Similar to other studies in the literature, several studies about the impact of public health emergencies such as SARS  and Ebola [20,21] outbreaks on the public mental health problems were presented. Currently, Iran is the 4th most infected country with COVID-19 in the world after China, Italy, and Spain. Rapidly increasing numbers of cases and deaths in the past weeks, lack of medical facilities and protective tools and receiving contradictory news about the nature of the disease have caused fear, distress, and panic among the general population of Iran. On the other hand, health care workers have faced serious challenges due to the inadequacy of protective equipment and the stretching of hospitals to the breaking point due to the rapidly increasing number of patients seeking medical treatment.
Our cross-sectional survey demonstrated that 15% and 20% of participants reported indicators of depression and anxiety, respectively. Being female, young, and single are considered as associating factors for depression and anxiety. Furthermore, the higher number of individuals in a household was also an additional related factor for anxiety and being a health care worker as an associated factor for depression. Our data also showed that receiving information about the disease from scientific articles and journals was considered as a related protective factor from depression whereas having higher education was considered a related protective factor for both anxiety and depression.
Several studies have reported the prevalence of depression and anxiety in the Iranian population in the past. According to a national survey of the mental health of Iranians in 2011, the levels of depression and anxiety were reported 12.7% and 15.6%, respectively . In a survey on the adult population of Iran, Noorbala, et al reported the depression rate of 10.4% in 2015 . The already existing level of anxiety and depression would most likely rise among the general population of Iran during the COVID-19 outbreak. Similar studies during the COVID-19 outbreak in China reported higher rates of anxiety and depression which ranged from 34 to 48% and 18 to 22%, respectively [24,25]. Compared to the Iranian population, these higher rates of anxiety and depression could be due to the strict quarantine by the government of China and the higher rate of infected cases and deaths, or because of using different methods and cut off points for the questionnaires. Previous studies have shown quarantining to be a predictive factor for developing depression up to 3 years post-outbreak due to risk factors such as inadequate supplies and financial loss [26,27].
Our results showed that females and younger people are at a higher risk of developing anxiety and depression compared to males and older individuals. This was confirmed by what Huang et al reported in the outbreak of COVID-19 in China . A WHO based survey reported that the rate of depression decreases as people get older, even though it is accompanied by other comorbid diseases . Additionally, studies on the Iranian population stated that females are at higher risk for psychiatric diseases [29,30].
In a study by Gao et al , married individuals were more prone to anxiety. This is in contrast to our results that demonstrated marriage to be a related protective factor for both anxiety and depression, which is also supported by other studies [31,32]. This might be caused by marriage as an element for an increased human to human interaction which can subsequently reduce the risk of mental health problems. Our study also showed that crowded households (above 4 individuals) had higher levels of anxiety and those who lived in dormitories had higher levels of depression. In a study that was done during the SARS outbreak in 2007, Su et al stated that those who had been diagnosed with depression had poor neighborhood relationships . These results can be supported by the fact that although factors such as close human to human contact in small families and marriage can protect the person against mental disorders, more crowded households and environments can increase the chance of infection by the virus due to increased contact, and result in augmented anxiety and depression during outbreaks.
Our study demonstrated that individuals with lower levels of education had a risk of developing depression and anxiety. This might be due to the fact that people with higher education have better knowledge about the virus and are able to take protective measures against it and, as a result, have lower levels of depression and anxiety. This is supported by Gao et al who presented in their study that higher educational level results in lower levels of anxiety and depression . Additionally, those who received information about the disease from scientific articles and journals, rather than other sources such as social media, had a lower rate of depression and anxiety. It can be inferred that evidence-based information from scientific articles can reduce depression and anxiety by providing the reader with trustworthy information. Similar studies also reported that people who used mass media as their source of information had higher rates of depression due to “infodemic” .
Based on our data, the individuals who didn’t worry about the disease infecting themselves, their family members, or infecting their living place had a significantly less level of depression and anxiety. So, the virus jeopardizes the individual both physically and mentally. The highest concern among people with anxiety and depression was the infection of a family member. That is why most of them agreed to avoid contact with suspicious or infected surfaces and individuals. These results show that being worried about the close ones at the time of outbreak can have a burden on the mental health of individuals in society.
It is worth mentioning that based on our results, individuals believed that compared to others, they are less at the risk of contracting the virus. Similar results were also reported by Klein et al in China . Individuals, when addressing risks that familiar and based on volitional control, tend to have a more optimistic approach towards the disease while they act more pessimistic towards risk that are less under their control and mainly affected by others [35-37]. Both cognitive and emotional matters including fear and worry have a significant attitude on managing health threats. In other words, since the individual is in control of avoiding the contraction of the disease, he or she is less anxious; since they are both worried about their dear ones and are not in control of their protective measures. This understanding and emotional bond makes the individual struggle to manage their health threats.
It seems that numerous factors are affecting the mental status of the Iranian population alongside the pandemic. Among these one can name the firm sanctions against Iran. Although sanctions against Iran have been in place for the last 40 years since the Islamic Revolution and have covered nearly all sectors, such as insurance, banks, energy, commerce, and transport , The COVID-19 pandemic in Iran coincides with the country's ever-highest politically driven sanctions and amid a national economic downturn in which sharp spikes in the price of medication have infected over 6 million patients with complicated and chronic diseases . Even before COVID-19, the healthcare system in Iran had felt the burden of the sanctions.  Their impact is now severe in that they restrict the capacity of the government to raise funds or import essential goods. [41,42] This issue has caused a dramatic social concern leading people to excessively purchasing and hoarding medical supplies, resulting in a shortage in other areas. Also, the pandemic had a significant impact on the healthcare workers with a high mortality rate  Every member of the medical staff who died from the disease was declared a martyr and a national hero; this reflected the moral dimension of the issue and helped strengthen efforts to combat the disease and win public support for health workers.
Among the other factors is the army which adopted a wartime attitude. All religious ceremonies, including religious congregations and masses and Friday prayers, were closed along with universities and schools, entertainment centers, theatres, cinemas, and sporting events and gymnasiums; car and real estate transactions decreased; hotels and accommodation centers received nearly zero guests.  this causes the public to be deprived of entertainment centers, as well as impacting the religious population worshiping habits, as Iran is amongst the religious countries in the Middle East, which one cannot deny the effects of these factors on the individuals’ mental health.
Of course, the COVID-19 pandemic in Iran also led to good events, one of which was greater popular solidarity. There was not one report in Iran about the invasion or looting of shops. People also disinfected passages and ATMs. Some landlords forgave the rental payment, and household workshops were opened to produce masks. Around the same period, people formed an intimate bond with the health care professionals, and several retailers also offered health care staff discounts. Threats changed into opportunities. Pollution decreased in some cities and the Islamic Republic of Iran Broadcasting motivated people to read books and watch movies. The release of several inmates was also good news. However, on the other hand, some disasters took place such as misinformation on social media regarding the impact of consuming alcohol on disease prevention − and since alcoholic drinks are illegal in Iran – cased numerous deaths and methanol poisoning in different cities, especially in southern Iran  As hospitals faced a lack of ICU beds for COVID-19 patients, alcohol poisoning doubled the healthcare and medical systems. Also, on March 28, inmates in several prisons were distressed enough that they clashed with guards, set fire to prisons, and somehow escaped. Jahanshahi et al suggest that adults in Iran suffer more distress than adults in China, with levels of distress predicted by various factors . Our survey in Iran was conducted during the early days of the reported outbreak, however, it is still hard to evaluate the effect of the policies exercised by the government and people on the populations’ mental health status, however, one cannot deny that special attention should be given regarding safeguarding the populations mental alongside their physical health to avoid long-lasting and even permanent consequences.
As the final point, the results of this study shed light on the unseen burden of COVID-19 outbreak on the mental health of the general population of Iran. Although locking down the cities can have a good effect on controlling the spread of the disease, it can also lead to more serious mental health problems in that area. Health authorities should be aware of this burden and be prepared to take immediate action whenever needed, particularly targeting groups at higher risks such as younger and female individuals. Furthermore, the implantation of preventive measures, especially for these risk groups, could be beneficial for further similar situations and public health emergencies .
One of the strengths of our study was the significant number of participants in the early days of the outbreak. On the other hand, this study has several limitations too. Firstly, the study was cross-sectional which makes it difficult to precisely explain causal relationships. Therefore, further longitudinal studies are essential to be conducted in the future. Secondly, since COVID-19 can be transmitted via droplets or close contacts, a web-based approach was adapted for this study, However, there are several selection biases such as illiteracy and the absence of internet access and an over-representation of females and higher-educated individuals. Since educational attainment and occupation are frequently considered as proxy measures of socioeconomic status , our results can only be comprehensive to relatively high socioeconomic status, particularly female Iranians. Moreover, no data regarding the previous mental health status of individuals were obtained nor any pre-pandemic mental health data assessment were available for comparison.