One of the most significant medical challenges nowadays is the Coronavirus Disease 2019 (COVID-19) outbreak caused by a strain of SARS– CoV 2 [1]. This pandemic started in late December 2019 in Wuhan city, China [2], and became an international problem and public health concern for many countries. Many ministries chose mass lockdown protocol to control the virus spread [3]. The lockdown method negatively affected the global economy, with a decline reported in different economic sectors, reflecting on the individuals' lives [4]. Moreover, the rapid continuous spread of Coronavirus along with the protective measures to prevent virus transmissions, such as maintaining social distance, strict isolation, and quarantine, are associated with a negative impact on the public's psychological status and mental health [5] due to the increase in the general sense of boredom and their confusion about time [6]. Moreover, fear of the COVID-19 pandemic, the forced lockdown, and economic deterioration brought great psychological stress, anxiety, and depression among the population, adding to its morbidity and mortality [4, 7, 8].

The literature shows a great deal of emphasis on identifying the virus's pathogenicity, transmission mode, clinical symptoms, clinical outcomes, treatments, and vaccine development, while the psychological effect was neglected [4, 9]. Psychological effects and signs of mental illness are characteristic of rapidly spread infection diseases [10]. Furthermore, the pandemic psychological effects are more pronounced and long- lasting compared to physical signs and symptoms [11]. After COVID- 19 deceleration in China, both negative emotions and social risk sensitivity increased, while positive emotions decreased [12]. Many studies were conducted to investigate the COVID- 19 pandemics' psychological effect and concluded that many mental health problems manifested among different communities, including stress, anxiety, fear, and anger [9]. Health care providers and females have the highest risk for psychological issues and mental health problems [13,14]. In an Italian study, higher scores of worries for different causes were reported among the Italian population; the anxiety and stress levels were above normal ones [15].

Moreover, participants in a study among the Indian population reported higher anxiety, sleep disturbance, distress, and paranoia about acquiring COVID-19 infection [16]. In a cross-sectional study in West Bengal, the respondents felt more worried, depressed, sleep disturbed, and took hydroxy- chloroquine as prophylaxis from COVID-19 [17]. Fear of death and feeling lonely were the main psychological effects that concerned COVID-19 infected patients [18].

Recently, several studies have been conducted to evaluate the pandemic’s psychological effect and the impact of the COVID-19 outbreak on different segments of the population since the initial outbreak [ 2,19–22]. A cross-sectional study conducted in Saudi Arabia [23] included 878 participant and showed that the majority of participants (67.6%) had a moderate level of stress related to COVID-19 lockdown, which has a significant effect on participant’s mental and physical quality of life. Firdous et al. (2021) [24] demonstrated that anxiety among females was significantly higher than males. The prevalence of depression was also higher among females, with no significant difference among genders during the COVID-19 pandemic. The study concluded that the mental well-being of health workers within the frontlines is crucial for sustainable health care services in medical care, and the psychological problems during the COVID-19 outbreak global disaster need special attention. One Italian study [25], in particular, examines the effect of government lockdown and restriction on mental health and stress. Mild/severe levels of depression almost doubled after lockdown from 15.39% before lockdown to 32.30% after lockdown. The study concluded that cognitive and mental health changes due to COVID-19 lockdown lead to higher severity and prevalence of depression, anxiety disorders, and other psychological issues involving lesser sleep, appetite, libido, and hypochondria. In a survey of the Chinese population conducted in the first two weeks after the COVID-19 outbreak, 53.8% said the outbreak had a mild to extreme psychological effect, with 28.8% reporting moderate to severe anxiety symptoms and 8.1% reporting moderate to severe stress levels [2]. According to a survey of the Indian people, the prevalence of anxiety was 3.29%, obsession 13.47%, and fear 46.9% [26].

In the Arabic region, limited number of studies have been conducted, including; Saudi Arabia, Kuwait and Bahrain, to assess the pandemic psychological effect and the impact of the COVID-19 outbreak on the general population [27-30] and another two studies have been conducted in Oman and Egypt on subgroups such as healthcare workers [31, 32]. These studies' findings revealed the presence of stress, anxiety, and depression symptoms at variable degrees

In Palestine, the first case of COVID-19 was diagnosed in the city of Bethlehem in March 2020. Palestinian health ministries have taken steps to limit the virus's spread by closing towns, counties and restrict people's movement. These steps were very successful in keeping the pandemic curve down; on the other hand, living with the fear of COVID-19 infection and closure protocols significantly impacted people's lives and psychological well-being. Locally, there have been no studies in Palestine that assess the psychological impact of the COVID-19 outbreak and its protective measures imposed. This study aims to find the impact of the COVID-19 pandemic on the Palestinian adults' psychological status by assessing the participant's practices, reports of anxiety, and depression during the pandemics.

People in the community face several challenges during the pandemics phenomenon. The impacts of these pandemics are often severe, which may negatively affect a given population's mental health. The depression and anxiety related to pandemics also influence the behavior of people in the community. Hence, this study attempted to evaluate the psychological impact of the COVID-19 pandemic on Palestinian adults in the West Bank.

The study results related to anxiety revealed that one- half of the respondents showed some signs of anxiety, whereas one- third have many signs. There was a debate on assessing anxiety in the literature, whether using a specific anxiety scale such as the Hamilton Anxiety Rating scale or any other possible way. However, many studies showed a modest interesting mean, percentages, and significance values for respondents who became anxious due to the COVID-19 pandemic, and almost one-third to one- half of the respondents in these studies became anxious [35, 36]. Younger respondents aged less than 21 years were less likely to have many anxiety signs compared to older respondents, that consistent with recent studies [37]. Younger adults have less financial responsibility, less comorbidity, keep a busy lifestyle to distract their thoughts away from COVID-19, unlike the older respondents who might experience fear of falling sick or dying. Respondents with no confirmed COVID-19 cases in their neighborhood were less likely to have many anxiety signs versus those who have cases in the neighborhood or do not know about their neighbor's infection status, and these results are similar to a study conducted by Sue et al. [38]. Increasing anxiety levels are due to the fear of getting infected with the virus due to the risk of social contact or livening proximity with an infected neighbor.

As far as depression, the study results showed that front line health care workers who interacted directly with confirmed COVID-19 cases are less likely to have many depression signs. These results are contrary to literature findings were health care workers revealed poor mental health because of COVID- 19, which had a negative impact on their well- being and quality of care provided to patients and most front- line healthcare workers reported high levels of stress and depression compared to other workers [39]. However, this finding has limitations and can not be generalized due to the small number of healthcare workers participating in the study.

Regarding gender, females have a more negative psychological impact than males due to the COVID-19 pandemic. This finding is similar to other studies stating that females are more likely to be affected or exposed to negative psychological consequences such as depression [40]. That might be due to several reasons related to the nature of the local community's prevailing culture, such as the dependence on the distance education system, overthinking about the financial situation, and being unemployment. Women have a different hormonal system that in stressful situations such as the COVID-19 pandemics emotionally responded in different way.

Moreover, financial stability and increased income have an inverse relationship with depression during the pandemic. Respondents with an increased income had no signs of depression compared to those with decreased or unchanged income. Other studies support this finding that respondents with increased income were less depressed compared to others with income instability, either decreased or unchanged during the pandemic [41]; that may be due to the significant stress and responsibilities added on the breadwinner of the family to meet their needs of food and shelter in the case of income instability.

However, regarding self- treatment or infection prophylaxis practice, most of the respondents had not taken either a prophylactic dose of (Hydroxychloroquine or Dexamethasone) or antibiotics, which is inconsistent with the results of other study conducted by Mehra [42]. That may be related to the higher level of education of the sample, that more than half of the participants hold a bachelor's degree. Education make them more aware to the inappropriate practices. Moreover, no conclusive research confirmed that Dexamethasone or Hydroxychloroquine help in preventing or treating COVID- 19, added to the fact that authorities are standing against self- medication with these types of medicine during the pandemic [43].

Furthermore most respondents had not taken either antidepressant, anti-anxiety, or sleep medication during the pandemic to control or treat anxiety, depression, or sleeping disorders. These results are in line with previous research, where the vast majority of respondents have not taken these medications during the COVID-19 outbreak [17].

COVID-19 pandemic has a negative effect on mental health; according to the study, most participants have signs of anxiety and depression, and it was more common in the middle age group, elderly and females. Confirmed COVID-19 cases in the neighborhood, not knowing the neighbors' infection status, and decreased income were factors associated with the increased risk of anxiety and depression.

Upon these results, governments, health institutions, and health care providers should provide psychological support, mental health education, counseling, and maybe intervention to vulnerable groups. Furthermore, we recommended taking a break from watching, reading, or listening to the news, including social media, and getting facts from global and local health authority platforms.

Mental health, psychological, and social support during this pandemic are essential components in compacting this pandemic, and it should be available and provided alongside health care services to improve community health and wellbeing.

This study is limited to people who own computers, laptops, or smartphones and have a Facebook or WhatsApp account to participate in the research. In Addition, it represents mainly the educated population, so it should not be generalized to the whole population.