{'fraction_non_alphanumeric': 0.0348869277440706, 'fraction_numerical': 0.028268063982349698, 'mean_word_length': 5.219982847341338, 'pattern_counts': {'":': 0, '<': 5, '<?xml version=': 0, '>': 2, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Prevalence and associated factors of depression, anxiety and stress among coronavirus disease 2019 (COVID-19) patients in Herat, Afghanistan

Objectives Coronavirus disease 2019 (COVID-19) pandemic has been associated with a great level of psychological distresses in people around the world. This study aims to assess the prevalence of depression, anxiety and stress among COVID-19 patients and identify the associated factors, in Herat Province of Afghanistan. Methods This cross-sectional study was conducted on 459 hospitalized patients between May and September 2021. Data was collected with a structured questionnaire on depression, anxiety and stress scale, which was the validated Dari-version. Chi-square test was adopted to analyze the associations of the prevalence of the mental disorders and the factors. Results The mean age of participants was 38.05; 51.9% (238/459) were male and 84.1% (386/459) were married. Median scores for depression, anxiety and stress were 5.0, 8.0, and 10.0, respectively. Gender, general health condition, nutritional status, COVID-19 clinical manifestation and concurrent comorbidities (except diabetes and hypertension) were significantly associated with mental disorders; while association between marital status and these psychological disorders was not significant. Moreover, a significant difference was observed in the level of anxiety between healthcare workers and other respondents. Conclusion This is the first study to report the high prevalence of depression, anxiety and stress among COVID-19 patients in Herat, which indicates the negative effect of mental health for COVID-19 patients globally and highlights the need for urgent and appropriate interventions to improve mental health of people during the pandemic.


Introduction
The coronavirus disease 2019 (COVID- 19) was first reported in Wuhan City of China at the end of 2019. 1 On 11 March 2020, the disease which is caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was characterized as "pandemic " by the World Health Organization (WHO). 2 In Afghanistan, the first case of COVID-19 was diagnosed on 24 February 2020, in Herat Province (hereafter referred as Herat). 3 , 4 The pandemic rapidly spreads in the world, affecting more people day by day. As of 1 February 2022, over 360 million COVID-19 cases and 5.6 million deaths have been confirmed in the world, of which over 160 000 cases and 7 400 deaths come from Afghanistan. 5 Due to the rapid spread and negative impacts on economy, health and well-being of people, many studies assessed the impact of COVID-19 pandemic on psychological status of the patients, mainly including impulsivity, insomnia, cognitive impairment, persistent fatigue and mood disorders. [6][7][8][9][10] Accumulating evidence suggests that COVID -19 Herat, which can serve as a baseline reference for future work in this field in the region.

Study design
This cross-sectional study recruited COVID-19 patients who from May to September 2021 attended Shahid Basim's COVID-19 Hospital in Herat. This hospital provides COVID-19 tertiary care services for Herat's residents.

Ethical consideration
The Human Ethics Committee of Herat University approved the study protocol (Approval number #200,221). A written informed consent was obtained prior to the conduct of interview and acquisition of data. Privacy and confidentiality of information was maintained throughout the study.

Survey instrument
Sociodemographic data including patients' gender, age, marital status, education, employment, respondents' self-perceived economic status, general health and nutritional status, along with clinical presentations and the existence of comorbidities were collected by a psychiatrist, at Shahid Basim's COVID-19 Hospital, using a paper-based structured questionnaire. Depression, anxiety and stress scale (DASS) questionnaire was employed in this study, 30 because it was recently used to assess psychological responses during COVID-19 pandemic in many countries, including China, Spain, the USA, Poland, Iran, the Philippines and Vietnam. [31][32][33][34][35][36] This DASS questionnaire was the validated Dari-translated version of 42-item. Each item was rated on a 4-point severity using 0 -3 scale; with 0 implying "it did not apply to me " and 3 "it applied to me very much ". Scores for each subscale were calculated by summing the scores of all items in relevant subscale. Therefore, the highest possible scores were 42 for each depression, anxiety and stress subscales. Patients considered "normal ", when their scores were 0 -7 for depression, 0 -4 for anxiety and 0 -10 for stress, respectively.

Statistical analyses
Statistical analyses were performed with SPSS 27.0 Statistics (IBM). Continuous variables with normal distribution were presented as means ± standard deviation ( ± s) . Non-normally distributed variables were shown as median and inter-quartile range ( IQR ). Categorical variables were presented as numbers and percentages. The association between categorical variables was assessed by Chi-square tests. The level of significance was set to P < 0.05.

Socio-demographic characteristics of the participants
A total of 459 patients were included in this study, which were aged 18

Prevalence of depression, anxiety and stress
Of all participants in this study, 31.7% (146/459) reported moderate to extremely severe depression, 42.9% (197/459) reported moderate to extremely severe stress, and 69.7% (320/459) reported moderate to extremely severe anxiety. Of a significant interest was the high percentage (42.3%, 194/459) of extremely severe anxiety among study participants. Table 2 shows the levels of depression, anxiety and stress among study participants. The median and IQR of depression, anxiety and stress in this study were 5 (1 -12), 8 (4 -13), and 10 (5 -18), respectively.

Association of socio-demographic characteristics with depression, anxiety and stress
More female participants were suffering from depression, anxiety and stress than males ( P < 0.001). Also, a significant association was observed between general health condition and nutritional status with depression, anxiety and stress (all P < 0.001). No significant difference was observed between depression, anxiety and stress and marital status. Table 3 displays the association of participants' socio-demographic characteristics with depression, anxiety and stress among study participants.

Association of clinical manifestations with depression, anxiety and stress
The majority of patients in this study presented with fatigue (78.2%), body-ache (73.0%), fever (70.2%), headache (69.7%), and cough (62.7%). Table 4 shows the association between clinical manifestations with depression, anxiety and stress among study participants. There were insignificant associations between fever and stress, cough and depression, and diarrhea and depression ( P > 0.05). Beside, significant associations were observed between all other clinical manifestations with depression, anxiety and stress ( P < 0.05).

Comparison of levels of depression, anxiety and stress between healthcare workers and other study participants
The chronic exposure of healthcare workers to occupational stresses may predispose them to different levels and severity of mental illnesses. Although no significant association was observed in the levels of depression and stress between healthcare workers and other participants ( P > 0.05), the difference in anxiety between them was significant ( P < 0.05).

Discussion
This is the first study that reported the prevalence and contributing factors of depression, anxiety and stress in general population suffering from COVID-19, in Afghanistan. The prevalence of depression, anxiety and stress in this study were 41.2% (189/459), 79.5% (365/459) and  48.6% (223/459), respectively. Our results indicate that the most prevalent mental health disorder in this study was anxiety; which is consistent with the findings of other studies from Ecuador, 16 China, 18 and Iran, 25 in which anxiety was reported the most common mental health disorder among study participants. However, studies from Saudi Arabia, 15 Turkey, 22 and China, 19 found that depression was the most prevalent mental disorder among study participants. Our findings indicated that female was significantly associated with higher levels of depression, anxiety and stress, which is in accordance with the findings of many other studies around the world. 15-17 , 19 , 20 , 24-27 However, it should be noted that females were also susceptible to higher levels of depression even before the pandemic. 37 We found that educational level was not significantly associated with depression, anxiety and stress. This is similar to the findings of studies from Saudi Arabia, 15 and China, 19 , 20 but is in contradiction with the results reported from Japan 28 and Iran 29 in which a significant association was found between educational level and mental illnesses under study. Unlike the popular belief that individuals with higher education levels may suffer from greater magnitude of psychological disorders due to their higher levels of self-awareness regarding their health, our study found that well over half the illiterate participants suffer from depression, anxiety and stress.
This study also found that marital status was not significantly associated with mental illnesses. A similar finding was reported from China. 19 , 20 This is unlike similar studies from Saudi Arabia, 15 Turkey, 22 and Ecuador, 16 that reported a significant association between marital status and depression, anxiety and stress, i.e. significantly higher rates of mental illnesses among single populations.
This study also found that respondents' employment status was significantly associated with depression and stress but not with anxiety. Higher and statistically significant number of self-employed respondents was suffering from anxiety and stress. This may be due to the fact that government employee and healthcare workers were certain that their wages would have been paid, regardless of their COVID-19 infection. Also, there was no considerable change in the income of unemployed participants before and during COVID-19 pandemic. Hence, selfemployed individuals were more concerned about their income and living costs, making them susceptible to mental disorders. A similar study in Saudi Arabia reported that the employment status of the participants was associated with depression, but not with anxiety and stress. 15 We also found that a poor health status of respondents was significantly associated with depression, anxiety and stress. This is in line with a study from Saudi Arabia which reported that poor health condition was associated with anxiety and stress, 15 while another study from India found that chronic health condition was associated with stress. 18 Our results indicate that economic status was associated with depression, but not with anxiety and stress. A study from China reported a significant association between household income with depression and anxiety, 19 while another study from Japan stated that economic status was associated with all three mental illnesses under study. 28 Another study in China reported that depression and anxiety were insignificantly associated with monthly income. 20 We found that COVID-19 symptoms in our participants were significantly associated with depression, anxiety and stress. Similarly, a study from Japan reported that respondents with COVID-19 symptoms were significantly more prone to mental health illnesses. 28 These indicate that being infected with COVID-19 can be an important correlate of psychological illnesses, due to its rapid progression, its consequences on health, economy and interpersonal relationship.
The current study highlighted an association between the age of respondents and anxiety, but not depression and stress. This aligns with the findings of a study from Japan, 28 which reported a significant association between age and anxiety, but not with stress and depression. This indicates that age can be a significant contributing factor for development of anxiety in COVID-19 patients.

Limitations
The current study had a few limitations. Firstly, a baseline prepandemic data was not available on the magnitude of depression, anxiety and stress for comparison. Therefore, we could not be certain whether there was a considerable increase in the level of these mental illnesses in study participants. Secondly, our data was collected from patients who were hospitalized at Shahid Basim's COVID-19 Hospital in Herat, not involving patients with mild illnesses under self-isolation at home. Thirdly, though COVID-19 was reported to impair the olfactory function [38][39][40] and specific questionnaires as well a smell identification test were recently developed to assess it, 41 , 42 the 42-item questionnaire which we used in this study did not cover the olfactory function issues yet. Fourthly, although studies revealed that COVID-19 causes hemorrhagic changes in the brain, 38 we only used a self-reported questionnaire to assess the magnitude and severity of depression, anxiety, and stress among participants in this study. At last, we restricted this study to Dari-speaking patients, because our instrument (DASS questionnaire) was only validated for Dari-speaking people. Therefore, COVID-19 patients with other languages were not included into this study.

Recommendation
Considering the high prevalence of depression, anxiety and stress among COVID-19 patients, accumulating evidence recommends psychological and behavioral interventions, particularly digital cognitive behavior therapy (CBT) and online psychological counselling, [43][44][45] as adjuvant therapy to help COVID-19 patients and their families.

Conclusion
Depression, anxiety and stress are very prevalent in general COVID-19 patients in Herat. Females, those with poor health condition and poor nutritional status, those with apparent COVID-19 symptoms, and concurrent comorbidities were at higher risk of developing these mental disorders. Considering global research evidence, including this study, it seems that COVID-19 negatively affects the mental health of people around the world. Public health sectors and policy makers should pay particular attention to mental health of COVID-19 patients as well as health workers, and minimize the pandemic's impact on mental health of all populations.