Prevalence of Anxiety and Depression during the COVID-19 Pandemic in a Sample of Houston-Based Middle Eastern and North African Residents

: The COVID-19 pandemic has contributed to anxiety and depression in many communities across the United States. Here, we have focused on a sample of Houston-based Middle Eastern and North African (MENA) residents and assessed the prevalence of anxiety and depression in this community. The 7-item Generalized Anxiety Disorder and the 9-item Patient Health Questionnaires were used to identify the prevalence and severity of anxiety and depression, respectively. A sociodemographic, general health, and COVID-19 survey was used for a multivariable logistic regression model to determine predictors of anxiety and depression. The outcome of interest was “minimal/mild” versus “moderate/severe” anxiety and depression. A total of 368 participants completed the survey, with 24.73% reporting “moderate/severe” anxiety and 31.79% reporting “mod-erate/severe” depression. Male participants were less likely (OR = 0.29, 95% CI = 0.12, 0.75) to have “moderate/severe” anxiety compared to females. Respondents with self-reported depression were more likely (OR = 3.41, 95% CI = 1.33, 8.83) to have “moderate/severe” depression. Participants who reported having “Excellent/Good knowledge” about the prevention of COVID-19 spread were less likely (OR = 0.37, 95% CI = 0.15, 0.93) to have “moderate/severe” depression, and less likely (OR = 0.22, 95% CI = 0.07, 0.64) to have “moderate/severe” anxiety, compared to those who had “average/poor/terrible” knowledge. Identiﬁed predictors may be critical for designing culturally sensitive interventions to improve the healthcare of MENA Americans.


Introduction
Mental health disorders are currently among the leading causes of the health-related burden. According to the Center for Behavioral Health Statistics and Quality, the lead Federal government agency for behavioral health data and research, an estimated 1 in 5 United States (US) adults (43.6 million) suffer from a mental illness and 1 in 23 US adults (9.8 million) suffer from a seriously debilitating mental illness [1]. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 revealed that depression and anxiety were the two most disabling mental health disorders, regardless of gender, age, and geographical location [2]. Although various successful interventions exist to reduce the impact of mental disorders, there has been no reduction in the global prevalence for either disorder since 1990 [3]. The coronavirus disease 2019 (COVID- 19) pandemic has emerged as the most consequential global health crisis since the influenza pandemic of 1918 [4]. COVID-19 is caused by the highly infectious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), resulting in almost 6 million deaths worldwide (WHO, February 2022). Nadia Abuelezam [15,18]. Sociodemographic and general health data collected included: gender, education, age, marital status, residency status, religion, annual income, health insurance status, smoking status, alcohol consumption status, overall health, and chronic disease comorbidities. The nine-item Patient Health Questionnaire (PHQ-9) scale was used for the assessment of depression symptoms, and the seven-item Generalized Anxiety Disorder (GAD-7) scale for the assessment of anxiety symptoms. The PHQ-9 is a nine-item self-reported instrument used to assess the prevalence and severity levels of depression symptoms experienced by participants over a two-week time period. The depression scale has been used to score each of the nine DSM-IV criteria. Participants were asked to score each item on a four-point Likert scale ranging from 0 to 3. Each item's computed score was summed by adding each item to obtain a participant's total score. The total scores range from 0 to 27 scale and are divided into five categories: minimal (1)(2)(3)(4), mild (5)(6)(7)(8)(9), moderate (10)(11)(12)(13)(14), moderately severe (15)(16)(17)(18)(19), and severe depression (20)(21)(22)(23)(24)(25)(26)(27) [21]. The GAD-7 scale is a seven-item self-reported anxiety questionnaire used in primary care and general populations. Participants were asked to score each item on a four-point Likert scale ranging from 0 to 3. Each item's computed score was summed to obtain a participant's total score. The total scores range from 0 to 21 scale and are divided into four categories: minimal (0-4), mild (5)(6)(7)(8)(9), moderate (10)(11)(12)(13)(14), and severe anxiety (15)(16)(17)(18)(19)(20)(21) [22].

Statistical Analysis
The G-power 3.1 statistical program was used to estimate the sample size. Since the MENA population in Houston is projected to be 98,300 people, a total of 242 participants were required to provide 80% power for a chi-square analysis at a 0.05-level with a 0.15 effect size. Furthermore, we determined that the minimum sample size of 308 patients would offer 80% power to detect an odds ratio of 1.5 for a two-tailed analysis at a 0.05 alpha level using logistic regression. Descriptive analysis was used to describe participants' sociodemographic, general health, and responses to COVID-19-related questions. All categorical variables had their frequencies computed and described as percentages. For categorical data, chi-square tests were used to analyze group differences.
To assess determinants of anxiety as well as depression during COVID-19, two multivariable logistic regression models were carried out. Outcome variables in these models were severity of depression as well as anxiety categorized as "moderate/severe" vs. minimal/mild" based on the GAD-7 and PHQ-9 total scores. Independent variables that were included in the model were gender, age, education, marital status, residency status, annual household income, religion, smoking status, alcohol consumption status, health insurance, general health perception, and comorbidities such as hypertension, hypercholesterolemia, obesity, and self-reported anxiety or self-reported depression. The COVID-19-related variables that were included in the model were prior infection, perceived infection risk, perceived severity of infection, perceived knowledge on preventing COVID-19 spread, nightmares about COVID-19, tried hard not to think about COVID-19, felt numb, capacity to perform errands and social activities, and reported capacity to avoid infection. SAS version 9.4 (SAS Institute, Cary, NC, USA) was used for all statistical analyses, with an a priori significance threshold of 0.05.

Characteristics of the Study Participants
The sociodemographic characteristics, PHQ-9 scores, and GAD-7 scores of the participants are summarized in Tables 1 and 2. The sample size was 368 participants, 66.03% of them being males. The majority of the participants (n = 248, 67.39%) were within the age group 26-39 years. Most of the respondents, 73.91%, reported being married/living with a partner. The average annual income for 41.58% of the respondents (n = 153) was less than USD 45,000 a year. More than half (53.26%) of the respondents identified themselves as Muslims, 34.24% as Christians, and 12.50% as Jewish/others. Of all the participants around 39.13% reported smoking cigarettes or hookah and 31.52% reported using alcoholic beverages. Most respondents (n = 240, 65.22%) self-reported "very good/good" general health, while some of the respondents reported the following health issues: hypertension (14.67%), high cholesterol (13.04%), and obesity (14.13%). Around one-third (28.53%) of the respondents reported having anxiety issues, and (21.20%) self-reported depression. In this sample, 69 individuals (18.96%) had COVID-19 infection. While 75.96% believed to have excellent/good information and knowledge on preventing COVID-19 spread. Only 41 individuals (11.23%) declared a high likelihood of acquiring COVID-19 infection, and 14.09% reported that avoiding COVID-19 infection is extremely/somewhat difficult. The average GAD-7 score for anxiety in this sample was 5.6 (SD = 4.9) and the average PHQ-9 score for depression was 6.9 (SD = 5.8). A strong positive significant correlation (r = 0.866, p < 0.001) was found between GAD-7 and PHQ-9 total scores as indicated by the Pearson correlation coefficient.

Predictors of Anxiety Symptoms among the Participants
The association between various sociodemographic characteristics, general health, and COVID-19 and anxiety score are presented in Table 3. Multiple logistic regression analysis revealed that male participants were less likely (OR = 0.29, 95% CI = 0.12, 0.75) to have "moderate/severe" anxiety compared to female participants. Individuals who responded "Yes" to the question "You had nightmares about COVID-19 or thought about it when you did not want to?" were more likely to have "moderate/severe" anxiety compared to those who said "No" (OR = 2.85, 95% CI = 1.08, 7.49). Individuals who said "Yes" to the question "Has the COVID19 outbreak been so frightening/upsetting that you tried hard not to think about it or tried to avoid situations that reminded of it?" were more likely to have "moderate/severe" anxiety compared to those who said "No". (OR = 7.69, 95% CI = 2.53, 23.35). In addition, those having "no difficulty" (OR = 0.10, 95% CI = 0.02, 0.59) doing errands alone, such as visiting a doctor's office or shopping, because of a physical, mental, or emotional condition were less likely to have "moderate/severe" anxiety compared to those with "a lot of difficulty/can't do at all". Moreover, those having "some difficulty" (OR = 0.22, 95% CI = 0.06, 0.82) doing social activities were less likely to have "moderate/severe" anxiety compared to those who had "a lot of difficulty/can't do at all". Those who reported having "Excellent/Good knowledge" about the prevention of COVID-19 spread were less likely (OR = 0.22, 95% CI = 0.07, 0.64) to have "moderate/severe" anxiety compared to those who had "average/poor/terrible" knowledge.

Predictors of Depression Symptoms among the Participants
The association between various sociodemographic characteristics, general health, COVID-19, and depression is presented in Table 3. Multiple logistic regression analysis showed that people with self-reported depression (OR = 3.41, 95% CI = 1.33, 8.83) were more likely to have "moderate/severe" depression compared to participants who reported no depression. Individuals who said "yes" to the question "Has the COVID-19 outbreak been so frightening/upsetting that you tried hard not to think about it or tried to avoid situations that reminded of it?" were more likely to have "moderate/severe" depression compared to those who said "no" (OR = 5.17, 95% CI = 2.03, 13.19). In addition, those having "no difficulty" (OR = 0.10, 95% CI = 0.02, 0.48) and those having "some difficulty" (OR = 0.22, 95% CI = 0.07, 0.67) doing errands alone such as visiting a doctor's office or shopping because of a physical, mental, or emotional condition were less likely to have "moderate/severe" depression compared to those with "a lot of difficulty/can't do at all." Moreover, those who reported having "Excellent/Good knowledge" about the prevention of COVID-19 spread were less likely (OR = 0.37, 95% CI = 0.15, 0.93) to have "moderate/severe" depression compared to those who had "Average/poor/terrible." Moreover, participants who responded, "Neither easy nor difficult" to the question "For me avoiding an infection with the novel coronavirus in the current situation is... " were more likely (OR = 4.21, 95% CI = 1.11, 15.59) to have "moderate/severe" depression compared to participants who reported "Somewhat difficult, extremely difficult".

Discussion
This study assessed depression, anxiety, and their predictors among a sample of MENA Houston residents during the COVID-19 pandemic. Previous studies have suggested a higher incidence of psychological distress among Arab Americans [23,24]. The majority of MENA individuals residing in the US are either refugees, immigrants, or first-generation Americans. A significant number of MENA individuals have faced political oppression or violent conflict in their country of origin before settling in the US, and often face cultural dispossession, and other resettlement stressors such as social exclusion and discrimination upon resettlement in the US [13]. In the sample surveyed, 28.53% of respondents selfreported anxiety, which is higher than the 12.4% prevalence of anxiety disorders among US immigrants [25]. Additionally, 21.20% of respondents self-reported depression which is also higher than the 15.6% aggregate prevalence of depression among international immigrants in the US [26]. Furthermore, our study showed a significant correlation between anxiety and depression, demonstrating the high comorbidity of the two disorders whose risk factors also overlap [27]. A landmark systematic review revealed that the prevalence of anxiety disorders is highest in North America (7.7%) and the MENA region (7.7%) when compared to other global regions such as Asia, Africa, and Europe [28].
In the present study, we observed that female participants were more likely to have anxiety during the COVID-19 pandemic compared to male participants, an observation which could be explained by the greater consistency of anxiety within the feminine gender role than a traditionally masculine role [29]. These results are also consistent with other studies conducted on anxiety symptoms and behaviors in MENA individuals, showing that immigrant MENA women have higher rates of anxiety [30,31]. Yussuf and colleagues [32] concluded that immigrant women in general, and women of MENA origin in particular, have higher rates of anxiety disorders compared to immigrant men and the general population, most likely from the additional sources of stressors they encounter on a daily basis such as acculturation issues, marital pressures, child care, household responsibilities, etc., thus increasing their susceptibility to anxiety and COVID-19-related worries [33]. A population-based study in the United States suggests that anxiety disorders are associated with a greater illness burden in women than in men [31]. Furthermore, the Anxiety and Depression Association of America (ADAA) explains that from the time a girl reaches puberty until about the age of 50, she is twice as likely to have an anxiety disorder as a man [34]. Findings of the study also showed that participants reporting "good/excellent" COVID-19 prevention knowledge were less likely to have anxiety, which underscores the importance of educational programs among immigrant populations, which can help control the anxiety around COVID-19 and promote prevention strategies and vaccine uptake. However, this present study did not assess the quality of the actual COVID-19 prevention knowledge since the data assessed were only self-reported. Therefore, future research should examine the quality of knowledge among this minority population to combat any misinformation.
Our study also suggests that self-reported depression appears to be reflective of potential depression as measured by the validated survey within the MENA American community. This is especially important since stigma around mental illness is one of the most prevalent barriers for MENA Americans [35]. Individuals specifically reported fears that other people would view them as "weak" if they sought therapy for mental illness [36]. There are many reasons why MENA individuals are hesitant to seek formal mental healthcare services. In MENA American communities, the most prevalent source of reported help-seeking is through informal sources such as family [37,38]. This is in line with a theory in the literature that MENA values are often aligned with the family rather than the individual [39]. In a study of Iraqi refugees in Texas, participants noted that family was the best suited for handling mental illnesses, but further clarified that they would only seek help from a medical doctor or other resources if the condition became too severe [40]. Therefore, since many MENA cultures regard the extended family as a significant source of social support and the primary route through which treatment is sought, when these individuals report symptoms of depression, such as in our study, there may be a need for professional help and medical attention. We suggest that our study emphasizes the need for developing culturally sensitive educational material to empower MENA individuals in seeking appropriate care and guidance leading to improved mental health outcomes among this immigrant population, particularly following COVID-19 pandemic.
Our findings also suggest that patients who had difficulty doing errands or visiting the doctor were more likely to be both anxious and depressed. This is consistent with the literature suggesting that individuals with physical disabilities or functional impairment often report depression and anxiety [41]. It is also well known that people with depression or anxiety disorders reported poorer physical functioning as compared to healthy controls [42,43]. However, based on this cross-sectional study, we cannot clarify if individuals' inability to do errands occurred before the anxiety and depression or afterwards (i.e., they became anxious and depressed because they cannot do errands). Future research should look at temporal relations between difficulties in doing errands and depression/anxiety.
There are several limitations of the study that must be recognized. Since this study consisted of a relatively small sample size of self-reported data, as a convenience sample, the results should be interpreted given this limitation. As a cross-sectional design, this study does not allow for cause-and-effect relationship analyses. Generalizability of the findings is also limited to similar populations. We believe that the results of our study emphasize the need for adopting culturally sensitive interventions, including educational and public health endeavors tailored toward Houston's MENA community, thus enabling better mental health outcomes. Additionally, a greater focus needs to be placed on the social and health needs of the MENA group in America's existing racial and minority health landscape. This would provide a more holistic picture of immigrant health in the United States. Finally, while this study focused on the impact of COVID-19 on anxiety and depression states, resilience measures were not explored. Future studies examining stress coping strategies, resiliency, and social support within the family structure as well as the role of community support will be informative. Integration of resilience measures can serve as a protective means for future interventions targeting positive mental health outcomes within the MENA community.

Conclusions
This study identified predictors of depression and anxiety in a sample of the MENA population of immigrants that experiences unique stressors. Mental health can impact COVID-19 prevention strategies, such as vaccination uptake, which affect the spread of COVID-19 within this community and the overall American community. Any interventions that help MENA individuals deal with mental health issues during the pandemic should take the identified predictors of our study into consideration. Furthermore, future research should focus on developing culturally sensitive interventions that take our predictors into consideration to address mental health in MENA communities.