*3.4. The Relation between the Precautionary Measures and Depression*

CES-D score correlated most strongly with anxiety (*r* = 0.44) and the next strongly with wearing a mask (*r* = 0.12) (Table 5). The total scores of precautionary measures taken by the participants positively correlated with CES-D score (*r* = 0.22).

A significant regression equation was found (F (1, 1107) = 59.37, *p* < 0.01) between total precautionary score and CES-D score with anR2 of0.051 (Table 6). CES-D score is equal to 2.61 × total precautionary score + 0.61 indicating that the participants' CES-D score increased 0.61 for each increase in precautionary measures.

**Table 5.** Pearson correlation coefficient (*r*) between the precautionary measures and the CES-D score describing depression (*n* = 1109, *p* < 0.05 when *r* > 0.06).


**Table 6.** Regression analysis between the total scores of precautionary measures and CES-D score.


#### **4. Discussion**

The level of following good disease preventing practices was moderate to high in our study. This result was expected, as public awareness has been improved in Saudi Arabia especially with the MOH adequately updated information presented on all media channels.

Only about half of the respondents washed their hands with water and soap and covered their mouth when coughing or sneezing. About one-quarter of the participants in our study did not always, or even most of the time, avoid sharing utensils during meals. The lack of precautionary practice during meals is probably accelerating the transmission. This has been observed previously, as many disease cases originate from sharing meals [17]. Moreover, asymptomatic individuals cover their mouths when coughing and sneezing more often than symptomatic individuals [18]. The situation during the COVID-19 pandemic may worsen because of the social nature of family-oriented Saudi people with many gatherings and family activities. Thus, maintaining precautionary measures is essential. Moreover, recommendations and updates from local authorities and WHO increases people's awareness and helps people to follow precautionary measures [19–21].

In this study, married and elderly people as well as members of large families obtained lower CES-D scores measuring depression. These factors were thus protective against depression. Females appeared to be more depressed than males. This was not surprising since, according to the WHO, women are susceptible to common mental disorders such as depression and anxiety [22]. The age of children was found to be correlated with depression symptoms; the younger the children were, the more likely their parents had depression. This has been reported previously; parents of young children declare more depressive symptoms than parents of adult children [23]. In our study, unmarried individuals were more depressed than married couples. Regarding age, we found that less depression was associated with older people; participants above 55 years were less depressed. The two latter observations contradict previous studies that mostly show more depression in married and older individuals. Marriage was attributed to the great number of responsibilities [24,25]. Older people, in turn, are thought to have greater risk for depression because

of their social disconnection and isolation feelings [26,27]. Our different findings might be explained by the family-oriented nature in Saudi Arabia. The conventional norms of the Saudi society also protect elderly people who mostly live with their children and not by themselves, and seldom in care houses. Additionally, bigger families protected against depression, as family members may provide support to each other.

It seems that the commitment to follow precautionary measures increased depression symptoms because a positive, although weak, correlation between the scores for CES-D and total precautionary measures was observed. The maximum score for depression in the depression scale CES-D is 51, and the cutoff score of 16 indicates a risk for clinical depression [28]. The regression analysis of our data indicated that the participants' CES-D score was increased by 0.61 units with each increase in the precautionary measures. Thus, it seems that the risk for depression is relatively high in small families, for females, unmarried, unemployed, individuals younger than 35 years old, or with no children. All these groups obtained a score higher than the cutoff of 16 in our study. This interpretation must be done with caution because the explanatory power of the regression analysis was relatively low, and the precautionary measures explained only 5% of the variation in CES-D score.

Behind the commitment to follow the precautionary measures was good knowledge about COVID-19, time spent on COVID-19 information, and high education, which were positively correlated with the commitment to follow precautionary measures. A recent study revealed that individuals with higher education had higher awareness about the precautionary measures of SARS virus [29]. Moreover, females appeared to follow precautionary practices better than males, which has been observed in some previous studies [29–31].

Lockdown and depression seem to be strongly linked. Despite that the curfew due to COVID-19 pandemic is different, it involves locking people in their houses and restricting their movements. Several studies have associated individual's lockdown with depression [32,33]. Studies have shown that limited outdoor activities can result in depression [34,35]. Outdoor activities are linked with physical exercise, which is known to improve mental health [36–38]. One important factor is light, as it provides signals to the brain to maintain circadian rhythm, which is involved in the sleep/wake cycle and is linked to the secretion of several mood and happiness hormones such as melatonin, cortisol, and serotonin [39–41]. Additionally, light exposure is linked to the maintenance of vitamin D levels, as lower levels of vitamin D are associated with depression [42,43].

The limitations of the research design have an effect on the reliability of the results. First, the survey lacks pre-COVID and post-COVID results about depression, and therefore the results must be interpreted with caution. However, several other recent articles report the increased depression symptoms and a number of psychological disorders during COVID-19 pandemic [44–47]. Moreover, the relation of the commitment of the individual to follow precautionary measures and depression symptoms can be assessed as reliable in our study. Second, the sociodemographic profile of the participants did not follow the actual profile of Saudi Arabia. Women, educated, and young people were overrepresented due to the recruiting process. However, our result that women felt more depression symptoms than men has been observed elsewhere, as reviewed [48]. One more limitation is that our cross-sectional design does not allow us to make any causal inferences. A web-based survey and snowball sampling recruitment method also create possibilities for selection bias. We were also not able to assess individuals' psychological condition before the pandemic. However, we suggest that the results show the potential of increased clinical depression cases caused by the pandemic.

#### **5. Conclusions**

We found a positive relationship between precautionary measures and depression. We also found that vulnerable individuals including elderlies and guardians with bigger families had relatively low depression levels in Saudi Arabia, which may be a benefit of a family-oriented lifestyle. It is recommended for governments and health authorities to not

only provide masks, soaps, and disinfectants, but also support for mental health. Online awareness programs initiated by the government, media channels, and universities are important to increase people's knowledge about the situation and guide them through the pandemic. Free consultation services and a trauma focused-cognitive behavior therapy can be launched online for people in need. Furthermore, follow-up procedures should be taken to ensure the well-being of people. Our findings can be used to formulate psychological interventions to improve mental health and psychological resilience during the COVID-19 epidemic and to improve the precautionary measures practice.

**Author Contributions:** H.S.: Collection and outline the study; H.M.A.: data analysis; R.A.A.: Statistical analysis & comparing work; K.A.: Revising; F.A.: analysis, writing, revising. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by the Deanship of Scientific Research at Princess Nourah bint Abdulrahman University through the Fast-track Research Funding Program to support publication in the top journal (Grant no. 42-FTTJ-79).

**Institutional Review Board Statement:** This work was approved by institutional committee of the Princess Nourah bint Abdulrahman University, Registration No. H-01-R-059.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** All data related to this manuscript is incorporated in the manuscript only.

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