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| Assessment of mental health among hospital-discharged patients of COVID-19 in North India: A cross-sectional study |
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Preeti Kour1, Manmeet Singh2, Bhavna Sahni3
1 Postgraduate Resident, Department of Psychiatry, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, Jammu and Kashmir, India
2 Head of the Department, Department of Psychiatry, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, Jammu and Kashmir, India
3 Associate Professor, Department of Community Medicine, Acharya Shri Chander College of Medical Sciences and Hospital, Jammu, Jammu and Kashmir, India
Click here for correspondence address and email
| Date of Submission | 21-Sep-2022 |
| Date of Acceptance | 31-Oct-2022 |
| Date of Web Publication | 29-Dec-2022 |
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Background: Psychological impact of COVID-19 is an emerging area of interest among researchers worldwide. We aimed to study the prevalence of anxiety and depression among COVID-19 survivors and its association with individual characteristics including demographic variables.
Methods: One hundred and fifty COVID-19 survivors from a tertiary care hospital were contacted to collect information regarding anxiety and depression using the Generalized Anxiety Disorder-7 (GAD-7) scale and Patient Health Questionnaire-9 (PHQ-9). The Pearson's Chi-square was used for univariate analysis of categorical variables. The Mann–Whitney test was used to check the significance between group medians.
Results: 21.3% of the survivors (n = 32) reported postdischarge COVID-19 anxiety. Mild, moderate, and moderately severe anxiety was reported by 17.3%, 3.3%, and 0.7% of the patients, respectively, on using the GAD-7 questionnaire. PHQ-9 revealed that 29.3% (n = 44) had depression. Minimal, mild, moderate, and moderately severe depression was reported by 19.3%, 24.0%, 2.0%, and 3.3% of the respondents, respectively. None of the survivors had severe anxiety or depression. In both the questionnaires, variation in median scores was statistically significant with age, whereas for GAD-7 scores, the difference in median scores was statistically significant only for gender. On analysis, age above 40 years was a statistically significant determinant for both anxiety (P = 0.041) and depression (P = 0.018) while male gender showed a statistically significant association in case of anxiety (P = 0.028). The correlation between age and respective scores and GAD-7 scores and PHQ-9 scores was also found to be significant (P < 0.001).
Conclusion: These preliminary screening results provide convincing evidence of anxiety and depression among COVID-19 survivors, thus reiterating the need of timely detection and management of mental health issues through formulation of strategies to tackle the concurrent psychological comorbidities amid the ongoing pandemic.
Keywords: Anxiety, depression, COVID-19 survivors, mental health
How to cite this URL:
Kour P, Singh M, Sahni B. Assessment of mental health among hospital-discharged patients of COVID-19 in North India: A cross-sectional study. Arch Ment Health [Epub ahead of print] [cited 2023 Mar 24]. Available from: https://www.amhonline.org/preprintarticle.asp?id=365909 |
| Introduction | |  |
Since the beginning of 2020, when COVID pandemic was declared a public health emergency of international concern by the WHO, it has wreaked havoc and adversely affected the lives of each and every individual globally.[1] Apart from morbidity and mortality, COVID-19 pandemic has also upended the health-care delivery system and the global economy.[2],[3],[4] It is common knowledge that no one was untouched by this disease and many perished. Due to an increase in rates of infectivity and unpredictable course of this illness, many patients developed psychological issues.[5],[6] Loneliness, fear of losing a loved one or oneself, and financial crisis are among significant factors that contribute to anxiety and depression.[7] Duan and Zhu reported the negative impact of the epidemic and the need for interventions to mitigate the adverse impact of the same.[8] Zheng highlighted an increase in occurrence of posttraumatic stress disorder (PTSD) and depression during the COVID-19 pandemic.[9] Moreover, existing literature documents that PTSD, anxiety, and depression were also prevalent among those who survived earlier outbreaks (2003 severe acute respiratory syndrome [SARS] and Middle East respiratory syndrome).[10],[11],[12] Among COVID-19 survivors, a recent meta-analysis evaluated the combined prevalence of mental health issues. As per this analysis, anxiety, psychological distress, and depression were 22%, 36%, and 21%, respectively.[13] A significant percentage of 31% for depression and 42% for anxiety were also observed among survivors by Mazza et al.[14] Clinically significant depression and anxiety among hospital-discharged COVID-19 patients were also reported by Liu et al.[15] In 2011, Manjunatha et al.[16] reviewed all the articles from 1950 to 2010 and inferred that there were acute and chronic ill effects of epidemics. The acute effects included behavioral disturbances and fear of being wrongly diagnosed, and the chronic effects ranged from mood disorders, dementia to mental retardation. The occurrence of anxiety and depression among COVID-19 survivors is an emerging domain of interest among mental health researchers globally. With this background, we conceptualized the present study in an attempt to screen individuals on a pilot basis so to estimate the burden of anxiety and depression among COVID-19 survivors in Jammu region. It is also the first dedicated investigation on the prevalence of anxiety and depression in our region and a practical and rapid screening tool in general practice to decide whether or not to seek further diagnostic confirmation.
Objectives
The aim of the present study is to assess the prevalence of anxiety and depression among COVID-19 survivors after hospital discharge and to examine its association with individual characteristics including demographic variables.
| Methods | | |
Ethics
The study protocol was approved by the institutional review board. Informed consent was taken from each patient, and confidentiality regarding it was maintained.
Study design
This study was conducted among patients who had confirmed COVID-19 diagnosis and were admitted in COVID-19 wards in a tertiary care hospital in Jammu region between September 1, 2020, and March 31, 2021. Patients were interviewed after being discharged from the hospital, i.e., data were collected retrospectively during July–December 2021. Verbal informed consent was obtained from all the participants after briefing them about the purpose of the study in a language they could understand. Patients who were alive at the time of interview and who were ready to participate in the study were included. Those with non-COVID respiratory tract infections and any history of past psychiatric disorders were excluded from the study.
The sample size required for the current study was calculated using OpenEpi toolkit version 3.01. The sample size of 144 was calculated using a prevalence of 10.4%,[15] and an absolute precision of 5% at 95% confidence limits, and a design effect of 1. However, after screening and applying inclusion and exclusion criteria, 150 subjects were included in the study [Figure 1].
Study procedure
All records of the patients were gathered from the hospital files, and patients were contacted telephonically as well as personally (where telephonic contact could not be made) and interviewed using the Generalized Anxiety Disorder 7(GAD-7) scale and Patient Health Questionnaire-9 (PHQ-9). GAD-7 is a seven-item questionnaire used to screen for and evaluate the severity of anxiety disorder. PHQ-9 is a nine-item questionnaire used to screen for, track, and assess the severity of depression.
Statistical analysis
The primary analysis was done to assess the prevalence of anxiety and depression after COVID-19. The secondary analysis was done to establish the relationship between suspected risk factors for COVID-19, i.e., age, sex, any comorbidity and corticosteroid administration, and presence of anxiety/depression. All data obtained from respondents were entered into Microsoft Excel and analyzed using the Statistical Package for the Social Sciences (SPSS) version 23.0 (IBM Corp., Armonk, NY, USA) and OpenEpi toolkit version 3.01 (Dean AG, Sullivan KM, Soe MM. Open-Source Epidemiologic Statistics for Public Health, version.www.OpenEpi.com, updated April 06, 2013), after performing the necessary checks for the completeness of the raw data. The normal distribution of study variables was assessed using Q-Q plots and the Kolmogorov–Smirnov test. Categorical variables were presented as counts and percentages (%) and quantitative data were presented as mean ± standard deviation/mean rank. The significance of group medians was determined using the Mann–Whitney U-test. The Pearson's Chi-square was used to investigate the association between categorical variables and increasing level of anxiety and depression. All tests were performed at a 5% level of significance, which means that a relationship was significant if the two-tailed “P” < 0.05.
| Results | | |
In the present study, 150 patients were included. 61.33% of the patients were male and 38.7% were female. The mean age was 56.8 years (±13.22). 78.7% belonged to urban areas and 21.3% were rural residents. Seventy-two percent of the patients were Hindus followed by 24.7% of Sikhs and 3.3% of Muslims. Sixty-six percent of the patients reported some sort of comorbid condition. During the course of treatment, steroids were prescribed to 81% of the patients [Table 1].
As depicted in [Table 2], the difference in median scores was statistically significant for all age groups for both questionnaires, whereas difference in median scores for gender was only statistically significant for GAD-7 scores.
According to [Table 3], 78.7% of the patients had no anxiety (n = 118) and 21.3% of the survivors (n = 32) had anxiety (mild to moderately severe). Severe anxiety was not present among the survivors. Age above 40 years (P = 0.041) and male gender (P = 0.028) showed a statistically significant association with anxiety using Chi-square test. However, in case of comorbidity and corticosteroid administration, it was observed that, out of all the respondents who reported anxiety (n = 32), 75.0% and 84.4% had comorbidities and were given corticosteroids, respectively, but the association was not statistically significant. Out of all the survivors, 29.3% (n = 44) had mild-to-moderately severe depression. None of the survivors had severe depression. Age above 40 years was found to be statistically significant with depression using Chi-square (P = 0.018). The proportion of males reporting mild-to-moderately severe depression (70.5%) was higher than females, but the difference was not statistically significant. In case of steroid intake, mild, moderate, and moderately severe depression was more (70.5%) among those who were given corticosteroids, but the results were not statistically significant as was the case with regard to comorbidities [Table 4]. | Table 2: Comparison of Generalized Anxiety Disorder-7 scores and Patient Health Questionnaire-9 scores among COVID-19 survivors
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 | Table 3: Association of demographic and health variables with increasing levels of anxiety using Generalized Anxiety Disorder-7 scores
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 | Table 4: Association of demographic and health variables with increasing levels of depression using Patient Health Questionnaire-9 scores
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On evaluation, majority of the patients, in proportion, have mild anxiety and depression, as depicted in [Figure 2] and [Figure 3]. | Figure 2: Percentage of anxiety among COVID-19 survivors. *None of the survivors reported severe anxiety
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 | Figure 3: Percentage of depression among COVID-19 survivors. *None of the survivors faced severe depression
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As shown in [Table 5], the correlation between age and respective scores and GAD-7 scores and PHQ-9 scores was also found to be statistically significant at the 0.001 level (two-tailed). Survivors with anxiety or depression were asked to come to the outpatient department for counseling and management wherever required. | Table 5: Correlation between General Anxiety Disorder-7 scores and age, Patient Health Questionnaire-9 scores and age, and General Anxiety Disorder-7 scores and Patient Health Questionnaire-9 scores
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| Discussion | | |
The world has witnessed many epidemics. In historical times, influenza epidemics such as Asian flu, Spanish flu, Asian flu, Hong Kong flu, Russian flu, and H1N1 flu have affected the human race more than any other. As per Lee et al., 10%–20% of those who recovered from 2003 SARS outbreak reported psychological disturbance.[10] In our study, 21.33% of the patients had anxiety. These findings are similar to those reported by Cai et al.[17] According to Imran et al., COVID-19 survivors shared a comparable prevalence of anxiety.[18] This study's outcomes are in agreement with Xiao et al. data, which states that 22.6% of the survivors suffered anxiety.[19] Dorri et al. stated that 18% of the survivors reported facing anxiety.[20] As per our results, 29.3% of the patients had depression which is in concordance with a study by Xiao et al.[19] According to Mazza et al.[14] and Cai et al.,[17] COVID-19 survivors had depression in respective proportions of 31% and 38.1%. Another evaluation by Jafri et al.[21] is in line with our study which reveals majority of the patients had mild depression. Data of a meta-analysis of psychological sequelae among COVID-19 survivors also depicted that 22% of the patients had anxiety and 21% had depression.[13] The most plausible causes of increased psychological morbidity appear to be the intensity of the sickness in comparison to past pandemics[22] and the potential for severe acute respiratory syndrome coronavirus 2 reinfection following recovery.[23],[24] People are inundated with information as a result of the use of cell phones and the Internet, which has increased uncertainty about the condition as well as unjustified worries and fears. Furthermore, high levels of externalized stigma were found in a study by Dar et al.[25] among COVID-19 survivors. Corticosteroids were given to more than half of the patients (81.33%) in the current study. Corticosteroids were included in the WHO model list of essential drugs and are widely available at lower costs in a variety of dosage forms, including tablets, intravenously, suppositories, and oral concentrates.[26] This could have been the reason for prescribing more corticosteroids. Regardless of the fact that steroid-related psychiatric side effects among COVID-19 survivors have been documented in the literature, they were not statistically significant in the present analysis.[27] In our research, 66% of the patients were suffering from comorbidities, which is in congruence with the results from the west, where Martos Pérez et al. showed an overall 62% prevalence of comorbidities.[28] As per our study, anxiety and depression are more common in those over the age of 35 years which is consistent with a study by Dar et al.[29] Our investigation shows that male survivors suffer anxiety more than female survivors, which is contrary to Wang et al.[30] findings, which suggested that female survivors experienced anxiety more than male survivors. In our region of the world, young to middle-aged males work mostly for wages and support the family. Moreover, the financial repercussions and long-term socioeconomic uncertainty brought by the epidemic were even more significant than any previous economic downturns and recessions and are known to seriously influence men's mental health and lead to an increase in suicides.[31],[32],[33] Reason for this disagreement can be that in our study we have 72% of males. In line with a study by Lee et al., the current analysis highlights a significant correlation between the questionnaires PHQ-9 and GAD-7.[34] Furthermore, the present report identifies the correlation between age and GAD-7 scores and between age and PHQ-9 scores, which is in consistent with the research by Alharthy et al.[35] and Saldanha et al.[36]
The current study is monocentric, which means that the number of participants and their diversity are both limited. In this investigation, there was no baseline information on the individual's mental health. Being a cross-sectional study, we did not track the mental health of the participants over time. Literature review suggests that occupation may have an impact on anxiety and depression, but data on occupation were not collected in the present study. However, the study's strength is that the patients were interviewed by a postgraduate undergoing training in psychiatry which increased the internal validity of the study and enabled the researchers to focus on clinical diagnosis of the patients which would serve as baseline information for future reference and management. Furthermore, interview technique used in the present study is better than self-administered questionnaire as far as collection of data is concerned. In our study, we used a standardized questionnaire to collect the data; therefore, our findings also have external validity.
| Conclusion | | |
The present study has documented convincing evidence of anxiety and depression among COVID-19 survivors, thus emphasizing on the need to sensitize primary care physicians at grassroots level on the usage of simple scales such as GAD-7 and PHQ-9 for screening and grading of severity of mental health issues. Strengthening of primary health-care settings to screen, diagnose, and manage psychological morbidities among COVID-19 survivors should be prioritized. There is a pressing requirement for multicentric, longitudinal studies evaluating various aspects of mental well-being after suffering from COVID-19 which should include women and men in numbers adequate for assessment of gender effects. Randomized trials are also needed to examine the effect of counseling and health education, so as to guide the formulation of treatment guidelines for mental health of COVID-19 survivors to improve the quality of life among them.
Acknowledgments
The authors would like to thank all the study participants and respondents for their cooperation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Correspondence Address:
Manmeet Singh,
Department of Psychiatry, Acharya Shri Chander College of Medical Sciences and Hospital, Majeen Sidhra, Jammu - 180 017, Jammu and Kashmir
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/amh.amh_147_22
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5] |
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