This cross-sectional online survey was designed for internet users. The target population was adults between the ages of 18 and 70 years old, both Saudi and non-Saudi, living in Saudi Arabia (SA) during the first wave of the COVID-19 pandemic in 2020. Exclusion criteria included refusal to participate in the study, not using the internet, being illiterate, and being under the age of 18 or over the age of 70. Those with complicated medical or mental health conditions such as psychosis were excluded.

The first COVID-19 case in KSA was detected on March 2, 2020. At the beginning of this study, there were 65077 confirmed COVID-19 cases and 400 deaths all over the Kingdom, mainly in the Eastern Region, Mecca, and Riyadh. The study was conducted from May 2020 to July 2020 [24].

As a cross section study, the sample size was estimated according to the following equation: The sample size (n) is calculated according to the formula: n = z² * p * (1 - p) / d². Where: z = 1.96 for a confidence level (α) of 95%, p = proportion (expressed as a decimal), d = margin of error [25].

There is limited data about the prevalence of mental or emotional health disorders in Saudi Arabia during COVID-19. A previous study showed [26]. The prevalence rate for significant depression was 42.9% with a 95% confidence level and 54.9% with an 80% power of the study. With this information, the calculated sample size was 420 participants. In this study, we took double this figure, with an N of 857.

Using a multi-stage sampling method. The sample was collected from all the administrative regions and weighted per proportion of population density, and the percent of urban to rural in KSA was found to be 213 (24.9%). Riyadh, 218 (25.5%) Al-Mokaramah, 56 (6.5%); Al-Momawarah, 39 (4.5%); Al-Qassem, 125 (14.5%); and the Eastern Region, 62 (7.3%). Asser, 26 (3.0%) Tabouk, 20 (2.3%) 10 (1.2) Northern borders, 44 (5.1) Gazan, 16 (1.9%) Najran, 14 (1.6%) Al Baha, 14 (1.6%), Al Jouf. Then data from each administrative region was collected (90% from inside the city, and 10% from outside the city) [27].

The data was collected through an online self-administered, structured questionnaire. Participants completed and submitted the questionnaire after approval of participation in the study. The participants gave informed consent. The questionnaire was distributed through the most common platforms in SA (Twitter, Snap Chat, and WhatsApp groups). In addition, and to have a representative sample, we used the official platforms of every 20 Health regions all over SA.

To increase the response rate, reminder messages were sent every week until the target response figures were met. Pilot testing was done and involved 15 participants in order to ensure clarity of the questionnaire, and the results of the pilot were not included in the study. Cronbach alpha was calculated to be 0.87%.

The data were analyzed using SPSS version 25 and a level of significance (p<0.05). Qualitative data were presented as frequency and percent, while quantitative data were presented as mean± SD, median, and range. Chi2 test was used to test the association between categorical variables. T-test, ANOVA (Analysis of Variance), Kruskal Wallis test were used to test the association between quantitative variables. Pearson's correlation coefficient (r) was used to test the association between two continuous variables.

Ethics Committee of the King Fahad City, The Saudi ministry of health IRP (Exempt type) H-01-R-012, approved the study methodology. All participants provided electronic informed written consent after clarification of the goals, data confidentiality, voluntary participation, and withdrawal.

Among the studied participants, 377(44.0%) were aged between 35 and 50 years old. There were 489(57.1) females and males (42.9%). There were 616(71.9%) Saudi nationals. 715(83.4%) were university-educated or postgraduate. 619(72.2%) were unmarried. 768(89.6%) were urban. 497 (58.0%) were working in the medical field, 63(77.4%) were living in areas with a partial lockdown at the time of the study. 381(44.5) were working as before the COVID-19 pandemic. In terms of work status, nearly half of the 381 participants (44.5%) reported that their work status had not changed because of the COVID-19 pandemic. Almost three-quarters of the participants (663 or 77.4 percent) were subjected to a partial curfew (Table 1).

The total depression score was statistically significant (p<0.05) in a number of areas. The results were significant, with higher depression among participants less than 35y - 7.5(8.3 ±5.5) (0-20), females 6(7.2 ±6.4), Saudi nationals, those with lower educational levels, those who only read and write n 13(13 ±5.7)(9-17), married 8(8.6 ±6.7), students 8(8.6 ±6.7), those with work suspended 6(7.5 ±6.3) and complete lockdown 10.5(11.1 ±6.9) (Table 1).

The total anxiety score was statistically significant (p<0.05) with a higher score among participants in the age group between 20 to 30 years {4(5.1 ±5.50(0-21)}, females 3(4.8+_5.3)(0-21), Saudis 2(4.2 ±4.9)(0-21), lower education levels (read and write) 10.5(10.6 ±10.5), and unmarried 4(5.5 ±4.5), students 5(6.3 ±5.6), with Tele work 3(4.5 ±4.9) and with no curfew 7(7.8 ±3.9) (Table 1).

If there was a history of contact with someone with confirmed or suspected symptoms of COVID 19, there were significantly higher rates of depression and anxiety scores (Table 2). The main sources of information about COVID-19 among the studied participants were Scientific and official websites (83.3%), Social media (38.9%), Mass media (36.3%), and other Websites (19.4%).

There were statistically significant differences between different health regions in their total scores of anxiety and depression. The total scores were significantly higher in Al Qureat 23.1 ±2.4, Tabouk 23 ±2.9, Northern border 21.4±3.7, and Hael 21.  ±7.0 and the lowest at Hafr El Batten. The total depression scale was significantly higher in Hael 19.5 ±0.7, Mecca 12(11.6 ±6.9), Asser 12(10.3 ±6.9), Riyadh 11.5(10.9 ±6.7), and lowest were in Al Qureat 0 (3.2 ±5.3). The total anxiety scores were significantly higher in Hael 8.5(2.5 ±2.1), Riyadh 6(7.6 ±6.1), and Mecca 6(7.6±5.8), and the lowest were the Northern Border and AlQureat (Table 3).

The majority of the studied participants (> 94%) stated good knowledge about the practice of sneezing etiquette and hygienic hand washing. More than three-quarters of study participants (> 70%) mentioned the good practice of washing hands with soap and water or alcohol, keeping a safe social distance, sterilizing surfaces, wearing face masks, sanitizing purchases, and staying at home. The median of the precaution preventive COVID-19 Practice score was 20 with a range of (9-27) while (mean±SD) was 19.7±3.9 (Table 4).

The total anxiety GAD-7 scores were as follows; Median (mean ±SD) (minimum-maximum) were two (4.01±4.9) (0-21) respectively. Nearly 60% of the participants in the study had a GAD-7 score of mild to moderate anxiety, while 30.2 percent and 9.8 percent had none and severe anxiety, respectively (Table 5). The total score of depression (PHQ-9) was median (mean± SD) (minimum-maximum) was 5(6.4±6.0) (0-27) respectively. The prevalence of depression by symptom severity by the PHQ-9 was that more than 60% of study participants had mild to moderate depression, while 30.2 percent and 9.8 percent had none and severe anxiety, respectively (Table 5).

There was a positively strong significant correlation between anxiety and depression (r=0.79), with (p< 0.0001). Respondents with higher levels of anxiety were found to be more likely to use preventive measures(r=0.01) with a non-significant association p-value =0.73. Preventive measures use is inversely related to depression levels(r=-0.02) with a non-significant association p-value =0.49 (Table 6).

In terms of the British Colombia COVID-19 online Self-Assessment Tool, Table 7 shows that more than 89 percent of participants in the growth and learning zones answered yes. Furthermore, in the fear zone, more than 79 percent said no.

Table 8 showed that the main participants’ perceptions or feeling towards COVID_19 were as follows (75.1%) fear that they would infect their family, (72.7%) that the courses of the disease are in the hand of God (72.7%), and fear of COVID 19 complications as they have risk factors (25.9%).

The Emotional Contagion Scale measures the individual differences in susceptibility to catching the emotions of other individuals. Emotional contagion describes a certain sensitivity to the emotions of others and induces the individual to unintentionally 'catch' those emotions from mere exposure to others' behavior. The EC Scale shows that the highest measured emotional arousal, the congruence of emotional stimulus and response in KSA during the first wave of COVID-19 pandemic were at the following domains in descending orders; (happiness, love, Anger, sadness than fear Table 9. So we say by this that fear can be the least infectious emotion while happiness is the highest.

The age group of 35–50 years old had the highest prevalence of mental disorders. This finding is consistent with the findings of an Iranian study conducted during the COVID-19 pandemic [11], where older people had better mental health. This result, however, contradicts the findings of previous mental health surveys conducted under normal conditions [41]. This resilience among older participants may be due to the interaction of many internal factors; for example, physical health, cognitive capacity, biological response to stress, and personality traits, along with other external resources;

These results are very important for public health because of the current situation, caused by COVID-19 and the lockdown. The complete curfew was statistically significantly associated with the highest median total anxiety score of 6 and the total depression score of 12. These results are very important for public health because of the current situation, caused by COVID-19 and the lockdown that followed [42].

This puts older people at a high risk of stress. Social functionality is an important element of resilience to stress and depression. Older adults experienced significantly during the COVID-19 pandemic due to less social contact with relatives, friends, and healthcare workers; poor access to care; an interruption of daily routine activities; and poor social communication. Moreover, they are at the highest risk of death if infected. Thus, all factors that could determine resilience to stress should be investigated and studied to provide useful plans for prevention in the future [43].

Students were also found to be psychologically affected by the pandemic, with higher levels of anxiety and depression. This finding could be explained by the closure of all schools at all levels. The uncertainty and potential negative impact on academic progression may have a negative impact on student’s mental health.

The public with reading and writing skills or primary education had a higher likelihood of depression and anxiety during the pandemic, according to this study. To assist those with a lower educational background during the pandemic, local agencies must provide information in an easy-to-read, diagrammatic, or audio format using simple language [44].

We found a higher risk of mental health disorders among participants whose work was suspended or who were under a complete curfew. This is matched by an Italian study. This could be explained by COVID-19-related working difficulties [5].

According to a systematic review of the impact of the COVID-19 pandemic on mental health in the general population worldwide, anxiety is frequently comorbid with depression. Some predictors of anxiety and depression symptoms include a younger age group (40 years), lower education levels, poor self-rated health, loneliness, female gender, divorced or widowed status, quarantine status, worry about being infected, property damage, history of mental health issues or medical problems, presence of chronic illness, and living in urban areas [45]. These findings agree with ours.

In this study, only 82 (9.6 percent) and 51 (6.0%) of the respondents had direct or indirect contact with people who had confirmed or suspected COVID-19. These findings are higher than those reported in the China study, where 1 percent had a history of contact with COVID-19 cases [39]. The first COVID-19 case in KSA was detected on March 2, 2020. At the beginning of this study, there were 65077 confirmed COVID-19 cases and 400 deaths all over the Kingdom, mainly in the Eastern Region, Mecca, and Riyadh. The study was conducted from May 2020 to July 2020 [24].

During the COVID-19 pandemic, the Internet (scientific and official websites) was the main public source of health information about COVID-19 (83.3%). This finding is lower than that reported during the early stages of the COVID-19 epidemic in China, where the Internet (93.5%) was the primary health information channel for the public [37].

The vast majority of respondents (about 94%) reported expert knowledge of both sneezing etiquette and hygienic hand washing. More than three-quarters of study participants (more than 70%) reported washing their hands with soap and water or alcohol, keeping a safe distance, sterilizing surfaces, wearing facemasks, sanitizing purchases, and staying at home. This is higher than the results from China, where more than half of the people surveyed washed their hands with soap after touching something contaminated, covered their mouths when they coughed or sneezed, and wore masks as a precaution whether they had symptoms or not [38].

Our findings suggest that anxiety is significantly correlated with depression in relation to COVID-19. The significantly higher prevalence of reported adverse mental health conditions associated with the COVID-19 pandemic highlights the pandemic's broad impact. It highlights the need to prevent and treat these conditions and identify vulnerable groups. The identification of populations at high risk for psychological distress and unhealthy coping can help shape policies to address health inequity, such as increasing access to resources for clinical diagnosis and treatment options. Increased use of telehealth, which is a good way to treat mental health problems like depression and anxiety, may reduce the mental health effects of COVID-19 [46, 47].

The practice of preventive measures is inversely related to depression levels. Specific precautionary measures, such as practicing hand hygiene and wearing masks regardless of symptoms, were associated with lower levels of depression, anxiety, and stress [36]. In agreement with what has been reported in the United States, the use of proactive precautionary measures such as avoiding people who cough, unnecessary travel, and the use of public transportation or public places [48], was associated with lower COVID-related anxiety even if people experienced isolation. Having more close or meaningful relationships may be more protective than just having more interactions with others, as the quality of the relationship is key rather than the number of social connections [49].

This finding was inconsistent with the Chinese study [37]. This discrepancy may be explained by the 2003 SARS-CoV-I epidemic in China, where the general public's perception of precautionary measures was changed, leading to a positive effect on the initial psychological responses to the COVID-19 pandemic by giving respondents confidence and a sense of control in prevention. This reason could explain the difference between the Saudis and the Chinese population.

Following the British Colombia COVID-19 online Self-Assessment Tool results, during the first wave, the majority of the studied participants were in the growth and learning zones, and only a little less than 15% were in the fear zone. This can be explained by the fact that 83.3% of the studied participants got information from trusted scientific and official websites.

As regards the ECS, happiness was the emotion of high cognition among the studied participants, in agreement with the recently published report by the UN Sustainable Development Solutions Network about the World Happiness Rank of 95 countries in 2021 during the COVID-19 pandemic, which reported that KSA was the 1st Arabic country and the 21st global country according to the happiest index [50].

A relatively large representative sample of the 13 geographic health regions from all over the KSA. This study included 24 nationalities. We conducted a complete mental and emotional cognition assessment through a detailed questionnaire using four validated scales and scores.

being a cross-sectional study. The majority of participants who were working in the medical field may be a bias, but they were the most active users of websites.