 score was not statistically significantly different according to type of work.
COVID-19 outbreak was associated with higher PTSS for Syrians outside Syria, which might be from Syria having fewer cases and being more stable socially as they lived with their families in their houses, not in a foreign country. This could also be from the four-week lockdown providing a break for people, which helped in decreasing their symptoms in Syria.
New methods should be introduced to target Syrian populations as up-to-date and accurate data can be protective against mental distress (Alyousbashi and Almahayni) (Luo et al., 2020). This is particularly prominent in societies like Syria as the majority of people are daily users of Social Media and therefore it will provide an easy and fast way to reach the population.
The majority of Syrians get their information from Social Media which leaves a large window of false information. It was difficult to reach the targeted population in our study, so online surveys in Social Media groups were used which may expose to bias and might have https://www.cambridge.org/core/terms. https://doi.org/10.1017/gmh.2021.12 made it more difficult to compare with other samples. However, Social Media has proven to be a viable item for global mental health which allowed to reached populations, easier and faster, but we still need to develop the tools to tackle this multi-dynamic crisis. This also justifies the high response rate as these are people who had time and the surveys were easy to fill in, which might have also biased the results as the people who did not have time or Internet access would not have seen the surveys.
In conclusion, as Syria did not have many active cases and the conflict was relatively less severe at the time of this study, Syrians in Syria were particularly concerned about providing food and a reduced ability to earn. This study suggests that Syrians who had to leave and live in a foreign country where COVID-19 outbreak started to rise faced a different mental distress than those who stayed during the war despite both groups having roughly the same social support. This study suggests that mental issues inside Syria are mostly from the deteriorating economy while for Syrians outside suffered mostly from COVID-19.In a time of accelerating, ongoing, dynamically overlapping and rapidly evolving global crises like COVID-19, more nimble and versatile ways of tracking mental health change longitudinally and comparatively are needed.

Declarations:
 Ethics approval and consent to participate: Online informed consent was taken before proceeding with the survey for participating in the research, and for using and publishing the data. We assured to maintain confidentiality and https://www.cambridge.org/core/terms. https://doi.org/10.1017/gmh.2021.12 asked no questions that might reveal the person's identity. No subjects were under the age of 16.
Our study protocol and ethical aspects were reviewed and approved by Damascus University deanship, Damascus, Syria.

 Consent for publication:
Online consent for using and publishing the data was taken before participating in the research.

 Availability of data and materials:
The data can be made available upon reasonable request.

 Competing interests:
We have no conflict of interest to declare. This is an Accepted Manuscript for Global Mental Health as part of the Cambridge Coronavirus Collection. Subject to change during the editing and production process. DOI: 10.1017DOI: 10. /gmh.2021 This is an Open Access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work.