|Ahead of print publication
Psychological status of asymptomatic and mildly symptomatic patients hospitalized for COVID-19
Prateksha Golas1, Uzma Hashim1, Amrit Kumar2, Seby Kuruthukulangara1, Vivek Hande3, Sheila S Mathai3
1 Department of Psychiatry, INHS Asvini, Mumbai, Maharashtra, India
2 Department of Internal Medicine, INHS Asvini, Mumbai, Maharashtra, India
3 INHS Asvini, Mumbai, Maharashtra, India
|Date of Submission||20-Aug-2020|
|Date of Decision||02-Sep-2020|
|Date of Acceptance||19-Nov-2020|
|Date of Web Publication||07-Apr-2021|
Department of Psychiatry, INHS Asvini, Mumbai - 400 005, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: The pandemic of COVID-19, with its high rates of infectivity, unpredictable nature, and measures taken to deal with it such as extended periods of lockdown, has had an adverse impact on the psychological status of individuals affected by it directly or indirectly. To the best of our knowledge, this is the first report from India on the psychological status of COVID-19-positive individuals. Aim: The aim of the study was to assess the impact of COVID-19 pandemic on the psychological status of persons tested positive for COVID-19. Setting and Design: This was a case–control study in a tertiary care hospital setting at Mumbai. Materials and Methods: A total of 104 individuals detected to have positive COVID-19 status and admitted to the hospital from May 1, 2020 to May 30, 2020, were compared with 106 age- and gender-matched controls from the general population for the psychological impact of COVID-19 as measured by Perceived Stress Scale-10, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7 Questionnaire, Insomnia Severity Index, and World Health Organization Well-Being Index-5. Statistical Analysis Used: Group comparisons on nominal variables were analyzed by Chi-square test. P < 0.05 was taken as statistically significant. Results: About 58.6% from COVID-19-positive group and 76.4% from control group reported moderate-to-high perceived stress. Moderate-to-severe depressive symptoms were reported in 6.7% versus 15%, moderate-to-severe anxiety symptoms in 1.9% versus 14.1%, clinical insomnia in 3.8% versus 14.1%, and poor quality of well-being in 22.1% versus 35.8%, in cases versus controls, respectively. Control group reported significantly higher levels of perceived stress (P = 0.020), depressive symptoms (P = 0.021), anxiety symptoms (P = 0.013), insomnia severity (P = 0.045), and poorer well-being index (P = 0.018) compared to COVID-19-positive group. Conclusions: Despite limitations, study findings, if replicated, highlight the urgent need for incorporating psychological screening and interventions into protocols for dealing with ongoing COVID-19 pandemic not only for infected individuals but also for the community as a whole.
Keywords: Anxiety, COVID-19 positive, depression, insomnia, perceived stress, psychological status, well-being
| Introduction|| |
The pandemic of COVID-19 with enforced lockdown measures has resulted in widespread public distress and mental health issues which are fueled by an increasing number of reported cases, unpredictable future of this pandemic, travel bans, and misinformation, often driven by erroneous news reports and the public's misunderstanding of health messages. Those with preexisting mental health conditions face a deterioration in their mental health. Others, who were previously unaffected by mental health issues, have found that they too are vulnerable. Those people who contract the disease, or are at an increased risk, like the elderly or those with compromised immune function, are particularly vulnerable to the psychosocial issues.
India has reported 6,227,295 number of COVID-19 cases as of October 13, 2020. Mumbai is one of the worst affected cities in India with 231,070 number of cases reported as of October 12, 2020. Although there have been a few studies from India focusing on the mental health impact of the COVID-19 pandemic in the general population and in health professionals,, to best of our knowledge, no studies have been reported from India about the psychological status of COVID-19-positive individuals. The aim of this study was to assess the impact of COVID-19 pandemic on the mental health status of persons tested positive for COVID-19.
| Materials and Methods|| |
This was a case–control study.
This study was conducted at a tertiary care hospital setting in Mumbai, India, which caters to serving armed forces personnel, veterans, and their dependents. All persons who were detected to have positive COVID-19 status reporting to the hospital were admitted irrespective of whether they were symptomatic or asymptomatic.
The study was conducted in persons detected to have positive COVID-19 status by RT-PCR and admitted in a tertiary care hospital setting at Mumbai from May 1, 2020, to May 30, 2020. Persons who were critically ill or had respiratory distress (SpO2 <85%) were excluded as they were too ill to respond to the survey through an online form. Age- and gender-matched healthy persons selected from the same community as cases were the controls.
After obtaining informed consent, the sociodemographic data and measurements for psychological status were collected through an online form from the participants. Clinical details were sourced from the treating team. Psychological status of cases and controls was measured through the following scales:
Perceived Stress Scale
Perceived Stress Scale (PSS-10) is a ten-item instrument for measuring the perception of stress. It is a self-administered measure of the degree to which situations in one's life are appraised as stressful and has been used in previous Indian studies.
Patient Health Questionnaire
Patient Health Questionnaire (PHQ-9) is a nine-question self-administered instrument which is used to grade the severity of depressive symptoms and has been used in previous Indian studies.
Generalized Anxiety Disorder Questionnaire
The Generalized Anxiety Disorder (GAD-7) questionnaire is a seven-item, self-administered questionnaire which is used as a screening tool and severity measure for anxiety symptoms and has been used in previous Indian studies.
Insomnia Severity Index
The Insomnia Severity Index (ISI) is a seven-item self-administered instrument designed to assess the nature, severity, and impact of insomnia and monitor treatment response in adults and has been used in previous Indian studies.
World Health Organization Well-Being Index
The World Health Organization Well-Being Index (WHO-5) is a 5-item self-administered rating scale which is designed to measure subjective well-being and has been used in previous Indian studies.
Participants who reported psychological distress were provided the option of appropriate interventions in the form of telephonic counseling, pharmacotherapy, or both, in consultation with the primary treating team. The study protocol was approved by the institutional ethics committee.
Data were analyzed using GNU PSPP Statistical Analysis software version 1.2.0, Boston, Massachusetts, USA. Group comparisons on nominal variables were analyzed by the Chi-square test. P < 0.05 was taken as statistically significant.
| Results|| |
From May 1, 2020, to May 30, 2020, a total of 221 individuals who tested positive for COVID-19 by RT-PCR were admitted to the hospital. Out of this, 19 individuals were excluded from the study as they were either critically ill or had respiratory distress (SpO2 <85%). The questionnaire was sent to the remaining 202 individuals, of which 139 individuals (68.8%) responded and 104 individuals (51.5%) consented to participate in the study, who were included in the study. A similar online form was sent to 200 individuals selected from the same community as cases, of which 106 individuals (53%) consented to participate in the study.
Majority of the participants were from the younger age group (<30 years) (65.4% of the COVID-19 positive group and 65.1% of the control group). Majority were males (85.6% of the COVID-19 positive group and 80.2% of the control group).
The COVID-19 positive group and the control group did not differ significantly in the sociodemographic variables including age, gender, marital status, living circumstances, place of origin, education, occupation, and household monthly income [Table 1].
Out of 104 COVID-19-positive individuals, 16 individuals (15.4%) had preexisting medical condition, most common being hypertension (five individuals) and diabetes mellitus (three individuals). One person had a history of pulmonary tuberculosis and one person had chronic obstructive pulmonary disease in the past. Out of the 106 controls, five individuals (4.7%) had preexisting medical conditions, the most common being hypothyroidism (two individuals).
Out of 104 COVID-19-positive individuals, two individuals (1.9%) had a history of panic disorder. Out of 106 controls, four individuals (3.8%) had a history of psychiatric disorders, the most common being depression (two individuals).
Out of 104 COVID-19-positive individuals, 88 individuals (84.6%) received hydroxychloroquine, 38 individuals (36.5%) received antibiotics, and eight individuals (7.7%) each had received oxygen support and intravenous fluids.
The outcome data are tabulated in [Table 2]. Majority of individuals in the COVID-19-positive group (58.6%) and control group (76.4%) reported moderate-to-high perceived stress [Figure 1]. Moderate-to-severe depressive symptoms were reported by 6.7% individuals from the COVID-19-positive group and 15% of individuals from the control group [Figure 2]. The COVID-19-positive group reported moderate-to-severe anxiety symptoms in 1.9% of individuals, while 14.1% of individuals in the control group reported the same [Figure 3]. Clinical insomnia was reported by 3.8% of individuals from the COVID-19-positive group and 14.1% of individuals from the control group [Figure 4]. Poor quality of well-being (well-being index <25%) was reported by 22.1% of individuals from the COVID-19-positive group and 35.8% of individuals from the control group [Figure 5].
| Discussion|| |
In our study, majority of individuals in the COVID-19-positive group (58.6%) and control group (76.4%) reported moderate-to-high perceived stress as measured by PSS-10. No similar data of perceived stress in COVID-19-positive individuals were available from previous studies for comparison. A recent case–control study by Guo et al. assessed posttraumatic stress instead of perceived stress and reported posttraumatic stress symptoms in 1% of COVID-19 patients and 1.9% of individuals from the general population. A few recent studies reported lower levels of perceived stress in the general population during COVID-19 pandemic. For example, a study by Wang et al. conducted by online survey of 1210 individuals in the general population of China revealed 8.1% moderate-to-severe stress. An Indian study by Grover et al. in 1685 individuals from the general population reported a very high rate of moderate level of stress in 74.1%. Our study findings on perceived stress were similar to that reported by Grover et al. The higher rates of moderate-to-severe perceived stress found in our study compared to studies from China could be due to factors such as the Mumbai city being one of the worst affected in the country, alarming rise of reported cases in the month of May 2020 when the study was conducted, and the widespread distress associated with strictly enforced extended lockdown measures at that time.
Moderate-to-severe depressive symptoms as measured by PHQ-9 were reported by 6.7% of individuals from the COVID-19-positive group. Our study reported relatively lower rates of depressive symptoms among COVID-19-positive group as compared to other recent studies. A cross-sectional study by Zhang et al. in 57 COVID-19-positive patients reported significant depressive symptoms in 29.2% of COVID-19-positive patients, whereas Guo et al. reported depressive symptoms in 60.2% of COVID-19 patients. Mak et al. reported 15.6% of survivors of a previous SARS epidemic to be having depressive disorders.
On the other hand, our study revealed that 15% of individuals in the control group reported moderate-to-severe depressive symptoms as measured by PHQ-9 which were similar to that reported in recent studies. Wang et al. reported moderate-to-severe depressive symptoms in 16.5% of individuals from the general population, whereas Zhang et al. reported severe depressive symptoms in 14.3%. However, Guo et al. reported depressive symptoms in higher number of individuals (31.1%) from the general population. Compared to studies from China, Grover et al. from India reported depressive symptoms in 10.5% of the general population studied.
Moderate-to-severe anxiety symptoms as measured by GAD-7 were reported by 1.9% of individuals in COVID-19-positive group, which were much lower than that reported in recent Chinese studies. Guo et al. reported anxiety symptoms in 55.3% of COVID-19 patients, whereas Zhang et al. reported depressive symptoms comorbid with anxiety among 21.1% of COVID-19-positive patients.
Further, 14.1% of individuals in the control group reported moderate-to-severe anxiety symptoms as measured by GAD-7. This was lower than that reported in other recent studies. Wang et al. reported moderate-to-severe anxiety symptoms in 28.8% of individuals from the general population, while Guo et al. reported anxiety symptoms in 22.3% and Zhang et al. reported depressive symptoms comorbid with anxiety among 22.4% of individuals from the general population. From India, Grover et al. reported anxiety symptoms in 38.2% of individuals in the general population studied.
Clinical insomnia as measured by ISI was reported by 3.8% of individuals from COVID-19-positive group and 14.1% of individuals from the control group. Well-being index <25%, which indicates poor quality of well-being as measured by WHO-5, was reported by 22.1% in COVID-19-positive group and 35.8% in the control group. No similar data on insomnia and well-being were available for comparison from previous studies on COVID-19-positive individuals.
Interestingly, our study found higher levels of perceived stress (76.4% vs. 58.6%), depressive symptoms (15% vs. 6.7%), anxiety symptoms (14.1% vs. 1.9%), insomnia severity (14.1% vs. 3.8%), and poorer quality of well-being (35.8% vs. 22.1%) in the control group as compared to that in COVID-19-positive group. This was an unexpected finding, and we postulate possible factors for these findings based on telephonic interviews with some of the cases and controls. First, COVID-19-positive individuals who were critically ill or had severe respiratory symptoms had to be excluded from the study, and the sample studied had asymptomatic or mildly symptomatic individuals with understandably relatively less psychological distress. Second, some of the COVID-19-positive individuals in the study reported perceiving the hospital setting to be a safer confinement compared to some in the control group who had a fear of the unknown. Third, a few COVID-19-positive individuals reported having a sense of mastery over the situation, as they had been infected with the perceived deadly virus but did not have complications, and would be developing antibodies for it, thus rendering them immune.
Our study had some limitations. As this was an explorative study, the sample size was not calculated. A case-to-control ratio of 1:1 was kept in our study for logistical reasons, though a ratio of 1:2 would have increased the statistical power of the study. There were potential biases in our study. Only asymptomatic or mildly symptomatic individuals were included in the study, and persons who were critically ill or had respiratory distress (SpO2 <85%) who are likely to have poor psychological health as reported in previous studies were excluded from the study. Due to the requirement of isolation, individuals could not be interviewed in person, and data were collected through online forms. The response rate was 51.5% in COVID-19-positive group and 53% in controls, possibly due to restrictions on in-person access to individuals to motivate them to participate. As the sample size was small, multivariate analysis could not be done. Finally, caution is needed in extrapolating findings from our control group to the general population, as the sampling of controls from the community was not random.
| Conclusion|| |
Despite these limitations, our study findings have important implications in tackling the psychological distress from the ongoing pandemic. Our findings of high levels of perceived stress, symptoms of depression, anxiety and insomnia, and low levels of well-being, in both COVID-19-positive individuals and controls from the community, highlight the need for routine screening for psychological issues and psychological interventions to be incorporated into the protocol for dealing with the pandemic not only for the infected individuals but also for the community as a whole. There is also an urgent need to replicate our study findings, preferably in a large sample, multi-site research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]