Study of Psychological Distress among Iranian Community

Mohsen Niyazi,[1] Ali Farhadiyan,^*[2] Mahdiye Kazemiyan[3], Fatemeh Khoshbayani Arani[4]

[1] - Professor, Department of Social Sciences, Faculty of Humanities, Kashan University, niazim@kashanu.ac.ir

[2] - Assistant Professor, Department of Management and Entrepreneurship, Faculty of Management, Kashan University, (corresponding author) farhadian@kashanu.ac.ir

[3] - Research Master's student, Faculty of Humanities, Kashan University, mahdiekazmian79@gmail.com

[4] - PhD research student, Faculty of Humanities, Kashan University, Kashan, Iran

Abstract

Introduction: Some mental health practitioners use the term psychological distress to describe various symptoms and experiences in a person's inner life that are usually disturbing, confusing, or unusual. And it is used to describe a person with a combination of symptoms of depression, anxiety and, stress. Psychological distress can severely destroy interpersonal relationships, because these people raise more tension while interacting with their spouses, children, and friends. The current research aims to examine the conducted studies on psychological distress using the qualitative meta-inductive approach.

Research methods: This method includes seven steps that systematically evaluate and analyze the findings of previous studies. Therefore, the results of previous researches have been collected and analyzed from domestic references during the years 2016 to 2022. In the current research, we studied 73 valid scientific papers to design a model of affected factors by psychological distress. We excluded some of the papers due to their incompatibility with the dimensions of psychological distress.

Findings: After an initial review, the results led to 102 codes. After exploring the sub-fields, 16 main fields were obtained, which are: background variables, emotions, neurotic states, disorders, family status, quality of couple relationships, diseases, medical services, Covid-19, religious attitudes, and social, cultural, educational and economic status, drug abuse, and control impulses. Also, one can highlight the most notable components based on their repetition: anxiety, depression, stress, domestic violence, various diseases, personality disorder, etc. Indeed, nowadays life is stressful; and due to various social, economic reasons and various physical and mental illnesses, people suffer from psychological distress.

Conclusion: Psychological distress can severely destroy interpersonal relationships because these people experience more tension with those around them.

Keywords: Anxiety, Depression, Model designing Psychological distress, Stress

Received: 14/ July/ 2023                     Accepted:  28/ October/ 2023

Introduction:

Psychological distress is a term used to describe a general psychiatric condition in a person with a combination of symptoms of depression, anxiety, and stress. It is recognized as a pathological factor in many types of mental disorders. Also, distress is widely defined as a condition in response to stressful factors and perceived discomfort (1). People who suffer from psychological distress temporarily or permanently experience a specific discomfort and emotional state in response to specific stressors and traumatic requests (2). According to Tizdel and Antal in 2016, psychological distress is an unpleasant mental condition of depression and anxiety that manifests both emotional and physiological symptoms. The results of studies show that psychological distress as an emotional disorder may affect people's social performance and daily life (3).

Psychological distress can severely destroy interpersonal relationships, because these people raise more tension while interacting with their spouses, children, and friends. Also, psychological distress degrades marital satisfaction. As a result, these people use incompatible strategies to solve the problem when faced with a problem (4). Psychological distress is a term that describes the general psychopathology of an individual with a set of symptoms of depression, anxiety and perceived stress and refers to the general concept of maladaptive psychological activity at the level of stressful events in life (5). Therefore, psychological distress is a unique and uncomfortable emotional state for a person in response to a stressor or special need that leads to temporary or permanent damage for them (6).

Psychological distress, compared to psychological disorder that origins from clinical diagnostic classes, implies a non-specific level of psychopathology and is defined as an abnormal emotional response to stressors. Psychological distress as one of the diagnostic symptoms, if accompanied by other symptoms, covers the diagnostic criteria of a mental disorder (7). This occurs to such an extent that some research concluded that those who have high psychological distress have lower health and have higher rumination (8). It is difficult to accurately state the prevalence of psychological distress due to the variety of scales that measure it; however, due to the lower severity of distress compared to mental disorders, it is considered to be more prevalent (9). Guazaron (2018) considers psychological distress as an umbrella term to describe unpleasant feelings or emotions that affect a person's performance level. In other words, it is a mental disorder that negatively affects the daily activities of a person's life. Psychological distress can establish negative views towards the environment, others and oneself. Sadness, anxiety, confusion and symptoms of mental illness represent psychological distress. Psychological distress with associated symptoms of depression and sometimes anxiety is related to an emotional condition. Symptoms of psychological distress are realized in the form of a physical problem (10). Indeed, it worth noting that various research has found that, diseases such as cardiovascular disease (Rahnama 2016), Covid-19 (Hessari 1401 S.H), Brain tumor (Hashemi 1401 S.H), Thalassemia (Yousefian 1398 S.H), Rheumatoid arthritis (Zahedi 1398 S.H), Breast cancer (Ali Akbari 1400 S.H), Type 2 diabetes (Dibayyan 1401 S.H), and so on can be effective in psychological distress. Ablouf et al (2000). Defined psychological distress as the general concept of emotional or physical functions, and activities in daily life. Psychological distress refers to a wide range of conscious and unconscious mental activities with symptoms of sadness and restlessness, which are an integral part of human experiences. Their low levels are necessary for human activity at low levels. But if the experienced discomfort intensifies, this distress annoys and harms the person (11).

According to recent studies, people with high mental distress complain more about the symptoms of physical illness. And the frequency of physical illnesses is a valid predictor of damage caused to their physical, psychological, and social functioning. Psychological distress is associated with changes in the neuro-endocrine system, hypothalamus, pituitary and adrenal axis, blood platelet function, heart rate. Research has shown that people who have a lower distress tolerance show avoidance behaviors when exposed to stressful situations or they express their feelings. And to quickly reduce their distress, they continue the avoidance behaviors and turn them into a pattern of behavior. Experiential avoidances mostly show themselves in the form of physiological experiences and thoughts, feelings and memories (12). One of the other effective factors shows itself when an individual is diagnosed with a brain tumor, their spouse experience psychological pressure, which in some cases disappears spontaneously. This spontaneous recovery can be considered as a natural adaptation, but in some cases, it leads to more severe problems and mental pressure, which degrades the quality of life, daily functioning, and the occurrence of physical and emotional adaptation disorders and psychological distress (4). Also, marital infidelity causes feelings of doubt, guilt and rumination in the spouse who has cheated. Research shows that one of the prominent factors that activates these fundamental beliefs is the rumination response style (13). Nurses are always exposed to extreme degrees of tension and psychological distress and mental pressure due to their long working time and the necessity of their presence in clinical and hospital environments (14).

The global prevalence of mental disorders in 2016 is estimated at 15.5%, which varies from 13 to 22% in different countries. The prevalence of these disorders in Iran is reported to be 21 to 39.6%. Depression, anxiety and mental distress are the most common mental disorders in the general population. Mental distress is a type of mild mental disorder that is used as an indicator of mental health in demographic and epidemiological studies (16). Psychological distress is a term that describes the general psychopathology of an individual with a set of symptoms of depression, anxiety, and perceived stress. Psychological distress refers to the general concept of non-adaptive psychological activity at the level of stressful events in life (17). Therefore, one can conclude that psychological distress is a unique and uncomfortable emotional state for a person in response to a stressor or special need that leads to temporary or permanent damage for them (18). Several factors in psychological distress (anxiety and depression) play a role, and these factors are classified into three categories: biological, psychological and social factors.

Biological factors: Biological risk factors of anxiety have been obtained from cross-sectional studies. Cognitive disorders and high blood pressure, some chronic diseases, functional limitations and poor self-perception have been associated with anxiety. Several risk factors such as chronic diseases, vascular factors, health status, drug use, self-perception, disability, and habits such as heavy alcohol or tobacco consumption have been identified from cross-sectional and longitudinal studies on depressive symptoms and disorders. Findings on the genetic factors of depression are ambiguous. Based on longitudinal studies, chronic diseases, cognitive impairment, functional limitations, and visual impairment are known as predictive factors for depression and not anxiety (19).

Psychological factors: Neurological disorder, disorder in adaptation strategies, psychopathology, lack of self-efficacy, negative self-identity, low self-esteem and psychological history of personality disorders are related to disorders and symptoms of anxiety and depression.

Social factors: In relation to the social risk factors of anxiety, limited evidence of the relationship between quantitative (e.g., the number of friends) and qualitative aspects (e.g., social support) of social networks have been expressed. Many studies have considered stressful events and a fewer number of studies have considered demographic variables (mainly female gender) as risk factors for anxiety disorders and its symptoms. The level of education and low amount of income can also act as a risk factor for depression. Also, female gender is often a predictive factor for depression. Religious practices have been recognized as a protective factor in a sample of several studies for depression. Differences between risk factors for anxiety and depression have been observed. For example, loneliness has been associated with depression in most studies, while no such relationship has been observed with anxiety. On the other hand, being childless and a history of experiencing traumatic events are associated with anxiety, but no relationship with depression has been seen (19).

Depression: It is classified as a mood disorder. American Psychiatric Association states that depression can occur at any stage of life. Depression symptoms present in all age groups, but people with in different age groups describe it differently (19).

Stress: American Psychiatric Association (2012-2013) defined stress as "a pattern of specific and non-specific responses of a person to the stimuli of events that upset the person's balance, as well as excessive pressure that impairs the person's ability to cope".  Stress is a general term that refers to two separate concepts of "stressors" and "pressure". Stressors are environmental characteristics or thoughts, which lead to an unfavorable reaction in a person. DSM defines a stressor as: "any type of emotional, physical, social, economic, or other factor that disrupts the natural physiological, cognitive, emotional, and behavioral balance of a person." The term pressure refers to adverse/side reactions of a person to stressful factors (20).

Anxiety: Anxiety is a multidimensional concept and has different levels. It manifests itself as physical, cognitive, emotional and interpersonal phenomena. Anxiety is a warning sign and it should be noted that some anxiety is necessary for continued survival. Although, anxiety is considered a motivational factor, but when it exceeds a limit, it disturbs the organization of behaviors. Various studies divide anxiety is into different ways, but most of them divided it into five categories:

Symptomatic anxiety: This type of anxiety is caused by the anticipation of danger and the transmission of danger and the feeling of being threatened.

Trait anxiety: This type anxiety shows the personality anxiety of the person. In other words, it develops through the transformation and growth of one’s personality. Some people are more prone to anxiety than others. Such people may experience symptomatic anxiety or more stressful events.

Situational anxiety: It is an anxiety that occurs in special situations. And it differs from symptomatic anxiety in a way that the situational source of anxiety can be identified. People who suffer from a high level of situational anxiety experience severe anxiety when faced with a stressful situation.

Natural anxiety: It is necessary for survival and provides the necessary energy to accomplish a task.

Pervasive anxiety: This type of anxiety is very intense. A person suffering from this anxiety panics and cannot direct it to any kind of thought or borderline. This anxiety is very penetrating and occurs insidiously. (The concepts of situational and personality anxiety were first expressed by Kettle in 1966 and developed by Spielberger et al.)

Situational anxiety is actually an emotional state that appears at a certain period of time. It manifests itself with states such as mental pressure, anxiety, anger, worriedness, and the activation of the automatic nervous system. Personality anxiety is associated with stable individual differences in the tendency to cause anxiety. Restlessness, sadness, anorexia, increased blood pressure, increased respiratory irregularity, heart palpitations, disorder in concentration and disruption of daily activities are symptoms and signs of stressful factors (19).

       Ridner (2003) characterized the definition of psychological distress, into five components, which are perceived inability to cope effectively, change in emotional status, discomfort, relationship between discomfort and damage. Psychological distress indicates a less specific level of psychopathology than psychological disorder that refers to clinical diagnostic classes. Darnvand et al. (1980) defined psychological distress as a set of psychophysiological and behavioral symptoms such as anxiety, depressive reactions, restlessness, and decline in intelligence, sleep disorders, absenteeism, and so on. A review study on mental health monitoring indicators in Europe defined psychological distress as a non-specific syndrome that includes factors such as anxiety, depression, cognitive issues, irritability, anger and practical obsession. Psychological distress is often experienced as a part of normal life as a result of permanent or transitory problems such as changes in life stages and transitions, challenges and loss in education, job, family life, and relationships. And it is related to failure and social exclusion (20).

Wheaton (2007), stated that due to non-specificity of given definitions of psychological distress, this phenomenon should be characterized by depression and anxiety symptoms. In practice, scales used to measure psychological distress often include items that measure depressive disorders and generalized anxiety disorder. Despite the fact that psychological distress and these psychiatric disorders are distinct phenomena, they are generally not independent of each other. The relationship between distress and depression, and to a lesser extent with anxiety, is whether psychological distress leads to depression or not. Unfortunately, the phenomenon of psychological distress remains largely unknown (21). Turner (1987) stated that, in addition to intra-psychological difficulties, distress also raises tension and conflict in the interpersonal space. Distress also interferes in different areas of a person's performance (20). The stress-distress model shows that the characteristics of psychological distress exposed to a stressful event, cause a threat to physical or mental health. And such a person cannot efficiently cope with this stressful event and the resulting emotional turmoil. The role identity model refers to the role that people take in certain social situations. It seems that stressors that revolve around behavior related to specific roles, such as chronic health issues, only affect psychological well-being if they disrupt social roles. Pearlin (1989) pointed out that the stress process exists at three levels of the social structure: social satisfaction (such as gender, age, socioeconomic level, race), social institutions supporting roles and bases, and facing specific stressors and strategies to deal with this stress. According to Pearlin, social roles require five categories of stress: Role overload (such as the ineffective capacity to cope with the demands of a role), Interpersonal conflicts in the role base such as marital conflicts), Intra-role conflict (such as the conflict of a spouse, mother, employee), Role captivity (such as being stuck in an unwanted role), and role reconstruction within a role base (20). In this research, various theories have been used as the theoretical foundations. Some of the most notable theories used are mentioned in the Table 1:

Table 1: Summary of considered theories in the study.

Thus, there are different views on psychological distress that believe that a series of biological, psychological, social factors, depression, anxiety and stress can affect psychological distress. Also, we have used various viewpoints to study psychological distress, such as Wheaton's, Turner's, and Pearlin's viewpoint. Indeed, psychological distress can be considered as an emotional disorder that may affect a person's social functioning and daily life.

In 2019, Behbahani Mandanizadeh and Homai conducted a research titled "Relation between stigma of infertility and mental distress with the quality of marital relationship through the mediation of emotions in infertile women." using he method of questionnaire and targeted sampling. Their results showed that infertile people are facing one of the most major crises in their life, which creates psychological problems and serious stressful experiences for them. In this stressful situation, they may blame themselves and others and consider the situation to be catastrophic, which ultimately It harms their health. Also, the stigma of infertility in women creates an absolutely negative psychological attitude that causes negative and disturbing consequences due to the results of infertility. They lose their support and social base, which causes anger and hyper-anxiety, and reduces intimacy and commitment in infertile couples, which can lead to a weakening of the family foundation or even divorce. Infertility creates a repetitive series of negative thoughts on the reason for their infertility, which causes psychological distress. And negative overexcitement reduces concentration and causes them to be overly involved in details (22). In 2021, Mohajerani et al conducted research titled "Relation between psychological distress and physical symptoms of functional indigestion with the mediating role of mental images related to pain, visceral sensitivity, pain catastrophizing and pain self-efficacy" using the method descriptive-cross-sectional. The results showed that psychological distress is related to symptoms of functional dyspepsia. Indeed, burning and bloating as annoying physical symptoms of this disease generally isolates the sufferers and leaves them out of the normal routine of life. And un-isolated patients become angry and irritable due to the mental pressure caused by their disease, which reraise the anxiety. Also, the several numbers of mental images are related to the unpleasantness of pain and the development of disease symptoms. These images construct in the patient's mind in an unwanted and disturbing way and are often distressing. Indeed, these images change the attitude toward a negative mood. As a result, negative moods and emotions such as anxiety, anger, and sadness build up and positive emotions decrease (23). In 2021, Pahanhande et al. conducted a descriptive study titled "Prediction of Covid-19 Anxiety Based on Psychological Distress in Nurses of the Covid-19 Ward of Ardabil Hospitals" using correlational method. The results showed that nurses experienced more psychological distress during the outbreak of the coronavirus. It can also be said that the presence of Covid-19 disease, due to its high mortality, causes Covid-19 anxiety in people. In this regard, one of the most notable psychological risks that can increase the chance for the presence of Covid-19 anxiety is the psychological distress of a person such as stress and anxiety. When a person has stress and anxiety, the body's immune system is weakened and this factor can intensify Covid-19 infection (24). In 2022, Salehian et al. conducted a descriptive-analytical study titled "The Effect of Adverse Childhood Experiences, Psychological Distress and Resilience on the Depression of Amateur Athletes" via sampling. Unfortunate childhood experiences can cause mental problems among amateur athletes due to negative attitudes among people and affecting some essential psychological indicators such as self-confidence. Indeed, unfortunate childhood experiences among amateur athletes can affect their mental aspects; Create conditions for depression among this group of people. Also, psychological distress due to mental crises in athletes can cause mental and behavioral crises, which result in occurrence of mental injuries. Therefore, psychological distress plays a notable role in creating mental tensions among people, which can depress them. Therefore, the negative effects caused by psychological distress in amateur athletes have caused conditions to increase the levels of depression in them (25). Fatehi et al. conducted research in 2022 titled "Development of a Model for Experience of Violence by Husband in Women Based on Personality Characteristics with the Role of Mediator of Psychological Distress" using a cross-sectional descriptive method. The results showed that psychological distress with dimensions such as stress, anxiety and depression can lead to physical damage or mental discomfort, and these symptoms can affect the couple's performance with unpleasant feelings or uncontrollable emotions in the long run. And in this case, couples who can’t control their behavior, found themselves in quarrels and conflicts, such as harassment and wife abuse. Therefore, psychological distress with its symptoms can cause mental disorders in and lack of self-control in couples. So that couples lose their control over their marital relations and become incompatible couples. Also, quarrels and conflicts between them increase, and spousal abuse occurs. Moreover, as a result of ataxia, couples experience more depression and anxiety, decline in self-esteem, and suicidal thoughts. Thus, it creates conditions for violence and harassment (26).

       Foreign researches: In 2016, in a study titled “Body Dissatisfaction and Psychological Distress: Self-confidence as a Mediator”, Dutch et.al. found the effect of self-confidence as a mediating factor in relation to body dissatisfaction and symptoms of depression and anxiety as examined the components of psychological distress. The results showed that the indirect effects of dissatisfaction on anxiety and depression are significant, confirming the mediating role of self-confidence. Therefore, body image dissatisfaction causes psychological distress by reducing self-confidence. In 2019, Eisenbek et al. conducted a study titled “Psychological Distress to Academic Procrastination, Investigating the Role of Psychological Inflexibility”. The results showed that higher levels of academic procrastination are associated with increased psychological distress or psychological flexibility. Also, negative emotional state and academic procrastination may be related to the problematic self-regulation pattern of inflexibility. Therefore, the results showed that by reducing psychological flexibility and promoting value-based measures, an individual can target psychological distress and academic procrastination. In 2019, Milliman, Czaploski, and Ferguson conducted a study titled “The Mediating Role of Self-regulation and Psychological Distress in the Relationship between Domestic Violence and Dysfunctional Attitudes in Women who are Victims of Spousal Abuse”. The results showed that the experience of domestic violence in women due to the ability of self-regulation, and the reduction of psychological distress reduce ineffective attitudes in them. In 2020, Petzold et al. conducted a study titled “Risk, Resilience, Psychological Distress and Anxiety at the Beginning of the Outbreak of Covid-19 in Germany”. The results showed that more than half of the people expressed psychological distress and anxiety due to the spread of the coronavirus. People have been thinking about Covid-19 for several hours during the day. In 2020, Argyropello and Volcopano conducted a study titled “The Role of Psychological Distress as a Potential Way through Which Procrastination May Reduce Life Satisfaction”. Students with a tendency to have specific academic commitments, report less psychological well-being, more anxiety, more psychological distress, less emotional relationships, less general positive affect, more decreased behavioral and emotional control, more depressive symptoms, and less life satisfaction. That the standard indirect effect of procrastination on life satisfaction is statistically significant and confirms the hypothesis that psychological distress mediates the relationship between procrastination and life satisfaction. As a result, the difficulty to accomplish a task within a period of time is due to the fact that, mental health and overall life satisfaction are declining, which shows academic procrastination, general procrastination, psychopathology, mental health, life satisfaction.

       Numerous researches have been conducted on psychological distress that highlight the importance of this condition in human life as one of the indicators of mental health. A review on experimental and theoretical studies shows that in the last few years, researchers have paid special attention to the category of psychological distress. In this way, a group of researchers have investigated the relationship between psychological distress and several factors such as: types of diseases (Covid-19 virus, heart disease, marital satisfaction, pregnancy, etc.), that may cause stress and anxiety. It seriously affects people's mental health. Also, one of the weaknesses of the past studies is that they have not considered all the dimensions and components of psychological distress. Thus, to fill this gap, this study has focused on meta-combination method in the category of psychological distress.

Prevention and timely diagnosis of mental distress can reduce its harmful effects to some extent. The consequences of the complications of these disorders are so vast that in absence of positive intervention, the affected people will face irreparable damages. Also, psychological distress causes pressure on surrounding individuals, through an increase in the number of requests for help from social networks and raised tension in the relationships between couples, children, and friends (15). Studying psychological disorder is important because it affects many aspects of people's lives in such a way that it negatively impacts the quality of life. Psychological distress can severely destroy interpersonal relationships because these individuals raise more tension while interacting with their spouse, children, and friends. In the field of psychological distress, prevention and timely identification can reduce its destructive effects to some extent. The consequences of these disorders are so wide that in absence of positive intervention, affected people will face irreparable damages. Endangered mental health of individuals in a society due to psychological injuries can endanger the family, educational, social and future status of them. Because it can damage the quality of life of the person. Therefore, the need to pay attention to this issue makes it possible to prevent these injuries and their transformation into other clinical disorders. Therefore, the main goal of this research is to design the model and effective dimensions on psychological distress. The research questions are divided into two categories.

1- What are the most influential factors on psychological distress?

2- What are the most major dimensions and components of psychological distress?

Research Methods:

In this research, we have used Sandelowski and Barroso's qualitative meta-combination inductive method achieve the desired goals. This method is a process that enables researchers to identify a specific research question and then search, select, evaluate, summarize, and synthesize qualitative evidence to answer it. This process uses rigorous qualitative methods to synthesize existing qualitative studies to achieve a deeper meaning through an interpretive process. Therefore, to collect data in a meta-combination study, we extracted information and findings from other studies with a related and similar topic. This method integrates the interpretation of the main findings of the selected studies it seeks comprehensive and interpretive findings, which requires a deep understanding on the topic. And instead of providing a comprehensive summary of the findings, its output is an interpretive combination of the findings. Sandlowski and Barroso introduce a seven-step method for meta-combination. In this research, we have explored past researches on psychological distress to collect data and then used the seven-step method of Sandlowski and Barroso to investigate them. We analyzed the data in three stages. In the first stage, a list of papers related to the field and even papers that have dealt with this topic in a secondary way were prepared by a complete review of the research literature. In the second stage, the abstracts of these papers were extracted and the papers were categorized. Finally, the codes and key elements of these papers were collected by selecting related papers. Next, in the third stage, by extracting these key elements, the final combination was made and the main categories were collected, and the final analysis and summary was reported (27).

Diagram 1: Steps and an overview on the meta-combination

Since we have considered multiple criteria for psychological distress, after specifying the target, we searched all the studies available on Iranian electronic sites with a focus on keywords related to the topic. We studied the results of the search and continued the research process. The unit of analysis of this research is the published scientific researches and scientific journals within the years 2016-2022. The analysis of the information obtained from the meta-combination method consists of seven steps. We have fully described each steps below.

Step 1: Choosing a goal: This study attempts systemically categorize psychological distress criteria based on previous research after presenting a brief introduction for each of them. Then, presents the resulted categories in the form a systematic model.

Step 2: Specifying the research questions, key concepts and search sources: We have considered various parameters to set the research question, which include the following:

                   1) What: The dimensions, components and criteria of psychological distress have been identified and studied;

2) Study population: Using Iranian scientific sites to collect the required data;

3) A time range between 2016-2022 for domestic papers was considered;

     4) Methodology: Document analysis method and qualitative data;

5) Keywords: Some of the most notable key concepts include the following:

Psychological distress, stress, depression, anxiety, resilience, diseases

Step 3: Review the selected search results of related papers and references: In this step, at each stage of review, papers were reviewed based on various factors such as the degree of relevance to the research topic, and those that were less relevant were excluded from the meta-combination process. The criteria for the inclusion of papers are: 1- The publication journal of the papers; 2- The subject under investigation: Design of the model and dimensions of psychological distress; 3- The general scope of the research: research published inside Iran; 4- Research method: meta-combination; 5 - Research time window: 2016-2022; 6- Language under review: Persian.

We considered 10 criteria to evaluate the quality of each included study. Each criteria receives a score from 1 to 5. According to Kasp Rubric scale, we proposed the following scoring system. And we excluded any paper with lower than score of 30 (Good).

0-10: Weak; 11-20: Moderate; 21-30: Good; 31-40: Very Good; 41-50: Perfect.

This type of scoring is based on ten basic factors, which include: research objectives, method logic, research design, sampling method, information collection, reflectivity, ethical considerations, and accuracy of data analysis, clear expression of findings, and the value of research. At this stage, we have given a few points to each of these questions and then created a form. Next, we summed the points we have given to each paper, and finally, approved the number of 37 papers. At this stage, out of the 73 extracted papers, 12 papers were excluded based on the title, 14 papers based on the abstract, and 10 papers based on the content. It was also not possible to access some of these papers. Finally, the remaining 37 papers were selected based on ten criteria (research objectives, method logic, research design, sampling method, reflectivity (including the relationship between the researcher and the participants), ethical considerations, accuracy of data analysis, clear expression of the findings in terms of quality) was finally reviewed.

Step 4: Extraction of concepts and codes related to the research topic: In this step, we carefully examined the content of the papers. And we selected the codes related to the keywords, concepts. Then, we formed categories based on them. Clark and Bloor used a 6-step process.

1) Knowing the data: Knowing the content of the data in-depth usually requires, frequently and actively reading the data.

       2) Creation of initial conceptual codes: At this stage, we extracted 73 included papers from the research.

3) Searching for selective codes (indices): At this phase, we obtained 102 selective codes.

4) Forming subfields of the components: This includes two stages, reviewing, and refinement and shaping of the subfields. By doing these two steps, the component was obtained.

5) Defining and naming the main fields (main dimensions): In this research, after exploring the sub-fields, 16 main fields were obtained. In the meantime, with the help of levels of analysis of the components of psychological distress (which includes dimensions of emotions, Neurological states, disorders, family status, quality of couple relationships, diseases, medical services, Covid-19, control impulses, drug use, religious attitudes, social dimensions, cultural dimensions, educational dimensions, economic dimensions) were determined.

6) Final review and report preparation: The final result of meta-combination research is presented in the findings section.

7) Explaining and extracting the results: In the stage of explaining and extracting the results, research information is categorized. In the first column of the specified chapters, the psychological distress criteria mentioned in each paper are explained. In the second column, the citations related to those chapters are mentioned and it is stated and finalized for the experts (27).

Step 5: (Analysis and synthesis of qualitative findings): The goal of meta-combination is to create a unified and new interpretation of the findings. This methodology aims to clarify the concepts and patterns and results in refining the existing states of knowledge and the emergence of operational models and accepted theories. During the analysis, it looks for themes that have become stable among the existing studies in the meta-combination. Sanluski and Barroso call this "thematic investigation". In the beginning, the researcher considers all the factors extracted from the studies as codes.

Step 6: (Quality control): Reliability and validity of the model: the designed model includes 16 main categories and 102 subcategories. After completing the meta-combination methodology steps, the designed model was presented in the meeting of the entire focal group with the participation of social science experts. In these meetings, all two levels of the model were examined and no changes were made. Indeed, new dimensions and components were not added or subtracted to the model. The validity of the current model is achieved through content validity, which is done from two aspects. The first aspect is the use of the components and factors of the previously presented models, which leads to the validity of the model, and the second aspect is the formation of focus group meetings and the presentation of the model in these meetings to the trustees of social sciences and management, which indicates that the model has not changed. The validity of the model has been designed because in the stages of model design, the criteria of the previous models were considered as codes, and taking into account the semantic similarities between the codes, they were merged and concepts were created. In this study, we used Kappa index maintain the quality of the study. The Kappa value fluctuates between zero and one, and the closer its value is to one, the more agreement among the reviewers.

Table 2: Stability of meta-combination method

Kappa coefficient varies between zero and one and is expressed as a percentage. Based on the available sources, the strength of the Kappa coefficient is shown in the Table 3.

Table 3: Reliability of different amount of kappa factor at determining agreement between code assigners (Gwet 2014).

As shown in the table above, the Kappa index was calculated as 0.87%, which is at the level of excellent agreement according to the status of the Kappa index.

Step 7: Presentation of findings (conceptual model): We used the coding scheme to analyze the research conducted on psychological distress criteria. Coding scheme is an operation which data is analyzed, conceptualized and put together in a new way. Open coding aims to transform data and phenomena into concepts. Then categorize these codes based on the phenomena discovered in the data that are directly related to the research question. Here, we consider the concept of each of these codes and categorizes them in a similar concept. In this way, by forming codes, we categorize the final concept and describe it in the best way. In the present research, the factors extracted from the studies are first considered as codes. And then we group each code in a similar concept by considering the concept of each one. In this way, the main concepts of the research are formed. The results of the aforementioned process for identifying and classifying psychological distress are presented in the Table 4 (27).

Table 4: Categories of the main extracted dimensions of criteria for psychological distress

Discussion and Conclusion:

Psychological distress describes a person with a combination of symptoms of depression, anxiety, and stress. It is known as a pathological factor in many types of mental disorders. Also, distress is widely defined as a condition arisen in response to stressful factors and perceived discomfort. Psychological distress is defined as a state of emotional suffering that is characterized by symptoms of depression (such as lack of interest, sadness, hopelessness) and anxiety (such as restlessness, feeling tense).

Considering the importance of the topic, this research has discussed the meta-combination study of pattern design and dimensions of psychological distress. According to the extracted papers that 37 of them reached the final approval stage, 16 main components and 102 conceptual codes were created, which include but not limit to: contextual variables, emotions, Neurological states, disorders, family status, quality of couple relationships, control impulses, diseases, medical services, religious attitudes, social dimensions, cultural dimensions, educational dimensions, economic dimensions, corona virus and, drug abuse. The results of this research are in line with the mentioned citations, using qualitative inductive method and studying several related papers. Then, in this research, all the mentioned dimensions and components were categorized in a table and drawn with the meta-combination model

Based on the research viewpoint, we can conclude the following: According to Guazaron in 2018, psychological distress is a umbrella term that describe unpleasant feelings or emotions that affect a person's performance level. Alternatively, it is a mental disorder that negatively affects the daily activities of a person's life. Psychological distress may lead to negative views towards the environment, others and oneself. Sadness, anxiety, confusion and symptoms of mental illness represent psychological distress. According to Turner (1987), in addition to intra-psychological difficulties, distress also raise tension and conflict in the interpersonal space. As a result, although less severe than a psychological disorder, distress also interferes in various areas of a person's performance. According to Ridner, in determining the characteristics of the definition of psychological distress, they point five components, which are perceived inability to cope effectively, change in emotional state, discomfort, the relationship between discomfort and damage.

The results of the research show that the conditions (depression, anxiety and stress) strongly influent on psychological distress, which conforms with viewpoints of researches by Yousefian, Ahadi and Kraskian(39), Mashak, Naderi and Chin Ave(44), Pour Naqash , Qalandrazadeh (40), Bayat, Tavakoli and Qanadi brothers (13), Talebi and Timuri (41), Mohajerani, Isazadegan and Soleimani (23), Bromandian, Mohammadi, Rahimi Taganki (43), Payandeh Darinejad, Moradi, Hosni And Nouri (36), Dawoodian, Hashemipour, Qalich Khan and Abu Zari (37). Indeed, stress in long-run may lead to problems if not managed. it may greatly impact their health, and cause depression with symptoms such as depressed mood, loss of interest and pleasure, decreased energy, disturbed sleep, feeling Guilt and poor concentration. Anxiety is characterized by disturbing thoughts and feelings. The results of the studies indicate that psychological distress as an emotional disorder may affect the social performance and daily life of people, which is consistent with the viewpoint of researches by Kawosi Abbasi and Mirzaian (34), Pour Fereydoun and Dasht Gharegi (30), Mehrabi and Afshari (32), Bromandian, Mohammadi and Rahimi Taganki (43), Heydari and Habi (45).

Also, psychological distress with related symptoms of depression and anxiety is associated with emotional problems; The symptoms of psychological distress are realized in the form of a physical problem, conforms with results of researches by Hashemi, Aini and Shahjooi(4), Elahi, Safarian, Shokri Javan and Iszadeh(42), Rahnama, Sajjadian and Reofi(12), Yousufian, Ahadi and Kraskian(39), Mahmoudpour, Darba, Kamandalo and Madani(5), Zahedi, Rafieipour and Khan Babaei(29), Talebi and Timuri(41), Pour Fereydoun and Dasht-e-Zorgi(30), Ali Akbari and Bitaneh(31) ), Mohajerani, Isazadegan and Soleimani (23). Another result of the research is that psychological distress degrades the quality of life and the occurrence of adaptive and mood disorders, conforms with the results of researches by Mahmoudpour, Darba, Kamandalo and Madani (5), Zahedi, Rafieipour and Khan Babaei (29). ), Raisipour, Shafiabadi and Borojni (28), Aini, Hosseini and Ebadi (38), Pour Fereydoun and Dasht-e-Zorgi (30), Mehrabi and Afshari (32), Heydari and Habi (45), Davoudian, Hashmipour, Qalich Khan and Abu Zari (37).

Also, psychological distress can severely destroy interpersonal relationships because these people raise more tension with their spouses, children and friends, which can degrade marital satisfaction. This finding also conforms with results of researches by Gol Mohammad, Ghasemi, Abdoli and Saqiha (48), Mahmoudpour, Darba, Kamandalo and Madani(5), Zamani Foroshan, Do Kaneei Fard and Niknam(8), Pour Naqash, Qalandrazadeh, (40), Raisipour, Shafiabadi and Borojni(28), Bayat, Tawakli, Qanadi Bradaran (13), Mohajerani, Isazadegan and Soleimani (23). Indeed, findings in this research, we determined that between psychological distress significantly relates with all its dimensions (emotions, Neurological states, disorders, family status, quality of couple relationships, diseases, Covid-19, control impulses, medical services, educational dimensions, economic dimensions, social dimensions, religious attitudes and drug abuse). Psychological distress is one of the greatest challenges that threatens the lives of many individuals around the world, especially the lives of Iranian families, because life is stressful nowadays. The severity of this issue can’t be overexaggerated in today's era. Psychological distress as a consequence of modern life is the precursor of some sort of psychological crisis. And if it is ignored, one should wait for its next consequences. In Iran, all kinds of diseases (physical and mental) are among the contributing factors of psychological distress. The stress caused by the development and fear of the development of a disease is a pressure or stimulus that raise tension in humans and has an inverse relationship with physical and mental health. According to the studies, disease such as Covid-19, cardiovascular disease, cancers, tumors and infertility problems caused the highest level of anxiety.

Also, one of the other dimensions contributing to psychological distress is the family situation. Cases such as domestic violence, conflict between spouse and children, infidelity and divorce occurred most frequently. Spouse abuse is one of the most influential variables because it can cause psychological distress in couples by suppressing emotions. On the other hand, psychological distress can contribute to violence and raise tension within the family through the intensification of dark personality traits. Also, Neurological conditions such as (stress, anxiety, depression, rumination, etc.) had the highest frequency. Indeed, nowadays in all countries of the world, especially Iran, people are suffering from psychological distress (depression and anxiety) every day, which is due to various social factors (such as lack of understanding of social support, lack of support from friends, social isolation, social rejection and reduction of relationships, socio-economic factors and medical services (such as type of job, amount of income, cost of medicines, visits, duration of illness, severity of illness, etc.). Moreover, Educational factors (such as academic pressure, exam anxiety, intense competitive environment, etc.) and emotions such as (disappointment, shame, guilt, doubt, loneliness, worry, etc.) have many consequences for the family at the micro level and for the society at the macro level. Also, legislators, institutions, institutions can use a series of practical suggestions to manage psychological distress. Since one of the key variables in psychological distress is the quality of couples' relationships, marriage counseling can be held in focus.

Suggestions: For future studies, we suggest that data be collected from multiple sources to generalize the result with more confidence. From a practical point of view, we suggest that educational workshops be held to raise public awareness. Also, to calm the level of psychological distress, one can use cognitive strategies such as (positive thinking, discovering strengths, sports and physical exercises, etc.). Considering Covid-19 and all kinds of physical and mental diseases, the impact of people's mental health is an essential issue. It is possible to keep mental health of vulnerable groups by psychological interventions. We also suggest that various training workshops be held to calm the level of psychological distress, such as: training workshops on managing and relieving stress and anxiety, teaching the elements of psychological capital to therapists and counselors of treatment centers, conducting self-differentiation training in counseling centers, holding a self-healing approach program in cultural centers and institutions, providing workshops to improve self-esteem and a sense of coherence, providing mental health services from responsible organizations and so on.

Research limitation:

The notable limitation of this study is not inclusion of foreign papers which restrict us to compare our results with others. Also, this research used a meta-combination method, which as a qualitative method cannot be generalized. Moreover, considering the limitations of research on diseases and other variables, it is necessary to investigate the impact of other social, cultural, economic and political variables on psychological distress.

Application of research:

Considering the growth of psychological distress due to stress and situations of daily life and the notable role it has in the quality of daily life, the results of this paper can be used by sociologists, psychologists, and physical and mental health planners.

Ethical considerations:

Ethical considerations include compliance with the principle of confidentiality, using data only in line with research goals without revealing the names of individuals, full freedom and authority of the participants as they wish to withdraw from further participation in the research and presenting detailed information on request of participants about research and its results.

Conflict of interest:

As authors declared, this research has not been financially supported by any institution or organization. And there is no conflict of interests.