**4. Discussion**

The difficult situation humanity is going through since the outbreak and declaration of the COVID-19 pandemic is unprecedented and unimaginable. The pandemic has adversely affected all walks of life, and every person on this earth has a direct or indirect impact. COVID-19 is a physical health problem, but it has the potential to cause a major mental health crisis if adequate and necessary steps are not taken in time. The World Health Organization recognized the implication of the COVID-19 pandemic on mental health and psychological functions and released a list of considerations to the public, health care workers, team leaders, and people under isolation and all other susceptible people to cut its impact [16]. Further, the United Nations proposed their recommendations to neutralize and combat the poor mental health outcomes by providing access to mental healthcare through creative means utilizing all other available and possible resources, especially across high-risk populations [17]. In addition to this, the Centers for Disease Control and Prevention (CDC) has shared measures and methods to overcome stress [18].

Although COVID-19 may produce altered mental health in any person, the section of the community vulnerable to mental alteration may get affected quickly. The mental health of all people of society is critical for the best functioning of the community. The well-being of the female population is a necessary element for the overall welfare of the system. Generally, women are more vulnerable to negative life events than men are, especially those without social support. A study carried out in Egypt reported a high prevalence of depression and anxiety in girls that are almost double that in boys [19]. In addition to this, there are several studies available in affirmation of the high incidence of mental abnormalities and quicker impact of events in females than men. Hence, the idea of this research to explain the impact of the ongoing pandemic on this vulnerable population of Riyadh, Saudi Arabia.

Overall, the mental status of the participant indicated mild alteration; however, around 44% of the participants acknowledge perceived depression due to the COVID-19 outbreak. The higher incidence of perceived depression in Saudi Arabian women is in accordance with the current global scenario [20]. People are continuously under fear of contracting infection, dying, and losing family members. Frequent misinformation through social media and other communication channels and nightmares about the future are common factors for the induction of depression. Possibly there is a role of organic changes in the central nervous system during the COVID-19 outbreak [21].

The psychological burden and alteration in mental status is a common feature of traumatic events. Studies done earlier have shown the negative implication of large scale traumatic events on the mental illness in the majority of vulnerable populations [22]. Additionally, the presence of co-morbid or riskier conditions may further enhance the impact of events. The impact of event scale-revised (IES-R) is one of the suitable scales subjectively measure the traumatic event such as COVID-19, especially in the response sets of intrusion (intrusive thoughts, nightmares, intrusive feelings and imagery, dissociative-like reexperiencing), avoidance (numbing of responsiveness, avoidance of feelings, situations, and ideas), and hyperarousal (anger, irritability, hypervigilance, difficulty concentrating, heightened startle), as well as total subjective stress IES-R score. The average score of this scale in our study showed a milder impact on the majority of the respondents, with an overall average of around 21. However, higher age groups and people of excess body weight have shown greater vulnerability to the COVID-19. The outcome of this study is in accordance with other studies reported earlier [10]. It is also interesting to note that the overall impact of the event was mild; however, 57% of the respondents still expressed added stress due to the pandemic, and 63% of them also feel apprehensive due to continuous reports of the pandemic. Probably, high stress and apprehension were due to the daily report of 2000–5000 new cases from the Kingdom of Saudi Arabia during the time

of this study. Our findings are also consistent with other published literature showing that having exposure to life stressors are directly associated with more depression during times of social isolation as well as at low-intensity periods [23–25]. In addition to the adverse impact of COVID-19 on the economy of the country, an individual's economic status is also adversely affected due to the pandemic in many countries. However, the government of Saudi Arabia took exceptional care for the economic well-being of their citizens by facilitating full salaries and wages in both the public sector and the private sector. Hence, in our study, we did not notice any significant effect of COVID-19 associated economic status on the psychological burden of the participants.

To the best of our knowledge, our study was one of the few studies that have given insights about the extent of mental disturbance experienced by the feminine gender of the Saudi Arabia population living in the capital city, Riyadh, due to the COVID-19 pandemic. Additionally, it covered several parameters of measurement of mental status ranging from general health status to negative attitude, negative impact as well as the overall impact of COVID-19 using a reliable measuring tool.

However, it is an advantage to get to know the mental status of the female population. Having the data on the male gender would have help in comparing the extent of difference between the two sets of the population. Since most parts of this study were carried out during the lockdown phase, most of the respondents were reached through the social media link. There was no support offered to the participants on the tricky questions that need clarification that may count for understanding or interpretation bias on the part of the respondents. With a high percentage of the respondents having depression (44%), stress (53%) and apprehension (63%), it would be a good idea to do a large-scale study across different regions of the Kingdom of Saudi Arabia. Further, having data on the specific aspect of COVID-19, such as loss of a job, death of some beloved ones in the family, and others, could have given more insight into the specific issues. Additionally, as the number of cases dropping down in the Kingdom, the latest research will be needed to assess the trajectory of depression in the Saudi population and develop the potential treatment for affected populations.

#### **5. Conclusions**

The COVID-19 pandemic is associated with stress (53%), anxiety (63%) and depression (44%) in our sample population. Participants in the higher age group and overweight people have a high risk for alteration in mental health. Large scale study spread across different regions of Saudi Arabia, covering several types of population needed to assess the trajectory of the mental health of the Saudi population.

**Author Contributions:** Conceptualization, S.M.B.A.; data curation, S.A.A.; funding acquisition, Y.M.; methodology, M.A.; project administration, A.A.; resources, A.A.A.; supervision, S.M.B.A.; validation, S.N.; writing—original draft, N.N. All authors have read and agreed to the published version of the manuscript.

**Funding:** The authors would like to thank the Research Center at King Fahd Medical City, Riyadh, for their financial support provided for the manuscript.

**Acknowledgments:** The authors are thankful to AlMaarefa University, Riyadh, for providing support to do this research.

**Conflicts of Interest:** The authors declare no conflict of interest.
