|Year : 2021 | Volume
| Issue : 1 | Page : 4-9
A cross-sectional study of psychological distress in patients hospitalized for COVID-19
Srilakshmi Pingali1, Ajay Kumar Joopaka2, Pradeep Sharma Telkapalli3, Molanguri Umashankar4
1 Associate Professor, Department of Psychiatry, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
2 Assistant Professor, Department of Psychiatry, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
3 Postgraduate, Department of Psychiatry, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
4 Professor and Head, Department of Psychiatry, Gandhi Medical College and Hospital, Secunderabad, Telangana, India
|Date of Submission||27-Nov-2020|
|Date of Acceptance||14-Jan-2021|
|Date of Web Publication||20-Apr-2021|
Dr. Ajay Kumar Joopaka
Department of Psychiatry, Gandhi Medical College and Hospital, Secunderabad - 500 003, Telangana
Source of Support: None, Conflict of Interest: None
Introduction: The novel coronavirus disease-19 (COVID-19) which started in China has now spread across the world. Many measures to contain the pandemic are being employed like hospitalization of patients tested positive, quarantine of contacts, and social distancing. The consequent social isolation and the uncertainty of the disease has led to psychological distress.
Aims and Objectives: The aim was to study the psychological distress and its associated factors in patients hospitalized for COVID-19.
Materials and Methods: A cross-sectional study was done in a designated COVID center where patients tested positive were admitted from all over the state. A total of 222 hospitalized COVID-19 patients were screened using the Patient Health Questionnaire-4 and those who screened positive had their diagnosis confirmed by using the International Classification of Disease 10 criteria.
Results: A total of 222 patients were screened of which 22.1% showed distress, 12.6% showed mild distress, and 9.5% moderate distress. Depression criteria were met by 5.5% and 3.2% had generalized anxiety disorder. Factors significantly associated with distress were deaths in the family and duration of hospitalization, whereas family members affected with COVID-19 were inversely related to psychological distress.
Conclusion: Having a number of family members affected and simultaneously admitted in the same hospital seems to have acted as a buffer against psychological distress. However, deaths in the family due to COVID-19 and long duration of hospitalization were found to be factors associated with psychological distress. Efforts should be made to treat not only the physical health but also address the psychological distress in patients hospitalized for COVID-19.
Keywords: COVID-19, hospitalized, Patient Health Questionnaire-4, psychological distress
|How to cite this article:|
Pingali S, Joopaka AK, Telkapalli PS, Umashankar M. A cross-sectional study of psychological distress in patients hospitalized for COVID-19. Arch Ment Health 2021;22:4-9
|How to cite this URL:|
Pingali S, Joopaka AK, Telkapalli PS, Umashankar M. A cross-sectional study of psychological distress in patients hospitalized for COVID-19. Arch Ment Health [serial online] 2021 [cited 2021 Oct 22];22:4-9. Available from: https://www.amhonline.org/text.asp?2021/22/1/4/314188
| Introduction|| |
COVID-19 or the novel coronavirus pandemic started in December 2019, like a viral outbreak in Wuhan city of Central Hubei province of China. Since then, it has spread rapidly across the globe and has been deemed a pandemic by the World Health Organization on March 11, 2020. India reported its first case in January 2020. As the medium of spread is via aerosols and droplet infections, containment measures such as quarantine, isolation, and hospitalization of positive cases have been undertaken. Studies have shown that measures like isolation which is separation of infectious patients from noninfectious ones to curtail the spread of disease takes a toll on mental health. Commonly detected mental health issues in this population included depression, anxiety, psychological distress, posttraumatic stress disorder, stigmatization, and low self-esteem among others., The uncertainty of the situation has further aggravated the effect on mental health. Studies in both the general population and in hospitalized patients show a significant impact on mental health. Studies from India in the general population have shown one-third of the population under study to be suffering from various degrees of psychological impact with the female gender, younger age group, and those having comorbid physical illnesses to be more likely to be affected. Symptoms of stress in the general population have ranged from 74% to 80%. Anxiety was shown in some studies to be 38.4% and depression to be 10.5%.,
Studies specific to the mental health of patients infected with or recovering from COVID-19 have also shown significant mental health issues such as loneliness, anxiety, depression, and phobia. A feeling of being stigmatized, prolonged periods of isolation, and uncertainty of the test report which determined their discharge from the hospital compounded the issue in patients hospitalized for COVID-19.
Studies specific to hospitalized patients have shown the stress levels to be 31%, anxiety 22.2%, and depression ranged from 24.5% to 38.1%. Like in Patients hospitalised with Covid 19 ,fyounger age group and female gender were significantly more stressed. In addition having family members infected with Covid 19 and having post infection physical discomfort also corelated strongly with stress.,
At the time of conducting this study, very few studies had been done on hospitalized COVID-19 patients in India, one of which is a case series on hospitalized COVID-19 patients that reported feelings of internalized stigma, guilt, and anger toward self to be the predominant feelings. To address this lacuna, we aimed to study the psychological distress of hospitalized COVID-19 patients and factors associated with the same.
| Materials and Methods|| |
The study was done in a designated COVID-19 center which caters to the entire state. At the time of study, all patients who tested positive, whether or not they were symptomatic, were hospitalized from all over the state in the above center with an aim to prevent community spread. They were discharged only after they tested negative after a minimum of 14 days of hospitalization. All patients were admitted in the general wards of the hospital.
All hospitalized COVID-19 patients were routinely screened face to face for psychological distress. A cross-sectional study of all adult cases screened between May 10, 2020 and May 1, 2020, not requiring intensive medical care, including supported oxygen were taken up for the study. Sampling technique was convenient sampling. Audio recorded, informed verbal consent was obtained and those willing were taken up for the study. A total of 222 cases were screened during this period of the study. Sociodemographic and clinical details were recorded using a semi-structured pro forma. The Patient Health Questionnaire-4 (PHQ 4) an ultrabrief screening for anxiety and depression was used to screen for depression and anxiety by the first three authors. PHQ-4 has a total of 4 questions, with the first two being taken from the generalized anxiety disorder (GAD 7), and the next two from the patient health questionnaire -9 (PHQ-9). PHQ-4 total scores range from 0 to 12, with categories of psychological distress being: none – 0–2, mild – 3–5, moderate – 6–8, and severe – 9–12. The first two questions make up the anxiety subscale with scores ranging from 0 to 6 and those scoring more than 3 were considered positive for screening for anxiety and the next two questions were for depression which were similarly scored. All those who screened positive for anxiety or depression were subject to further clinical interviews by the first and second authors and diagnosed applying the International Classification of Disease 10 criteria.
The data so obtained were analyzed using the Statistical Package for the Social Sciences 22.0 (IBM® SPSS® Statistics, New York, United States).
The categorical values were described in percentages and frequency and continuous variables as mean and standard deviation. Chi-square test was performed to examine the relationship between categorical variables and when the count was <5 in 20% of the cells, the Fisher's exact test was used. Nonparametric test, the Kruskal–Wallis test, was applied where the continuous variable followed a nonnormal distribution. Institutional ethics committee approval was obtained.
| Results|| |
A total of 222 patients were evaluated during the study period and the results are presented below.
The sociodemographic profile of the patients showed the mean age of patients to be 32 years with the majority of them between the ages of 18 and 35 (53.2%), male gender (55.9%), having high school education (33.8%), married (69.8%), belonging to nuclear families (65.8%), and hailing from an urban background (87.9%). About 21.6% had comorbid physical illness, mostly diabetes or hypertension. Only three cases of the total population under study had a past history of mental illness and two had a positive family history of mental illness. Multiple family members were found to be affected in 42.8% of the cases and deaths due to COVID in the family were found to be 6.3% [Table 1].
The PHQ-4 scores showed 22.1% to be having psychological distress of which 12.6% had mild and 9.5% had moderate distress. Patients scoring between 6–8 and 9–12 were clubbed into one category of scores above 6 (moderate) as only one scored between 9 and 12. On evaluating for depression and anxiety in the patients screened positive on PHQ-4, 5.5% met the criteria for depression and 3.2% met the criteria for GAD [Table 2].
The factors showing significant association with distress were deaths in the family (P = 0.023), with cases having deaths in the family having more distress. The other factor significantly associated was the number of family members affected, with less distress expressed in those who have multiple family members affected (P = 0.013). No other variable under study was significantly associated with PHQ scores [Table 3].
|Table 3: Association of sociodemographic variables with Patient Health Questionnaire scores|
Click here to view
As the variable “number of days since hospitalisation” followed a nonnormal distribution, the nonparametric test, Kruskal–Wallis test, was conducted. This was conducted to determine if there were differences in days of hospitalization scores between the groups that differed in their PHQ scores. The median scores of numbers of days of hospitalization were significantly different among the various PHQ groups, χ (2) = 5.995 and P = 0.05. Subsequent pairwise comparison showed a statistically significant difference in median scores of numbers of days of hospitalization between the PHQ 3–5 (mild distress ) and PHQ 0-2 (no distress ), P = 0.021.No difference was found between other group comparisons [Table 4].
|Table 4: The association between days since hospitalized and the Patient Health Questionnaire scores|
Click here to view
| Discussion|| |
The COVID-19 has changed the world as we know it. The uncertainty of the disease course, lack of a definite treatment, and the complete disruption of daily life due to measures such as quarantine, isolation, and lockdown has bought in its wake psychological distress. The patients hospitalized for COVID-19 form a special subgroup, as after being positive for COVID-19 they are isolated from family and friends and hospitalized. We aimed to study their psychological distress and associated factors. It was done in the early stages of the pandemic where any person who tested positive for COVID-19 was hospitalized, irrespective of whether they were symptomatic or not. As per our knowledge, there are no other studies from India in this population during this period. We therefore compared our findings with similar studies done in China. A study done on 103 quarantined mildly symptomatic COVID-19 patients reported high levels of anxiety and depression with 60% screening positive for depression and 55.3% for anxiety, whereas our study showed 5.5% and 3.2%, respectively. This marked difference could possibly be due to the different populations under study with circumstances unique to their own countries. This is further corroborated by the fact that the control group in the China study drawn from the general population showed high levels of depression (31%), whereas studies from India in the general population showed depression in about 10.5%. Similarly, studies done on psychological distress in the state of Tamil Nadu from India showed 77.2% having no or low stress, similar to our findings in hospitalized patients.
Our study also differed in the sociodemographic parameters where majority of our study subjects were below the age of 35 years, whereas the population under study from China were older, between the ages of 31 and 50 years.
Another study from China on stress, depression, and anxiety in early convalescence of COVID-19 survivors showed postinfection physical discomforts and the presence of family members or relatives being infected was significantly associated with more symptoms of stress response, anxiety, and depression. Studies have shown that the isolation from family members and friends brings out helplessness and loneliness. Good social support acts as a buffer against stress. This could perhaps explain the low level of distress in our study population. Majority had family members who tested positive and admitted along with them in the same ward. They themselves would have acted as social support for each other keeping the stress levels low.
A multisite online study in 770-admitted patients in China showed depression to be 43.1%, half of which was mild depression. Depression was correlated with having a family member positive, female gender, and older age group. Less use of social media and severe COVID infection also correlated with a higher risk of depression.
The low prevalence of depression in our study could be explained by multiple factors different from the above study. Majority of our patients were male and of younger age group with mild or no symptoms. Although it was not specifically studied, there was no restriction on the use of mobile phones by our patients which, in turn, would have helped them to keep in touch with their family and friends and also receive regular updates about the illness. Our study subjects were either asymptomatic or mildly symptomatic which would have also contributed to low distress levels.
Studies have shown that having a past history of mental illness and having COVID-19-related physical symptoms were significantly associated with anxiety and depression. Our study had only three cases with a past history of mental illness probably accounting for the low rates of anxiety and depression.
Death in close relatives due to COVID was also another factor significantly associated with distress. The sudden expectedness of the death has probably added to the distress.
A longer stay in the hospital was associated with distress. Similar findings were found during the SARS pandemic where the duration of more than 10 days in quarantine was associated with symptoms of posttraumatic stress disorder. In our study, the mean duration of stay was 18.4 days which would explain the distress associated with the duration of hospitalization. In our study population, there was uncertainty regarding the duration of hospitalization as discharge was dependent on the patient testing negative for COVID after a minimum of 14 days of hospitalization. The later change in guidelines to 10 days' isolation and discharge followed by 7 days of home quarantine in COVID-positive patients, without any repeat testing, would have probably gone a long way in reducing the distress associated with prolonged hospitalization.
While the psychological distress in hospitalized COVID patients is inevitable, a number of factors contributing could easily be addressed. A clear admission/discharge policy, clear communication and allaying the patients' concerns, a regular supply of basic necessities, and providing timely mental health support could go a long way in mitigating the distress.
The strengths of the study have been that the patients were evaluated face to face and not by online or telephonic surveys. Patients who tested positive were further clinically evaluated by qualified psychiatrists to reach a diagnosis. The limitations of the study are that it is a single hospital-based study done on stable patients. Data collected during routine screening was used, without using a formula for sample size calculation. The questionnaire used was brief to limit the exposure of the researcher, but this, in turn, limited the illnesses screened to anxiety and depression. Further studies using a control group drawn from the general population would address the limitations of our study.
| Conclusion|| |
The low rate of distress, depression, and anxiety is possibly due to the fact that it was done in the early stages of the pandemic. Other than that, asymptomatic or mildly symptomatic cases taken for the study and having multiple family members admitted at the same time may have acted as a buffer against distress. Further studies focusing on feelings of shame, stigma, and discrimination should be considered which has shown to be high in other studies and psychological support planned accordingly.
We would like to acknowledge the Gandhi Medical College and hospital staff and faculty for cooperating with us during the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al
. First case of 2019 novel coronavirus in the United States. N Engl J Med 2020;382:929-36.
WHO Director-general's Opening Remarks at the Media Briefing on COVID-19. Geneva: World Health Organization; 2020 World Health Organization - 2020.
Gupta N, Praharaj I, Bhatnagar T, Vivian Thangaraj JW, Giri S, Chauhan H, et al
. Severe acute respiratory illness surveillance for coronavirus disease 2019, India, 2020. Indian J Med Res 2020;151:236-40.
] [Full text]
Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E, Villamizar-Peña R, Holguin-Rivera Y, Escalera-Antezana JP .Latin American Network of Coronavirus Disease 2019-COVID-19 Research (LANCOVID-19). Electronic address: https://www.lancovid.org
. Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel Med Infect Dis. 2020 Mar-Apr;34:101623. doi: 10.1016/j.tmaid.2020.101623. Epub 2020 Mar 13. PMID: 32179124; PMCID: PMC7102608.
Purssell E, Gould D, Chudleigh J. Impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis. BMJ Open 2020;10:e030371.
Hossain MM, Sultana A, Purohit N. Mental health outcomes of quarantine and isolation for infection prevention: A systematic umbrella review of the global evidence. Epidemiol Health 2020;42:e2020038.
Hawryluck L, Gold WL, Robinson S, Pogorski S, Galea S, Styra R. SARS control and psychological effects of quarantine, Toronto, Canada. Emerg Infect Dis 2004;10:1206-12.
Varshney M, Parel JT, Raizada N, Sarin SK. Initial psychological impact of COVID-19 and its correlates in Indian community: An online (FEEL-COVID) survey. PLoS One 2020;15:e0233874.
Roy D, Tripathy S, Kar SK, Sharma N, Verma SK, Kaushal V. Study of knowledge, attitude, anxiety & perceived mental healthcare need in Indian population during COVID-19 pandemic. Asian J Psychiatr. 2020 Jun;51:102083. doi: 10.1016/j.ajp.2020.102083. Epub 2020 Apr 8. PMID: 32283510; PMCID: PMC7139237.
Grover S, Sahoo S, Mehra A, Avasthi A, Tripathi A, Subramanyan A, et al
. Psychological impact of COVID-19 lockdown: An online survey from India. Indian J Psychiatry 2020;62:354-62. [Full text]
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al
. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.
Grover S, Dua D, Sahoo S, Mehra A, Nehra R, Chakrabarti S. Why all COVID-19 hospitals should have mental health professionals: The importance of mental health in a worldwide crisis! Asian J Psychiatr. 2020 Jun;51:102147. doi: 10.1016/j.ajp.2020.102147. Epub 2020 May 5. PMID: 32473537; PMCID: PMC7199675.
Cai X, Hu X, Ekumi IO, Wang J, An Y, Li Z, et al
. Psychological distress and its correlates among COVID-19 survivors during early convalescence across age groups. Am J Geriatr Psychiatry 2020;28:1030-9.
Ma YF, Li W, Deng HB, Wang L, Wang Y, Wang PH, et al
. Prevalence of depression and its association with quality of life in clinically stable patients with COVID-19. J Affect Disord 2020;275:145-8.
Sahoo S, Mehra A, Suri V, Malhotra P, Yaddanapudi LN, Dutt Puri G, Grover S. Lived experiences of the corona survivors (patients admitted in COVID wards): A narrative real-life documented summaries of internalized guilt, shame, stigma, anger. Asian J Psychiatr. 2020 Oct;53:102187. doi: 10.1016/j.ajp.2020.102187. Epub 2020 May 30. PMID: 32512532; PMCID: PMC7261080.
Government of Telangana Director of Medical Education RC No: 51/SPL/1/DME/2020 2020 date: 29.03.2020 Circular-I Sub:-Public Health-COVID-19 Hospital Management-Revised Instructions.
Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics 2009;50:613-21.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.
Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-7.
World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organisation; 1992.
He F, Mazumdar S, Tang G, Bhatia T, Anderson SJ, Dew MA, et al
. Nonparametric manova approaches for non-normal multivariate outcomes with missing values. Commun Stat Theory Methods 2017;46:7188-200.
Guo Q, Zheng Y, Shi J, Wang J, Li G, Li C, et al
. Immediate psychological distress in quarantined patients with COVID-19 and its association with peripheral inflammation: A mixed-method study. Brain Behav Immun 2020;88:17-27.
Ramasubramanian V, Mohandoss AA, Rajendhiran G, Pandian PR, Ramasubramanian C. Statewide survey of psychological distress among people of Tamil Nadu in the COVID-19 pandemic. Indian J Psychol Med 2020;42:368-73.
Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry 2020;7:228-9.
Vishwak & Karri V, Satya & Jezreel, Tabitha & Afeen, Shadaan & Khairkar, Praveen. (2020). Psychosocial Impact of COVID-19 Lockdown on Mental Wellbeing among 11 States of India: A Markov Modeling Approach. Journal of Psychiatry and Psychiatric Disorders. 04. 10.26502/jppd.2572-519X0103.
Pignalberi C, Ricci R, Santini M. Psychological stress and sudden death. Ital Heart J Suppl 2002;3:1011-21.
[Table 1], [Table 2], [Table 3], [Table 4]