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Examination of individuals' depression, anxiety, and stress levels during the COVID-19 pandemic in Turkey

      Hıghlıghts

      • It was determined that women, those who are single, those who have no children and do not work are more depressed, anxious and stressed.
      • Those who were not vaccinated, did not receive healthcare and were not satisfied with healthcare were more depressed, anxious, and stressed.
      • The agreement between all DASS-21 sub-dimensions and participants' feeling is poor in terms of Cohen's kappa. The agreement is poor in the anxiety sub dimension, but moderate in the other sub-dimensions in terms of Gwet's AC1.

      Abstract

      Purpose

      This research was conducted to determine the depression, anxiety, and stress levels of individuals during the COVID-19 epidemic. In addition, the compatibility of the Depression-Anxiety-Stress Scale (DASS-21) scale results with the participants' feeling depressed, anxious, and stressed were examined.

      Design and methods

      The sample of the study consisted of 870 individuals over the age of 18 between May–August 2021. The data of the study were collected online, using the personal information form and DASS-21.

      Results

      In our study, it was observed that 22.3 % of the participants were severely depressed, 19.0 % were highly anxious and 14.3 % were highly stressed. In addition, a relationship was determined between many sociodemographic variables and depression, anxiety, and stress levels. It was found that individuals who were not vaccinated, did not receive health care, and were not satisfied with health care were more depressed, anxious, and stressed. The agreement between all DASS-21 sub-dimensions and participants' feeling is poor in terms of Cohen's kappa. The agreement is poor in the anxiety sub dimension, but moderate in the other sub-dimensions in terms of Gwet's AC1.

      Practice implications

      It is recommended that nurses develop new care and evaluation strategies for the psychosocial field in order to protect and maintain the health of individuals during the COVID-19 pandemic process, as well as more practices promoting the COVID-19 vaccine in our country.

      Keywords

      Introduction

      The new coronavirus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus (SARS-CoV), broke out in Wuhan, China in 2019 and quickly affected the whole world, and the situation was declared as a global pandemic (;
      • Lai C.C.
      • Shih T.P.
      • Ko W.C.
      • Tang H.J.
      • Hsueh P.R.
      Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and corona virus disease-2019 (COVID-19): The epidemic and the challenges.
      ). Many measures have been taken so far to control the spread of the COVID-19 pandemic all over the world. While these measures differ among countries, common initiatives include social distancing, lockdown, and stay-at-home (
      • Lin C.Y.
      Social reaction toward the 2019 novel coronavirus (COVID-19).
      ;
      • Pakpour A.H.
      • Griffiths M.D.
      The fear of COVID-19 and its role in preventive behaviors.
      ). Following the first case in Turkey, necessary precautions were taken on March 11, 2020. Despite the measures taken and the policies followed by the country, the number of cases and deaths has gradually increased. In the current situation report in our country, which is currently experiencing the fourth wave, the number of cases is 9.482.550; the number of deaths is recorded as 82.361 (
      Republic of Turkey Ministry of Health
      Information Platform, Daily COVID-19 Table.
      ).
      Factors such as the rapid spread of the COVID-19 epidemic and its high morbidity rate, the emergence of new variants, the lack of concrete information about the effectiveness of the vaccine, the start of the fourth wave, lifestyle changes, social isolation, and online work has caused psychological problems on individuals as well as physical ones (
      • Huang Y.
      • Zhao N.
      Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 epidemic in China: A web-based crosssectional survey.
      ;
      • Qiu J.
      • Shen B.
      • Zhao M.
      • Wang Z.
      • Xie B.
      • Xu Y.
      A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations.
      ;
      • Rajkumar R.P.
      COVID-19 and mental health: A review of the existing literature.
      ;
      • Torales J.
      • O’Higgins M.
      • Castaldelli-Maia J.M.
      • Ventriglio A.
      The outbreak of COVID-19 coronavirus and its impact on global mental health.
      ). In a systematic review, it was determined that intense stress, depression, and anxiety were experienced during the pandemic (
      • Xiong J.
      • Lipsitz O.
      • Nasri F.
      • Lui L.M.V.
      • Gill H.
      • Phan L.
      • Mclntyre R.S.
      Impact of COVID-19 pandemic on mental health in the general population: A systematic review.
      ). In another study, it was observed that individuals' fear, anxiety, and stress levels increased especially during the emergence of the pandemic and the increase in the number of cases (
      • Rajkumar R.P.
      COVID-19 and mental health: A review of the existing literature.
      ). In addition, it is emphasized that individuals who experience depression, anxiety, and stress during the pandemic period resort to alcohol consumption, have eating disorders, domestic violence, and insomnia problems (
      • Bradbury-Jones C.
      • Isham L.
      The pandemic paradox: The consequences of COVID-19 on domestic violence.
      ;
      • Usher K.
      • Bhullar N.
      • Durkin J.
      • Gyamfi N.
      • Jackson D.
      Family violence and COVID-19: Increased vulnerability and reduced options for support.
      ;
      • Vuillier L.
      • May L.
      • Greville-Harris M.
      • Surman R.
      • Moseley R.L.
      The impact of the COVID-19 pandemic on individuals with eating disorders: The role of emotion regulation and exploration of online treatment experiences.
      ).
      WHO emphasizes that high levels of depression, anxiety, and stress can weaken the body's immunity and reduce protection against the virus (). For this reason, it is of critical importance to address the mental health of individuals as well as their physical health levels during the pandemic period. The fact that Turkey is among the top 10 countries with the highest number of COVID-19 cases has made us think that the mental health of individuals should be addressed during the pandemic period (
      • Özdin S.
      • Bayrak
      • Özdin Ş.
      Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: The importance of gender.
      ). Based on this idea, our study aimed to determine the depression, anxiety, and stress levels experienced by individuals over the age of 18 living in Turkey during the COVID-19 process. In addition, Depression Anxiety Stress Scale (DASS-21) results and the concordance of participants' feeling depressed, anxious, and stressed were examined.

      Design and methods

      Design

      This study was cross-sectional in order to determine the depression, anxiety, and stress levels of individuals during the COVID-19 epidemic. In addition, the participants were asked how they felt about their depressive, anxiety, and stress situations and it was examined whether it was compatible with the results obtained from the DASS-21 scale.
      Inter-rater agreement is a very important issue in clinical research. Cohen's kappa statistic is a widely used statistic to test the agreement between two raters/diagnostic tests/methods/scales, where the variable of interest is nominal. Some researchers have stated that the kappa statistic is affected by the prevalence and bias index in the population. This problem is called the “Kappa paradox” by Feinstein and Cicchetti (
      • Cicchetti D.V.
      • Feinstein A.R.
      High agreement but low kappa: II.Resolving the paradoxes.
      ;
      • Wongpakaran N.
      • Wongpakaran T.
      • Wedding D.
      • Gwet K.L.
      A comparison of Cohen's Kappa and Gwet's AC1 when calculating inter-rater reliability coefficients: A study conducted with personality disorder samples.
      ). Gwet suggested using the AC1 statistic as a “paradox-resistant” alternative to the Unstable Kappa statistic (
      • Gwet K.L.
      Handbook of Inter-Rater Reliability. The definitive guide to measuring the extent of agreement among raters.
      ;
      • Cicchetti D.V.
      • Feinstein A.R.
      High agreement but low kappa: II.Resolving the paradoxes.
      ). In addition, in the study conducted by
      • Kanık E.A.
      • Orekici Temel G.
      • Erdoğan S.
      • Ersöz Kaya I.
      Comparison of agreement statistics in case of multiple-raters and diagnostics test being categorical: A simulation study.
      , it was revealed that Gwet's AC1 statistic was not affected by sensitivity, selectivity, prevalence, bias index, and a number of categories and performed better (
      • Kanık E.A.
      • Orekici Temel G.
      • Erdoğan S.
      • Ersöz Kaya I.
      Comparison of agreement statistics in case of multiple-raters and diagnostics test being categorical: A simulation study.
      ).

      Population and sample of the study

      The population of the study consisted of individuals over the age of 18 living in Turkey. The convenience sampling method, one of the non-probability sampling methods, was preferred for sample selection. In the research, 921 participants were reached by using an online survey between May–August 2021. Individuals under the age of 18 who filled out the online questionnaire or entered incorrect data were not included in the study, and a total of 870 participants from 54 cities in Turkey formed the sample of the study.
      Criteria for inclusion on the study were as follows: agreeing to participate in the study, being able to read and write Turkish, being open to communication, being aged over 18 years, being able to use a smart phone or computer, filling the online questionnaire between May–August 2021 completely and without errors.

      Data collection tools

      The research data were collected through an online questionnaire consisting of two parts, the “Personal Information Form” and the DASS-21 prepared by the researchers.

      Personal information form

      The personal information form includes the introductory information of individuals and the characteristics of the COVID-19 process.

      Depression Anxiety Stress Scale-21 (DASS-21)

      DASS-21, which was developed by Lovibond and Lovibond in 1995, was used in the study to determine the depression, anxiety, and stress levels of individuals during the COVID-19 epidemic. DASS-21 was adapted into Turkish by Sarıçam in
      • Sarıçam H.
      The psychometric properties of Turkish version of Depression Anxiety Stress Scale-21 (DASS-21) in health control and clinical samples.
      . DASS-21, which has three sub-dimensions as depression, anxiety, and stress, is in 4-point Likert type. Evaluation of the scale is made over sub-dimensions. Accordingly, it is categorized as: the depression subscale was normal (0–4 points), mild/moderate (5–10), and severe/very severe (11+); anxiety subscale is normal (0–3 points), mild/moderate (4–7) and severe/very severe (8+), and stress subscale is normal (0–7 points), mild/moderate (8–12) and severe/very severe (13+). Test-retest correlation coefficients of DASS-21 in normal samples are 0.68 for depression sub-dimension, 0.66 for anxiety sub-dimension, and 0.61 for stress sub-dimension (
      • Sarıçam H.
      The psychometric properties of Turkish version of Depression Anxiety Stress Scale-21 (DASS-21) in health control and clinical samples.
      ). In our study, the Cronbach's alpha internal consistency coefficient of the scale was calculated as 0.91 for the depression sub-dimension, 0.84 for the anxiety sub-dimension, and 0.89 for the stress sub-dimension.

      Ethical considerations

      Ethical permission was obtained from Mersin University, Social and Human Sciences Ethics Committee (18/05/2021-06) to conduct this research. For the DASS-21used in the study, written permission was obtained from the author, who adapted the scale into Turkish, via e-mail and the study was carried out in accordance with the Helsinki Declaration principles. Each participant received a copy of the informed consent in the invitation e-mail. In order to access the online questionnaire, participants needed to give their consent. Participants were asked to mark the statement “I agree to participate in the study” if they agreed to participate in the study. The participants were told that participation in the study was on a voluntary basis. Participants who completed the data collection form online were deemed to have agreed to participate in the study.

      Statistical analysis

      Normality controls of continuous variables were tested with the Shapiro Wilk test. Independent Samples t-test and Variance Analysis test were used for the differences between the scale scores, sociodemographic characteristics, and the characteristics in the COVID-19 process. Homogeneity of variances was tested with Levene's test. One Way ANOVA test was used in case of homogeneity of variance, and Bonferroni test was used for paired comparisons. When the homogeneity of the variances could not be achieved, the differences among the groups were tested with the Welch test and paired comparisons were tested with the Games Howell test. Mean and standard deviation values are given as descriptive statistics. Spearman correlation coefficient was used for the relationship between scale scores and age. Cohen's kappa and Gwet's AC1 statistics were used to determine the agreement between the results obtained from the DASS-21 scale and how the participants felt in terms of depression, anxiety, and stress. Statistical significance value was accepted as p < 0.05.

      Results

      It was determined that 68.2 % of the participants were female, 31.8 % were male, and the mean age was 33.6 ± 12.2. It was determined that 45.7 % of the participants were married, 43 % had children, and 82.6 % had university and postgraduate education. In addition, 54.9 % of the participants have a profession, while 17.2 % of them work as health staff. It was found that 55.6 % of the participants had an income equal to their expenses, 87.5 % had social security, 69.4 % lived in the city center and 28.4 % smoked. When the blood groups of the participants were examined, it was found that 43.2 % had A blood group, 32 % had 0 blood group, 16.6 % had B blood group and 8 % had AB blood group. In addition, it was determined that 13.4 % of the participants had a chronic disease and 14.4 % of the participants with a chronic disease had more than one chronic disease.
      It was determined that 50.9 % of the participants included in the study had been vaccinated, 38.4 % of those who had been vaccinated were tested, and 21.8 % of these individuals had positive test results. It was determined that 36.8 % of those who did not have the vaccine were tested and 40.8 % of these individuals had positive test results.
      The average scores of participants from DASS-21; It was found to be 7.4 ± 4.8 in the depression sub-dimension, 4.7 ± 3.6 in the anxiety sub-dimension, and 7.5 ± 4.4 in the stress sub-dimension (Table 1). When the relationship between age and DASS-21 sub-dimensions is examined, it is seen that as age increases, depression (r = −0.325), anxiety (r = −0.267) and stress (r = −0.302) levels decrease (all p values <0.001). It was determined that 22.3 % of the participants experienced severe depression, 19.0 % experienced severe anxiety and 14.3 % experienced severe stress.
      Table 1Distribution of DASS 21 sub-dimensional scores.
      Dimensions of scalesNumber of itemsMin-maxX¯±SSCronbach α
      Depression70–217.0 ± 4.70.91
      Anxiety70–194.6 ± 3.60.84
      Stress70–217.4 ± 4.40.89
      When the agreement between DASS-21 sub-dimensions and participants feeling depressed, anxious, and stressed is examined, it is seen that there is a poor agreement in the depression, anxiety, and stress sub-dimensions in terms of Cohen's kappa statistics. When Gwet's AC1 statistic is examined, it is seen that there is a poor agreement only in the anxiety sub-dimension, but a moderate agreement in the depression and stress sub-dimensions. In addition, 83.6 % of participants who are depressed, anxious, and stressed at a normal level, in reality, describe themselves as normally depressed, 70.6 % with normal anxiety, and 63.7 % as normally stressed (Table 2).
      Table 2Agreement statistics for depression, anxiety and stress sub-dimension.
      DASS-21 depression sub-dimension
      NormallyMild/moderateSevere/very severeCohen's Kappa

      (p)
      Gwet's AC1
      NumberPercentageNumberPercentageNumberPercentage
      DepressionNormally22583.616039.32512.90.378

      (<0.001)
      0.420
      Mild/moderate4215.621653.18644.3
      Severe/very severe20.7317.68342.8
      DASS-21 anxiety sub-dimension
      NormallyMild/moderateSevere/very severeCohen's Kappa

      (p)
      Gwet's AC1
      NumberPercentageNumberPercentageNumberPercentage
      AnxietyNormally25970.612637.31810.90.314

      (<0.001)
      0.374
      Mild/moderate9225.116548.87545.5
      Severe/very severe164.44713.97243.6
      DASS-21 stress sub-dimension
      NormallyMild/moderateSevere/very severeCohen's Kappa

      (p)
      Gwet's AC1
      NumberPercentageNumberPercentageNumberPercentage
      StressNormally31263.74517.632.40.344

      (<0.001)
      0.404
      Mild/moderate15732.012348.04435.5
      Severe/very severe214.38834.47762.1
      It was determined that participants who were women, single, with no children, unemployed, with no social security, and with lower income than expenditure were more depressed, anxious, and stressed. It was found that the participants who were health staff had higher anxiety levels (all p values p < 0.05) (Table 3).
      Table 3Distribution of the average scores of the DASS-21 sub-dimension according to descriptive characteristics.
      DepressionAnxietyStress
      GenderFemale (n = 593)7.3 ± 4.75.0 ± 3.77.9 ± 4.4
      Male (n = 277)6.4 ± 4.94.0 ± 3.46.7 ± 4.4
      t2.5373.9343.733
      P0.011<0.001<0.001
      Marital statusMarried (n = 398)5.5 ± 4.13.7 ± 3.26.2 ± 4.0
      Single (n = 472)8.3 ± 5.05.5 ± 3.78.6 ± 4.5
      t−9.139−7.689−8.120
      P<0.001<0.001<0.001
      Status of having childrenYes (n = 374)5.6 ± 4.03.8 ± 3.26.3 ± 3.9
      No (n = 496)8.1 ± 5.15.3 ± 3.88.4 ± 4.6
      t−8.207−6.515−7.190
      P<0.001<0.001<0.001
      Educational levelPrimary education (n = 25)5.7 ± 3.33.4 ± 2.56.8 ± 3.3
      High school (n = 126)7.4 ± 4.94.8 ± 3.97.9 ± 4.5
      University and above (n = 719)7.0 ± 4.84.7 ± 3.67.5 ± 4.4
      F1.3051.5370.883
      P0.2720.2160.414
      Working statusEmployed (n = 478)6.0 ± 4.44.1 ± 3.46.6 ± 4.3
      Unemployed (n = 392)8.3 ± 5.05.4 ± 3.78.6 ± 4.4
      t−7.018−5.736−6.620
      P<0.001<0.001<0.001
      Working status as health employeeYes (n = 82)6.8 ± 4.34.8 ± 3.47.2 ± 4.0
      No (n = 396)5.9 ± 4.43.9 ± 3.46.5 ± 4.3
      t1.7562.0871.365
      P0.0800.0370.173
      Income levelIncome is less than expenses (n = 161)8.2 ± 5.05.4 ± 3.78.4 ± 4.5
      Income is equal to expense (n = 484)7.2 ± 4.74.7 ± 3.57.6 ± 4.3
      Expenses are less than income (n = 225)5.9 ± 4.6
      Shows differences with the first category.
      Shows differences with the second category.
      4.1 ± 3.6
      Shows differences with the first category.
      6.6 ± 4.5
      Shows differences with the first category.
      Shows differences with the second category.
      F11.5206.4177.830
      P<0.0010.002<0.001
      Social securityYes (n = 761)6.9 ± 4.74.6 ± 3.67.3 ± 4.4
      No (n = 109)8.2 ± 5.05.4 ± 4.08.6 ± 4.3
      t−2.636−2.199−2.804
      P0.0090.0280.005
      Living settlement unitVillage/town (n = 32)6.9 ± 5.24.5 ± 3.77.5 ± 4.5
      District (n = 234)7.1 ± 4.74.5 ± 3.57.4 ± 4.4
      Province (n = 604)7.0 ± 4.84.7 ± 3.77.5 ± 4.4
      F0.0230.3240.091
      P0.9770.7240.913
      Smoking statusYes (n = 247)7.2 ± 5.04.9 ± 3.87.6 ± 4.6
      No (n = 623)7.0 ± 4.74.6 ± 3.57.4 ± 4.3
      t0.6611.2330.557
      P0.5090.2180.578
      Blood groupA (n = 376)6.9 ± 4.74.5 ± 3.57.4 ± 4.2
      B (n = 144)7.6 ± 5.15.1 ± 3.98.0 ± 4.9
      AB (n = 70)6.6 ± 5.04.4 ± 3.96.9 ± 4.2
      0 (n = 280)7.1 ± 4.74.8 ± 3.57.6 ± 4.4
      F0.9711.2291.303
      P0.4060.2980.272
      The bold values show p < 0.05.
      a Shows differences with the first category.
      b Shows differences with the second category.
      Table 4 includes the evaluation of the DASS-21 sub-dimension scores of the participants according to the characteristics of the COVID-19 process. Accordingly, it was determined that the depression, anxiety, and stress levels of the participants who were not vaccinated, did not receive adequate health services, and were not satisfied with the health service were higher. In addition, it was found that participants who were in contact with a COVID-19 positive person and who did not have social support after being diagnosed with COVID-19 had higher levels of anxiety, while those who did not have a chronic disease had higher depression levels (all p values p < 0.05).
      Table 4Distribution of DASS-21 sub-dimension scores by characteristics in the COVID-19 process.
      DepressionAnxietyStress
      Having a chronic diseaseYes (n = 117)6.2 ± 4.64.7 ± 3.67.1 ± 4.0
      No (n = 753)7.2 ± 4.84.7 ± 3.67.6 ± 4.5
      t−2.0770.086−1.275
      P0.0380.9320.204
      Contact with a COVID-19 positive personYes (n = 273)7.3 ± 4.95.1 ± 3.77.6 ± 4.3
      No (n = 597)6.9 ± 4.74.5 ± 3.67.5 ± 4.5
      t1.1012.0340.476
      P0.2710.0420.634
      VaccinationDone (n = 443)6.0 ± 4.14.0 ± 3.36.6 ± 4.0
      Not Done(n = 427)8.2 ± 5.15.4 ± 3.98.5 ± 4.7
      t−6.980−5.515−6.527
      P<0.001<0.001<0.001
      Social support after diagnosisReceive (n = 69)6.2 ± 4.74.3 ± 3.46.9 ± 4.2
      Not receive (n = 32)8.3 ± 5.16.4 ± 3.98.3 ± 4.6
      t−1.978−2.666−1.561
      P0.0510.0090.122
      Getting enough health care deliveryYes (n = 85)6.4 ± 4.54.4 ± 3.46.8 ± 4.1
      No (n = 17)9.5 ± 5.88.1 ± 3.610.2 ± 4.7
      t−2.480−4.054−3.058
      P0.015<0.0010.003
      Satisfaction with health care servicesYes (n = 79)6.3 ± 4.64.4 ± 3.46.9 ± 4.0
      No (n = 22)9.0 ± 5.57.2 ± 3.99.2 ± 4.9
      t−2.327−3.275−2.226
      P0.0220.0010.028
      The bold values show p < 0.05.

      Discussion

      In our study, the depression, anxiety, and stress levels of the participants were mild/moderate. In addition, 22.3 % of the participants had severe depression, 19.0 % had severe anxiety and 14.3 % had severe stress. Another interesting finding in the study is that there is a poor agreement (p = 0.374) between the scores obtained from the DASS-21 sub-dimensions and the state of individuals feeling anxious, while there is a moderate agreement in terms of depression and stress levels (p values; 0.420 and 0.404, respectively). In the adjustment statistics, individuals who were actually severely/very severely depressed, anxious, and stressed reported themselves as depressed at a rate of 42.8 %, as anxious at a rate of 43.6 %, and as stressed at a rate of 62.1 %, respectively.
      The study of Togluk
      • Yiğitoğlu E.T.
      • Karadede H.
      • Karadede Ö.
      • Karaali R.
      • Aydın E.
      COVID-19 tanılı bireylerin anksiyete ve depresyon düzeylerinin belirlenmesi.
      found that 44.67 % of individuals diagnosed with COVID 19 were at high risk for depression and 20.81 % for anxiety(
      • Yiğitoğlu E.T.
      • Karadede H.
      • Karadede Ö.
      • Karaali R.
      • Aydın E.
      COVID-19 tanılı bireylerin anksiyete ve depresyon düzeylerinin belirlenmesi.
      ).In the study of
      • Verma S.
      • Mishra A.
      Depression, anxiety, and stress and socio-demographic correlates among general Indian public during COVID-19.
      with the general population in India, 25 %, 28 % and 11.6 % of the participants were found to be moderately to severely depressed, anxious, and stressed, respectively(
      • Verma S.
      • Mishra A.
      Depression, anxiety, and stress and socio-demographic correlates among general Indian public during COVID-19.
      ).In a study conducted during the first seven months of the COVID-19 pandemic, the prevalence of depression was determined as 20 %, the prevalence of anxiety as 35 %, and the prevalence of stress as 53 % (
      • Lakhan R.
      • Agrawal A.
      • Sharma M.
      Prevalence of depression, anxiety, and stress during COVID-19 pandemic.
      ).In another study, the interaction between pre-existing mental health status and waves was found to be statistically different. Accordingly, the rate of showing depressive symptoms in the 2nd and 3rd waves compared to the 1st wave gradually decreased (
      • O'Connor R.C.
      • Wetherall K.
      • Cleare S.
      • McClelland H.
      • Melson A.J.
      • Niedzwiedz C.L.
      • Robb K.A.
      Mental health and well-being during the COVID-19 pandemic: Longitudinal analyses of adults in the UK COVID-19 Mental Health & Wellbeing study.
      ). Studies show that individuals have different levels of psychological symptoms. The reason why individuals showed relatively lower levels of symptoms in our study compared to other studies and that they felt different in terms of their mental state may be related to the time interval in which the study was conducted. The data of the current study were collected in the third wave of the COVID-19 pandemic in our country. During this period, we can think that individuals who depend on the removal of restrictions to a large extent become freer, get used to the new normal process, and therefore do not see mental problems as “a problem anymore”. In addition, we can say that the initiation of COVID-19 vaccine applications is an important factor in protecting the mental state of individuals.
      It was found that depression, anxiety, and stress were statistically higher in women (p values 0.011 and <0.001, respectively). At the same time, it was determined that as the age increased, the depression, anxiety, and stress levels of the individuals decreased (r = −0.325, p < 0.001; r = −0.267, p < 0.001; r = −0.302, p < 0.001, respectively).
      • Khademian F.
      • Delavari S.
      • Koohjani Z.
      • Khademian Z.
      An investigation of depression, anxiety, and stress and its relating factors during COVID-19 pandemic in Iran.
      , in a study conducted in Iran, found women's anxiety levels to be higher than men's (
      • Khademian F.
      • Delavari S.
      • Koohjani Z.
      • Khademian Z.
      An investigation of depression, anxiety, and stress and its relating factors during COVID-19 pandemic in Iran.
      ).
      • Hyland P.
      • Shevlin M.
      • McBride O.
      • Murphy J.
      • Karatzias T.
      • Bentall R.P.
      • Vallières F.
      Anxiety and depression in the Republic of Ireland during the COVID-19 pandemic.
      , found that the risk of anxiety or depression decreases as age increases, while the risk of depression or anxiety is approximately 1.5 times higher in women than in men (
      • Hyland P.
      • Shevlin M.
      • McBride O.
      • Murphy J.
      • Karatzias T.
      • Bentall R.P.
      • Vallières F.
      Anxiety and depression in the Republic of Ireland during the COVID-19 pandemic.
      ). Unlike our study,
      • Verma S.
      • Mishra A.
      Depression, anxiety, and stress and socio-demographic correlates among general Indian public during COVID-19.
      study found that men are at twice the risk of women than women. In the same study, no significant difference was found in mental status symptoms in terms of age (
      • Verma S.
      • Mishra A.
      Depression, anxiety, and stress and socio-demographic correlates among general Indian public during COVID-19.
      ). Similar results have been obtained in many studies. In this context, more results have been obtained for the symptoms of mental status (post-traumatic stress disorder, depression, anxiety, insomnia, etc.) of women and young individuals during the COVID 19 process (
      • Rossi R.
      • Socci V.
      • Talevi D.
      • Mensi S.
      • Niolu C.
      • Pacitti F.
      • Di Lorenzo G.
      COVID-19 pandemic and lockdown measures impact on mental health among the general population in Italy.
      ;
      • Stanton R.
      • To Q.G.
      • Khalesi S.
      • Williams S.L.
      • Alley S.J.
      • Thwaite T.L.
      • Vandelanotte C.
      Depression, anxiety and stress during COVID-19: Associations with changes in physical activity, sleep, tobacco and alcohol use in Australian adults.
      ;
      • Wang C.
      • Tee M.
      • Roy A.E.
      • Fardin M.A.
      • Srichokchatchawan W.
      • Habib H.A.
      • Kuruchittham V.
      The impact of COVID-19 pandemic on physical and mental health of Asians: A study of seven middle-income countries in Asia.
      ). It can be thought that these findings obtained in our study may be due to the fact that women are more sensitive to mental problems than men and that their expressions are higher. In addition, as the age increases, the decrease in mental health problems can be associated with the fact that the social life of the elderly individuals is more limited than the young people due to their retirement, they spend most of their daily lives at home, and therefore they are not adversely affected by the pandemic as much as the young people.
      It was found that single individuals and individuals without children had higher depression, anxiety, and stress levels than other individuals (all p values <0.001). Similar to our study, in a study conducted by
      • Wang C.
      • Tee M.
      • Roy A.E.
      • Fardin M.A.
      • Srichokchatchawan W.
      • Habib H.A.
      • Kuruchittham V.
      The impact of COVID-19 pandemic on physical and mental health of Asians: A study of seven middle-income countries in Asia.
      , the depression and anxiety stress levels of the participants with children were found to be lower, while the single participants were found to be higher (
      • Wang C.
      • Tee M.
      • Roy A.E.
      • Fardin M.A.
      • Srichokchatchawan W.
      • Habib H.A.
      • Kuruchittham V.
      The impact of COVID-19 pandemic on physical and mental health of Asians: A study of seven middle-income countries in Asia.
      ). During the pandemic process, many restrictions have occurred in our country as well as all over the world. Shortly before the data of the current study were collected, the longest quarantine period in our country was experienced. Considering that individuals who are married and have children spend most of their time together in this quarantine, this finding obtained in our research can be explained by the existence and importance of social support.
      The depression, anxiety, and stress levels of the unemployed, low socioeconomic, and non-social security participants were found to be higher than the other participants (all p values <0.05). In a study conducted by
      • Wang C.
      • Tee M.
      • Roy A.E.
      • Fardin M.A.
      • Srichokchatchawan W.
      • Habib H.A.
      • Kuruchittham V.
      The impact of COVID-19 pandemic on physical and mental health of Asians: A study of seven middle-income countries in Asia.
      , similar to our study, it was found that individuals who did not work had higher depression and anxiety levels (
      • Wang C.
      • Tee M.
      • Roy A.E.
      • Fardin M.A.
      • Srichokchatchawan W.
      • Habib H.A.
      • Kuruchittham V.
      The impact of COVID-19 pandemic on physical and mental health of Asians: A study of seven middle-income countries in Asia.
      ). The COVID-19 pandemic has caused economic crises all over the world. In particular, individuals with low socioeconomic status may have been unemployed or their economies may have been adversely affected due to the measures taken during the pandemic. Therefore, the inability to meet their vital needs economically may have caused some mental problems in them. It is an expected result that the quality of life of individuals with low socioeconomic status will be more affected by this crisis.
      The anxiety levels of healthcare professionals were found to be higher than those working in other sectors (p = 0.037). Similarly,
      • Elbay R.Y.
      • Kurtulmuş A.
      • Arpacıoğlu S.
      • Karadere E.
      Depression, anxiety, stress levels of physicians and associated factors in COVID-19 pandemics.
      found that 64.7 % of 442 healthcare workers had depression, 51.6 % had anxiety and 41.2 % had stressed (
      • Elbay R.Y.
      • Kurtulmuş A.
      • Arpacıoğlu S.
      • Karadere E.
      Depression, anxiety, stress levels of physicians and associated factors in COVID-19 pandemics.
      ). Another study found that healthcare professionals had higher levels of anxiety and depression, as well as somatization and insomnia, compared to professionals in other fields (
      • da Silva Neto R.M.
      • Benjamim C.J.R.
      • de Medeiros Carvalho P.M.
      • Neto M.L.R.
      Psychological effects caused by the COVID-19 pandemic in health professionals: A systematic review with meta-analysis.
      ). During the pandemic process, the workload of health professionals has increased, and at the same time, they have faced risks to their physical and mental well-being (
      • Zhang W.R.
      • Wang K.
      • Yin L.
      • Zhao W.F.
      • Xue Q.
      • Peng M.
      • Wang H.X.
      Mental health and psychosocial problems of medical health workers during the COVID-19 epidemic in China.
      ). In addition, the lack of an effective treatment protocol for the virus has been one of the biggest challenges for healthcare professionals. All these have led to the development of mental problems such as anxiety, stress, and depression in healthcare workers (
      • Shigemura J.
      • Ursano R.J.
      • Morganstein J.C.
      • Kurosawa M.
      • Benedek D.M.
      Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: Mental health consequences and target populations.
      ).
      The anxiety levels of individuals with COVID-19 contact were found to be high (p = 0.042). The high contagiousness of COVID-19 and the death of many cases have caused many individuals to experience fear and anxiety (
      • Schimmenti A.
      • Starcevic V.
      • Giardina A.
      • Khazaal Y.
      • Billieux J.
      Multidimensional Assessment of COVID-19-Related Fears (MAC-RF): A theory-based instrument for the assessment of clinically relevant fears during pandemics.
      ). CDC and WHO also emphasized that this situation is increasingly overwhelming and individuals experience strong emotions (;
      World Health Organization
      Mental health and psychosocial considerations during the COVID-19 outbreak, 18 March 2020.
      ). Therefore, in our study, it is an expected result that individuals, who have been in contact at least once, feel such emotions.
      In addition, it was determined that individuals who were not vaccinated had higher depression, anxiety, and stress levels than other individuals (all p values <0.001).
      • Koltai J.
      • Raifman J.
      • Bor J.
      • McKee M.
      • Stuckler D.
      Does COVID-19 vaccination improve mental health? A difference-in-difference analysis of the Understanding Coronavirus in America study.
      , in a study conducted in the USA between March 2020 and June 2021, COVID-19 vaccination status was associated with a reduced risk of distress, perceived infection, hospitalization, and death (
      • Koltai J.
      • Raifman J.
      • Bor J.
      • McKee M.
      • Stuckler D.
      Does COVID-19 vaccination improve mental health? A difference-in-difference analysis of the Understanding Coronavirus in America study.
      ). The purpose of the COVID 19 vaccine, like other vaccines, is to prevent serious and life-threatening infections, hospitalizations, and deaths. Some of the COVID-19 vaccines made to date have demonstrated up to 95 % efficacy in preventing symptomatic COVID-19 infections (
      • Banerjee D.
      • Mukhopadhyay S.
      • Asmeen M.S.
      • Javed A.
      COVID-19 vaccination: Crucial roles and opportunities for the mental health professionals.
      ). Although vaccination in our country started in January 2021, intensive vaccination applications have been carried out since April 2021. Therefore, considering the data collection time of our study, it can be thought that vaccination applications positively affect the psychological well-being of individuals.
      The depression, anxiety, and stress levels of the individuals who did not receive adequate service from health services after diagnosis and were not satisfied with the health services they received were found to be higher than the other individuals (all p values <0.05). Similarly, according to
      • Isautier J.M.
      • Copp T.
      • Ayre J.
      • Cvejic E.
      • Meyerowitz-Katz G.
      • Batcup C.
      • McCaffery K.J.
      People's experiences and satisfaction with telehealth during the COVID-19 pandemic in Australia: cross-sectional survey study.
      , it was determined that individuals with a history of both depression and anxiety decreased their satisfaction in their health service purchases (
      • Isautier J.M.
      • Copp T.
      • Ayre J.
      • Cvejic E.
      • Meyerowitz-Katz G.
      • Batcup C.
      • McCaffery K.J.
      People's experiences and satisfaction with telehealth during the COVID-19 pandemic in Australia: cross-sectional survey study.
      ). In another study, it was found that individuals who were dissatisfied with access to health services avoided getting vaccinated (
      • Bass S.B.
      • Wilson-Genderson M.
      • Garcia D.T.
      • Akinkugbe A.A.
      • Mosavel M.
      SARS-CoV-2 vaccine hesitancy in a sample of US adults: Role of perceived satisfaction with health, access to healthcare, and attention to COVID-19 news.
      ). As in past epidemics (Ebola virus and SARS), reduced health services have been associated with poor health outcomes during pandemics (
      • Wang S.Y.
      • Chen L.K.
      • Hsu S.H.
      • Wang S.C.
      Health care utilization and health outcomes: A population study of Taiwan.
      ;
      • Wilhelm J.A.
      • Helleringer S.
      Utilization of non-Ebola health care services during Ebola outbreaks: A systematic review and meta-analysis.
      ). Based on this information, this finding obtained from our research can be explained by the fact that individuals may have experienced the same situation during the COVID-19 process and therefore are not sufficiently satisfied with health care services.

      Conclusion

      It was observed that 22.3 % of the participants were severely depressed, 19.0 % had severe anxiety and 14.3 % were highly stressed. It has been determined that women are more depressed, anxious, and stressed than men, singles are more than married, have no children, those who do not work are more depressed than those who do not have social security. In addition, it was determined that the health workers only had higher anxiety levels than the other participants. When examined in terms of income, it was observed that depression, anxiety, and stress scores decreased as the income level improved. Finally, it was found that those who were not vaccinated were more depressed, anxious, and stressed than those who did not receive health care and those who were not satisfied with health care compared to those who were satisfied.

      Limitations

      This research is limited to data that can be accessed for two months, with internet access and using digital tools such as smartphones, computers, tablets, etc. to fill in the data collection tools.

      Implications for nursing practice

      The COVID-19 pandemic has deeply affected the mental health of individuals in Turkey as well as all over the world. The long duration of the pandemic process and the incomplete vaccination still continue to negatively affect the depression, anxiety, and stress levels of individuals. In this direction, during the COVID-19 pandemic,
      Recommendations for nurses include
      • 1)
        Evaluate individuals accurately in terms of depression, anxiety, and stress
      • 2)
        Teach individuals new strategies to improve coping with these mental problems
      • 3)
        Provide individuals with more education and information about the COVID-19 vaccination.

      Funding

      None.

      Data availability

      The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

      CRediT authorship contribution statement

      All of the authors declare that they have all participated in the design, execution, and analysis of the paper, and that they have approved the final version. Study design were performed by (SE, AAC, AA, DVY); Data collection were performed by (AAC, AA) and Data analysis was performed by SE and manuscript writing were performed by (SE, AAC, AA, DVY). All authors read and approved the final manuscript.

      Declaration of competing interest

      The authors declare that they have no conflicts of interest.

      Acknowledgment

      The authors gratefully thank all individuals who by their participation made this study possible.

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