Several pieces of evidence showed that the COVID-19 pandemic has significant psychological repercussions. Recent studies reported that the COVID-19 pandemic is linked to distress, anxiety, depression, and insomnia in the overall population worldwide. In addition, the mental health sequelae of the pandemic are likely to last for months or even years and might peak later than the time of the actual pandemic outbreak. Thus, there is a necessity for further research into how the mental health effects of the COVID-19 pandemic can be mitigated during and after the outbreak [16, 36, 40, 52–56]. Therefore, this study aimed to investigate the psychological impact of the COVID-19 pandemic on the overall population in multi-countries during its initial phase.
Our socio-demographic data indicated that participants without PTSD rated higher (n = 639; 64%) than participants with PTSD (n = 360; 36.0%), which means that the PSTD symptoms of the COVID-19 pandemic were lower than recently reported by Pazmino Erazo et al. which exhibited a higher rate of PSTD symptoms (43.8%) [57]. In addition, the 22-item IES-R scoring diagnosis of PTSD found that males rated (36.6%) higher than females (35.6%). Contrary to our findings, Wang et al. reported that the pandemic's psychological impact on females was more significant than males [24]. Accordingly, the results revealed that group scores of participants without PTSD (Fig. 6) were less and negative on psychological effects such as insomnia, depression, and anxiety than participants with PTSD symptoms who scored high with positive coefficients (Fig. 7). In line with this, groups with and without PTSD on psychological outcomes as Latent Constructs, findings from the current study indicated that participants with PTSD have high scores on depression, anxiety, and insomnia than those without PTSD. Moreover, it is noteworthy to mention that the current study results indicated that IES-R for COVID-19 as a single latent construct has a strong effect on psychological outcomes with a large effect size (0.51) [51]. Furthermore, individual factors of IES-R for COVID-19 (intrusion, avoidance, and hyperarousal) are predictors for individual factors of psychological outcomes (depression, anxiety, and insomnia).
Regarding the psychological effect of COVID–19 using the IES-R scale, it was found that 64.0% of participants had an average psychological score, whereas 36% had mild to severe scores on the IES-R, which indicated a stressful impact. Surprisingly, 17.3% of the participants reported a severe psychological impact. Such findings confirmed that the participants without PTSD rated higher (64.0%) than those with PTSD (36.0%).
On the other hand, the results revealed that among participants, 365 (36.5%) had moderate to severe depression symptoms (PHQ-9 score ≥ 10), while 326 (32.6%) had mild depressive symptoms. However, 308 (30.8%) of participants reported that they did not experience any symptoms of depression (PHQ-9 score ≤ 10). These outcomes indicated that more than one-third of respondents included in the study suffered from depressive symptoms. In comparison with previous reports, the present study results are comparable to those of prior studies by Janati Idrissi et al. who reported that 35.6% of participants had symptoms of depression [58]. However, Choi et al. found that only 19% of respondents had depression (PHQ-9 score ≥ 10), which presents approximately half of the percentage found in the current study [36]. Also, Alkhamees et al. revealed that 16.4% of participants had severe depressive symptoms, which is slightly less than half of the percentage found in the current study [52]. Contrary to this, Elhadi et al. reported a higher rate of depression symptoms during the COVID-19 pandemic. The authors indicated that 46.2% of participants experienced symptoms of depression [56].
In respect to anxiety, the results of the current study found that 235 of respondents (23.7%) (GAD-7 score ≥ 10) had moderate to severe symptoms of anxiety, whereas 331 of participants (33.1%) had mild symptoms of anxiety. However, 431 (43.1%) of participants did not experience any symptoms of anxiety. These findings indicated that approximately a quarter of respondents in this study suffered from anxiety symptoms during the COVID-19 pandemic, which was associated with PTSD. In comparison with previous reports, 29.5% of participants experienced symptoms of anxiety [58], 14% of respondents had anxiety [36], 13.9% of responses indicated anxiety symptoms [52], and 19% of respondents suffered from anxiety symptoms [56].
Insomnia was one of the psychological impacts of the COVID-19 pandemic. The results of the current study found that 515 (51.5%) among participants experienced symptoms of insomnia based on the Insomnia Severity Index (ISI) (total score ≥ 8). In addition, 484 (48.4%) of participants reported that they did not experience insomnia symptoms during the pandemic. These findings revealed that the prevalence rate of insomnia symptoms was more than half of the total participants who responded to the questionnaire. Likewise, Janati Idrissi et al. [58] reported that 56.0% of participants suffered from insomnia symptoms, whereas Zhang et al. [59] inferred that the prevalence rate of insomnia among respondents was 36.1%. The highest rate of insomnia prevalence indicated the significant effect of the COVID-19 pandemic on communities' psychological quality and lifestyle during and in the aftermath of a pandemic. Therefore, these results confirmed the correlation between suffering from insomnia, depression, and anxiety.
On the other hand, groups with PTSD and without PTSD on psychological outcomes as items, DIF results indicated psychological outcomes work equivalently with participants with PTSD and without PTSD. Hence, both groups of participants perceived items of psychological outcomes equivalently. These are true for all psychological outcomes (PHQ-9, GAD-7, and ISI), reflecting measurement invariance and validation of three scales simultaneously. The equivalent results between the two groups (with PTSD and without PTSD) indicated that the instruments used for measuring the psychological outcomes were accurate and carefully prepared by professional experts and consistently with the previous studies d as well [32, 60, 61].
Differential item functioning (DIF) was found for two items from PHQ-9 (item7 and 8) and two items from ISI (item5 and 6). Differentially functional objects might cause measurement bias; thus, they should be removed or modeled as if they were given to various groups separately. Particularly, one apparent technique for eliminating DIF is to amend or remove DIF items from existing scales and test for DIF regularly when new measures are created. Another option for dealing with DIF is to simulate it [50].
According to Stojanov et al., the COVID-19 pandemic can induce various psychological consequences on people, particularly health care professionals, such as stress, anxiety, depression, insomnia [18]. Therefore, relevant stakeholders, including education authorities, need to establish online portals and web-based programs to offer information and other instructional activities throughout the epidemic [62, 63]. Moreover, young people are more receptive to smart devices [64], so the health agencies could consider offering electronic or smartphone-based psycho-education and psychiatric therapies (e.g., cognitive behavior therapy, CBT) to lower the risk of viral spread during face-to-face treatment [15, 65]. Therefore, this study recommends providing precise interventions and psychological support to individuals and communities suffering from the repercussions of psychological impact/ PTSD of the COVID-19 during and after the pandemic's outbreak.
4.1. Strengths and Limitations
This research has four significant novelties at least. The IES-R for COVID-19 is an essential tool for screening distress or traumatic event. One of the vital contributions is to the validity and utilization of the IES-R and for COVID-19 impact. Moreover, the result of the current study provides evidence for the validity of psychological outcomes particularly, depression (PHQ-9), anxiety (GAD-7), and insomnia (ISI). The validation of this research instrument is essential in cross-disciplinary disciplines such as mental health, psychology, public health, and medicine.
IES-R for COVID-19 impact has significant effects on psychological outcomes; particularly, depression (HP-9), anxiety (GAD-7), and insomnia (ISI) at the level of latent constructs (IES-R for COVID-19 and psychological outcomes) and individual factors (intrusion, avoidance, and hyperarousal dimensions with depression, anxiety, and insomnia).
The findings show that items related to depression (PHQ-9), anxiety (GAD-7), and insomnia (ISI) differ among groups validating the scales. There were just a few things that needed to be changed, altered, or modeled. The applications of the Structural Equation Model for MIMIC and MIMIC for DIF are described in a simple and easy-to-understand manner, avoiding the complications of these tools.
Although there are strengths for this research, it has various limitations: 1) this study was performed entirely online. Because of the long working hours and social segregation regulations of health care professionals, it could only be studied cross-sectionally and not longitudinally, 2) the data was acquired only through using an online survey, while interviews; either structured or semi-structured, could not be actualized, 3) the study's findings may not be generalizable due to a lack of a robust sampling frame [66]. However, the researchers opted to conduct the research believing that it is critical to document the secondary traumatization experienced by health care providers and the general public during the COVID process.
Next, healthcare professionals' mental health problems may worsen or improve over time depending on the pandemic's trajectory. As a result, more research into the long-term psychological repercussions of this group is recommended. Several demographic variables, levels of psychological outcomes (e.g., normal, low, moderate, and high), and multi-countries variables are not covered in this research as too many other variables. For example, the level of gender can be assessed to test DIF.
From a practical perspective, uniform DIF and nonuniform DIF are probably the easiest to conceptualize within MIMIC framework; however, these issues are not widely discussed in the current study, so it is considered one of the limitations.