ABSTRACT
Introduction:
Coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on mental health, including stress, anxiety, and depression. This study aimed to assess the incidence and severity of mental health issues among individuals diagnosed with COVID-19 infection.
Methods:
A semi-structured proforma for socio-demographic and clinical parameters was used to collect cross-sectional hospital-based data of subjects who tested positive for COVID-19 infection. The Modified Fatigue Impact Scale (MFIS), Hospital Anxiety and Depression Scale (HADS), and Perceived Stress Scale (PSS) were used to assess the presence of physical, psychological, and cognitive symptoms. The presence of anxiety, depression, and stress was based on the cut-off scores for HADS-A (≥8), HADS-D (≥8), and PSS (≥14), respectively.
Results:
A total of 101 patients comprising 39 (38.6%) males were recruited. Compared to nuclear families, we observed that patients living in joint families had significantly greater severity scores for fatigue [MFIS (p = 0.04)], anxiety [HADS-A (p = 0.004)], depression [HADS-D (p = 0.004)], and stress [PSS (p = 0.02)]. Based on the cut-off scores, we found that 44 (43.6%) patient had anxiety, 41 (40.6%) had depressive, and 72 (71.3%) had moderate to high stress symptoms, respectively. We also observed significantly greater fatigue and anxiety scores, that is, MFIS (p = 0.008) and HADS-A (p = 0.03) in those who received oxygen therapy compared to those who did not. The subjects who received corticosteroids were older (p = 0.01) and had significantly higher stress scores [PSS (p < 0.001)]. The study showed that patients who were assessed more than 3 months post-COVID-19 infection had higher fatigue and depression scores; however, the difference did not reach statistical significance (MFIS P = 0.058; HADS P = 0.059).
Conclusion:
Our study confirms that COVID-19 infection can cause various adverse mental health issues. Mitigating the hazardous effects of COVID-19 pandemic on mental health should be a top priority for public health to prevent long-term complications.
Keywords: COVID-19 pandemic, Depression, Long COVID, Mental health, Post-COVID-19 condition, SARS CoV-2 infection
INTRODUCTION
In March 2020, the World Health Organization (WHO) declared the coronavirus infection 2019 (COVID-19) a Public Health Emergency of International concern. Early in the pandemic, the WHO had anticipated the surge of mental health consequences and had brought about a series of measures to support and enhance mental health and psychological well-being.[1] The sudden and prolonged lockdown, uncertainty about the viable treatment options and outcomes, shortage of resources and manpower, conflicting news from the media, and constant changes in management guidelines augmented the social and psychological impact of the pandemic. The death and devastation heightened the already stressful working conditions exacerbating the impact on mental health.[2]
Evidence from previous outbreaks such as the severe acute respiratory syndrome (SARS) has demonstrated the impact on mental health conditions. Lee et al.[3] (2007) found that SARS survivors had higher stress during the outbreak and the stress level persisted a year after infection. Healthcare workers who survived SARS showed higher stress levels than non-healthcare workers; they were also found to have had higher anxiety, depression, and posttraumatic symptoms.[3] A study by Mak et al.[4] in 2009 found that 30 months after SARS, the prevalence of psychiatric disorders was 33.3% with 25% diagnosed to have posttraumatic stress disorders (PTSD, and 15.6% with depression. According to recent review of SARS and the Middle East Respiratory Syndrome (MERS), post-infection psychiatric and neuropsychiatric presentations were common such as confusion (19.9%), depressed mood (10.5%), anxiety (12.3%), impaired memory (18.9%), and insomnia (12.1%).[5] There are several studies that have explored the psychological impact of COVID-19 infection. In their evaluation of the psychopathological impact of COVID-19 in survivors, Mazza et al.[6] (2020) discovered 28% had symptoms of PTSD, 31% depression, 42% anxiety, 20% with obsessive compulsive symptoms, and 40% had insomnia.
Long COVID or post-COVID-19 condition has been referred to as the persistence of physical and mental symptoms beyond three months of COVID-19 infection.[7] Some studies have explored the development of mental health symptoms in different time intervals after diagnosis of COVID-19 and the extent to how demographic profiles of COVID-19 survivors predict long-term mental health.[8,9] A review by Renaud-Charest et al.[10] (2021) revealed that depression was commonly seen in individuals as part of long COVID. In a meta-analysis on the profile of psychiatric symptoms among COVID-19 patients, Xie[11] (2021) noted that severe psychiatric symptoms reported by acute COVID-19 patients persisted in the early stages of recovery but with decreasing levels of severity. Interestingly, Bourmistrova et al.[12] in a recent review on long-term effects of COVID-19 on mental health noted that the prevalence of anxiety, depression, PTSD, and sleep disturbance was comparable to general population suggesting that the symptoms at longer term could be attributed to the indirect effect of COVID-19 psychosocial factors. Mazza et al. (2022) evaluated COVID-19 survivors at 1, 6, and 12 months and found 45% to have at least one psychopathological dimension at 12 months, 33% had pathological fatigue in 12 months, and an increasing trend was observed in males for depression and anxiety.[8] In a study conducted in North India, Dar and colleagues found that older COVID-19 survivors (>50 years) were more likely to show symptoms of anxiety and also experienced a greater level of PTSD.[9] However, it is not clear how long after the infection the symptoms were assessed. A more recent meta-analysis highlights the increased prevalence of psychological sequelae among COVID-19 survivors and warrants further research to identify effective and safe methods to mitigate the impact of psychosocial sequelae.[13]
In this study, we evaluated the prevalence of mental health symptoms at various time intervals after the COVID-19 diagnosis in a tertiary hospital in North-East India, using validated mental health instruments assessing depressive, anxiety, fatigue, and stress symptoms. We hypothesized that mental health symptoms would decline with time after being diagnosed with the COVID-19 infection and to explore which demographic profiles would be associated with more adverse mental health symptoms. Identification of the social and demographic parameters of patients with greater likelihood of having persistent COVID-19 psychosocial sequelae can improve our understanding of the impact of the disease and aid in developing and refining management strategies that are specific to the region.
METHODS AND MATERIALS
Approval for the study was granted by the Institutional Ethics Committee (Project No. P202/2021/202 dated 26th April 2021). Informed written consent was obtained from all the participants.
This was a hospital-based cross-sectional study of patients previously diagnosed with COVID-19 and was willing to participate in the study. The demographic and clinical data that were collected included age, gender, marital status, occupation, family type (nuclear or joint), habitat (rural or urban), education level (below 12th standard and above 12th standard), and the need for hospitalization. For those who were hospitalized, additional information was obtained such as duration of hospital stay including need for intensive care unit (ICU) admission and the need for oxygen therapy. Diagnosis of COVID-19 was based on the Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) test from a nasopharyngeal swab or positive antibody test for SARS-CoV-2 infection. Based on the reported calendar month of diagnosis, the time from diagnosis until data collection was coded as 1 month (0—30 days); 2–3 months (31— 90 days); or >3 months (>90 days). We used several validated mental health instruments, including screening measures for depressive and anxiety symptoms (Hospital Anxiety and Depression Scale, HADS) with the recommended cut-off of ≥8 for the presence of anxiety or depressive symptoms,[14] Modified Fatigue Impact Scale (MFIS), a modified version of the Fatigue Impact Scale[15] with greater scores indicating severe fatigue, and the total score ranges from 0 to 84 and the Perceived Stress Scale (PSS) with a recommended score of 0–13 as low stress, 14–26 as moderate stress, and 27–40 as high perceived stress.[16]
Statistical analysis
Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 26.0 (IBM, Chicago, IL, USA). Descriptive statistics for the socio-demographic and clinical characteristics were reported as numbers and percentages. The scores for the different mental health scales, namely HADS, MFIS, and PSS, were presented as mean (±SD). Differences in mean values of the mental health scales between the various socio-demographic and clinical variables were assessed using the independent sample test or analysis of variance (ANOVA), as applicable. A P value <0.05 was considered to be statistically significant.
RESULTS
A total of 101 participants were evaluated which comprised 39 (38.6%) males and 62 (61.4%) females. The socio-demographic and clinical characteristics of the study population are presented in Table 1. Among them, 62.4% were married, 59.4% were educated above 12th standard, 75.2% were urban, 78.2% were nuclear families, 44.6% were semi-skilled workers, and 37.6% were professionals. Of the 101 study participants, 37 (36.6%) were hospitalized. Of these, six (16.2%) required ICU admission, nine (24.3%) received oxygen therapy, and 28 (75.7%) had a hospital stay of more than 10 days duration. Based on the cut-off scores for HADS-A, HADS-D, and PSS, we found that 44 (43.6%) had anxiety, 41 (40.6%) had depressive, and 72 (71.3%) had moderate to high stress symptoms, respectively.
Table 1.
Socio-demographic and clinical data of the cohort
| Characteristics | N (%) | |
|---|---|---|
| Age | Male | 39 (38.6) |
| Female | 62 (61.4) | |
| Marital Status | Unmarried | 38 (37.6) |
| Married | 63 (62.4) | |
| Education | Below 12th standard | 41 (40.6) |
| Above 12th standard | 60 (59.4) | |
| Habitat | Rural | 25 (24.8) |
| Urban | 76 (75.2) | |
| Family type | Nuclear | 79 (78.2) |
| Joint | 21 (20.8) | |
| Occupation | Semi-skilled | 45 (44.6) |
| Professional | 38 (37.6) | |
| Others | 18 (17.8) | |
| Hospitalization | Yes | 37 (36.6) |
| No | 64 (63.4) | |
| Hospital stay | <10 days | 9 (24.3) |
| >10 days | 28 (75.7) | |
| ICU admission among hospitalized | Yes | 6 (16.2) |
| No | 31 (83.8) | |
| Oxygen therapy among hospitalized | Yes | 9 (24.3) |
| No | 28 (75.7) | |
Table 2 shows the comparison of the different mental health scales for fatigue, anxiety, depression, and stress between the socio-demographic and clinical variables. We found that patients living in a joint family setting had significantly higher MFIS (p = 0.04), HADS-A (p = 0.004), HADS-D (p = 0.004), and PSS (p = 0.02) scores. We observed no significant differences in any of the mental health scales between gender, marital status, education level, habitat, occupation, need for hospitalization, and ICU admission (all P values >0.05).
Table 2.
Comparison of MFIS, HADS, and PSS scores across social and demographic variables
| MFIS | HADS A | HADS D | PSS | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|
|
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| Mean±(SD) | SE | P | Mean±(SD) | SE | P | Mean±(SD) | SE | P | Mean±(SD) | SE | P | ||
| Gender* | M | 37.3 (14.5) | 2.32 | 0.29 | 6.4 (4.6) | 0.74 | 0.85 | 5.7 (4.8) | 0.77 | 0.43 | 20.64 (8.0) | 1.29 | 0.58 |
| F | 34.5 (9.8) | 1.2 | 6.5 (4.6) | 0.58 | 6.6 (5.7) | 0.73 | 21.45 (5.5) | 0.70 | |||||
| Marital status* | No | 28.92 (17.5) | 2.88 | 0.18 | 5.5 (3.9) | 0.64 | 0.07 | 5.6 (5.6) | 0.90 | 0.32 | 21.1 (5.2) | 0.86 | 0.95 |
| Yes | 33.9 (18.4) | 2.31 | 4.9 (4.8) | 0.61 | 6.7 (5.3) | 0.67 | 21.2 (7.3) | 0.92 | |||||
| Family type* | Nuclear | 29.8 (18.2) | 2.05 | 0.04 | 5.8 (4.5) | 0.51 | 0.004 | 5.4 (5.2) | 0.59 | 0.004 | 20.5 (6.8) | 0.76 | 0.02 |
| Jt. | 38.7 (16.0) | 3.49 | 9.0 (4.0) | 0.59 | 9.1 (4.9) | 1.06 | 23.8 (5.0) | 1.18 | |||||
| Education* | <12 | 32.7 (14.8) | 2.34 | 0.36 | 6.9 (4.1) | 6.65 | 0.86 | 5.8 (4.3) | 0.68 | 0.11 | 22.6 (5.2) | 0.82 | 0.33 |
| >12 | 35.9 (17.9) | 2.49 | 7.1 (4.5) | 0.63 | 7.5 (5.9) | 0.81 | 21.3 (6.9) | 0.96 | |||||
| Habitat* | Rural | 34.5 (14.7) | 2.93 | 0.52 | 7.3 (3.9) | 0.79 | 0.38 | 7.0 (4.3) | 0.87 | 0.48 | 21.0 (4.9) | 0.97 | 0.74 |
| Urban | 31.8 (18.7) | 2.18 | 6.4 (4.7) | 0.54 | 6.1 (5.7) | 0.66 | 21.5 (6.7) | 0.78 | |||||
| Occupation† | Semi-skilled | 34.0 (15.9) | 2.42 | 0.90 | 7.3 (4.2) | 0.65 | 0.62 | 7.3 (5.6) | 0.85 | 0.63 | 22.5 (6.2) | 0.94 | 0.35 |
| Professional | 33.7 (18.6) | 3.1 | 6.4 (4.70 | 0.78 | 6.2 (5.1) | 0.85 | 20.6 (6.4) | 1.07 | |||||
| Others | 36.1 (6.3) | 4.36 | 7.5 (4.17) | 1.11 | 6.7 (5.0) | 1.34 | 22.6 (5.9) | 1.59 | |||||
| Hospitalization* | Yes | 32.0 (19.9) | 3.29 | 0.95 | 6.5 (4.8) | 0.78 | 0.97 | 6.1 (5.3) | 0.86 | 0.89 | 22.3 (7.5) | 1.24 | 0.18 |
| No | 31.8 (17.1) | 2.14 | 6.5 (4.5) | 0.56 | 6.3 (5.5) | 0.68 | 20.5 (5.9) | 0.74 | |||||
| ICU stay* | Yes | 32.3 (25.7) | 10.47 | 0.97 | 6.8 (5.7) | 2.33 | 0.85 | 6.2 (4.8) | 1.97 | 0.98 | 22.2 (7.7) | 3.14 | 0.96 |
| No | 31.9 (19.2) | 3.45 | 6.4 (4.7) | 0.84 | 6.1 (5.4) | 0.97 | 22.3 (7.6) | 1.38 | |||||
*Independent t-test. †Analysis of variance (ANOVA) test. MFIS Modified Fatigue Impact Scale, HADS-A Hospital Anxiety and Depression Scale Anxiety, HADS-D Hospital Anxiety and Depression Scale Depression, PSS Perceived Stress Scale, ICU Intensive care unit
Comparison of the mental health scores based on therapy received is given in Table 3. Patients who received oxygen therapy were significantly older (p = 0.001) and had significantly higher fatigue and anxiety scores, that is, MFIS (p = 0.008) and HADS-A (p = 0.03) compared to those that did not receive oxygen therapy. We also found that those who received corticosteroids were older (p = 0.01) and had significantly higher stress scores (PSS, P = 0.001).
Table 3.
Comparison of MFIS, HADS, and PSS scores based on the treatment received
| Age (Years) | MFIS | HADS A | HADS D | PSS | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|
|
|
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| Mean±(SD) | SE | P | Mean±(SD) | SE | P | Mean±(SD) | SE | P | Mean±(SD) | SE | P | Mean±(SD) | SE | P | ||
| Antibiotics* | Yes | 37.9 (12.0) | 12.0 | 0.08 | 33.9 (19.9) | 3.0 | 0.31 | 7.0 (4.7) | 0.7 | 0.33 | 6.9 (5.7) | 0.8 | 0.27 | 21.8 (7.7) | 1.1 | 0.40 |
| No | 33.8 (11.5) | 12.0 | 30.2 (16.6) | 2.2 | 6.1 (4.4) | 0.6 | 5.7 (5.7) | 0.7 | 20.6 (5.5) | 0.7 | ||||||
| Oxygen* | Yes | 49.2 (10.0) | 3.3 | 0.001 | 47.0 (15.3) | 5.09 | 0.008 | 9.4 (3.7) | 1.2 | 0.03 | 8.7 (4.9) | 1.6 | 0.10 | 24.9 (4.1) | 1.37 | 0.11 |
| No | 34.8 (10.4) | 2.0 | 27.2 (19.1) | 3.60 | 5.5 (4.7) | 0.89 | 5.3 (5.2) | 0.98 | 21.5 (8.2) | 1.55 | ||||||
| Corticosteroids* | Yes | 41.7 (12.8) | 2.9 | 0.01 | 39.0 (17.0) | 3.9 | 0.06 | 7.8 (4.4) | 1.0 | 0.16 | 7.2 (4.7) | 1.1 | 0.40 | 25.6 (6.3) | 1.4 | 0.001 |
| No | 34.2 (11.2) | 1.2 | 30.2 (18.1) | 2.0 | 6.2 (4.6) | 0.5 | 6.0 (5.5) | 0.6 | 20.0 (6.2) | 0.7 | ||||||
*Independent t-test. MFIS Modified Fatigue Impact Scale, HADS-A Hospital Anxiety and Depression Scale Anxiety, HADS-D Hospital Anxiety and Depression Scale Depression, PSS Perceived Stress Scale
There were 39 who were assessed one month after testing positive for COVID-19, 40 were assessed within 2–3 months, and 22 were assessed after 3 months. Table 4 shows the proportion of patients with anxiety, depression, and stress symptoms based on the cut-off values for HADS-A, HADS-D, and PSS, respectively. With longer duration from COVID-19 diagnosis, there was a higher proportion of patients with anxiety, depression, and stress; however, the differences did not reach statistical significance.
Table 4.
Prevalence of anxiety, depression, and stress by duration from COVID-19 diagnosis
| <1 month n=39 | 2–3 months n=40 | >3 months n=22 | P | |
|---|---|---|---|---|
| Anxiety (HADS-A ≥8) | 18 (46.2%) | 14 (35.0%) | 12 (54.5%) | 0.30 |
| Depression (HADS-D ≥8) | 14 (35.9%) | 14 (35.0%) | 13 (59.1%) | 0.14 |
| Stress (PSS ≥14) | 27 (69.2%) | 29 (72.5%) | 18 (72.7%) | 0.94 |
Table 5 examined the differences in the mental health scores comparing between times from COVID-19 diagnosis. While we observed higher fatigue and anxiety scores in those who were evaluated at a longer duration from COVID-19 diagnosis, the differences did not reach statistical significance.
Table 5.
Comparison of MFIS, anxiety, depression, and stress with time from COVID-19 diagnosis
| Duration since positive SARS CoV-2 | Mean±(SD) | Standard error | P | |
|---|---|---|---|---|
| MFIS-P† | <1 month (n=39) | 14.9 (8.9). | 1.43 | 0.181 |
| 2–3 months (n=40) | 12.8 (7.0) | 1.11 | ||
| >3 months (n=22) | 16.8 (9.4) | 2.05 | ||
| MFIS-C† | <1 month (n=39) | 11.9 (8.3) | 1.33 | 0.058 |
| 2–3 months (n=40) | 12.5 (8.6) | 1.37 | ||
| >3 months (n=22) | 17.3 (9.2) | 2.02 | ||
| MFIS-PS† | <1 month (n=39) | 3.9 (2.9) | 0.46 | 0.798 |
| 2–3 months (n=40) | 4.2 (3.0) | 0.48 | ||
| >3 months (n=22) | 4.3 (2.7) | 0.58 | ||
| HADS-A† | <1 month (n=39) | 6.1 (4.3) | 0.69 | 0.506 |
| 2–3 months (n=40) | 6.2 (4.8) | 0.76 | ||
| >3 months (n=22) | 7.4 (4.4) | 0.96 | ||
| HADS-D† | <1 month (n=39) | 5.6 (4.9) | 0.79 | 0.059 |
| 2–3 months (n=40) | 5.6 (4.9) | 0.78 | ||
| >3 months (n=22) | 8.7 (6.5) | 1.43 | ||
| PSS† | <1 month (n=39) | 19.7 (7.2) | 1.15 | 0.254 |
| 2–3 months (n=40) | 22.0 (5.6) | 0.89 | ||
| >3 months (n=22) | 21.9 (6.9) | 1.50 | ||
†Analysis of variance (ANOVA) test. MFIS-P=Modified Fatigue Impact Scale Physical, MFIS-C=Modified Fatigue Impact Scale Cognitive, MFIS-PS=Modified Fatigue Impact Scale psychosocial, HADS-A=Hospital Anxiety and Depression Scale Anxiety, HADS-D=Hospital Anxiety and Depression Scale Depression, PSS Perceived Stress Scale
DISCUSSION
In this cross-sectional study of patients diagnosed with COVID-19 infection, we investigated the different mental health measures across various social and demographic parameters, as well as the prevalence of mental health symptoms at different intervals from COVID-19 diagnosis. Our findings confirmed the high prevalence of mental health ailments like fatigue, anxiety, depression, and stress following SARS CoV-2 infection. Although we did not find any differences in mental health measures with respect to gender, marital status, education, habitat, or occupation, we discovered that people residing in joint families had higher measurements of the scores indicating greater severity of mental health problems in our cohort of patients. One of the main reasons could be the fear of SARS CoV-2 transmission to the family members. It is likely that larger number of family members in a joint family setup may make it difficult for some households to allocate a separate room for self-isolation for COVID-19.
The use of oxygen therapy and steroids was part of the clinical management guidelines of COVID-19 infection (Government of India, Ministry of Health and family welfare, 2021). In our population, those who received oxygen were older and reported more fatigue and anxiety, while those who received steroids were also older and had reported higher stress. Although several studies examined mental health in COVID-19 infection survivors, the long-term effects of COVID-19 infection in low and middle-income countries have received little attention.[17]
Long COVID symptoms may last for weeks or months following initial recovery from SARS CoV-2 infection. The long-term health risks of COVID-19 may include fatigue, cognitive impairment, and adverse mental health outcomes such as anxiety, depression, PTSD, and sleep disturbance which have been observed even in those who had mild disease.[18] Carfi et al. in 2020 studied the persistent post-acute COVID-19 symptoms in patients after developing acute COVID-19 infection. They found that 87.4% reported persistence of at least one long COVID symptom, particularly fatigue and dyspnea.[19] Nune et al. evaluated long COVID symptoms for up to 9 months in patients discharged from the hospital with SARS CoV-2 infection. They demonstrated that 62% of their cohort had long COVID for 3 months. Almost half of these patients suffered from multiple long COVID symptoms such as fatigue, sleep disturbance, and low mood for over 9 months.[20] In our study, we also observed that more than half of the subjects who were evaluated at least 3 months after COVID-19 infection still had symptoms of anxiety, depression, and moderate to high stress. The proportions were higher compared to those that were assessed within 3 months, although the difference in proportion was not significant. A likely explanation for the lack of significance could be the relatively small sample size of patients who were evaluated at more than 3 months. While the number of COVID-19 infections has gradually declined globally, yet it is imperative to recognize the anticipated rise in the prevalence of mental health symptoms among survivors of COVID-19. The clinical characteristics of long COVID and chronic fatigue syndrome overlap, and their treatment should incorporate a combination of holistic strategies such as graded exercise/pacing, mindfulness, coping skills, and sleep hygiene.[21]
Our findings are consistent with the limited existing literature, indicating that COVID-19 infection has a negative impact on mental health although the symptoms are not long lasting.[8,9] Some studies involving hospitalized patients have demonstrated that negative mental status lasted more than six months with 21% having depression[18,20], and at one-year follow-up, 26% had either anxiety or depression.[22] In previous outbreaks of other infectious diseases such as SARS in 2003, a high prevalence of PTSD and depression have been observed up to 4 years after the infection[23] and up to 12 months following the 2015 outbreak of Middle East Respiratory Syndrome (MERS).[24] Future studies with a longer time duration after COVID-19 infections are warranted to better assess prevalence and the impact on mental health.
Our limitations include a single-center with a relatively small number of patients and a cross-sectional design. Also, we did not screen our patients for mental health ailments at the time of presentation; thus, we cannot directly compare the prevalence of psychiatric diseases before and after COVID-19 infection.
CONCLUSION
The emphasis of COVID-19 management has been primarily on physical health, but our study reiterates that it can also have an impact on mental health, and it is critical that we also give equal importance to mental health to prevent long-term negative consequences. Knowledge from past research on similar public health emergencies has revealed that long-term mental health issues persist even after the acute infection has been treated. Prospective studies in a larger cohort will provide the true impact of the COVID-19 pandemic on mental health.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
Postdoctoral support to Arvind Nongpuir is by the Fogarty International Training Program in Chronic Non-Communicable Diseases and Disorders at the University of Florida, Grant #1D43TW009120 (Cottler PI).
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