Mental health impact on patients with COVID-19 in the community under a long period of full lockdown in Vietnam

Abstract

Objective

We aimed to investigate the impact on the mental health of patients with COVID-19 in a centralized isolation facility in the community who experienced a long period of full lockdown during the fourth wave of the COVID-19 pandemic in Vietnam.

Methods

We performed a retrospective cross-sectional study among 125 patients with COVID-19 in a centralized isolation facility in the community of Ho Chi Minh City from September to November 2021. We collected data on depression, anxiety, and stress symptoms, as indicated by scores on the Depression Anxiety Stress Scale-21, as well as sociodemographic characteristics.

Results

The prevalence of depression, anxiety, and stress among patients with COVID-19 was 14.4%, 20.8%, and 20.0%, respectively. Depression scores were significantly and positively correlated with body mass index whereas stress scores were significantly and positively correlated with age.

Conclusion

Our findings indicated an increased prevalence of depression, anxiety, and stress among patients with COVID-19 who were in a centralized isolation facility during the fourth COVID-19 wave in Vietnam. Overweight and older age were identified as risk factors for adverse mental health in patients with COVID-19. Psychological intervention programs should be implemented in isolation facilities for individuals with COVID-19 infection.

Introduction

The World Health Organization (WHO) declared the outbreak of COVID-19 to be a pandemic on 11 March 2020. To prevent spread of the outbreak, social distancing was strongly recommended as one of the most useful preventive strategies. The measure has been used successfully in the past to slow or prevent community transmission during a pandemic. ¹ However, the imposition of social distancing measures might have negative psychological effects on the population, especially among patients with COVID-19. ²

Since the onset of the COVID-19 pandemic, marked by the first confirmed case reported on 23 January 2020, Vietnam has experienced four epidemic waves of COVID-19. ³ Owing to the rapid increase in the number of patients with COVID-19 infection as well as patients who died, partial or full lockdowns have been imposed in some high-risk areas of Vietnam.^4,5 During such lockdowns, residents are required to stay at home as much as possible and only go outside for essential reasons, resulting in decreased community transmission of COVID-19. However, the psychological impact of a partial or full lockdown can result in an increased prevalence of depression, anxiety, and stress,^6–9 as well as a decline in quality of life and psychological well-being,^8,10,11 as reported in the Vietnamese population from the first to the third waves of the pandemic. The fourth COVID-19 epidemic wave lasted for 3 months during the third quarter of 2021 and has been determined to have had the greatest impact on residents’ lives, especially in Ho Chi Minh City, the largest city in Vietnam.^3,12 At the peak of the fourth COVID-19 wave, many centralized isolation zones were established in the community, including in schools and army barracks. This measure was recommended to be beneficial for the treatment and reduction of COVID-19 infection sources, thereby alleviating overload of the medical system.^13,14 The psychological impact during the fourth nationwide lockdown among patients with COVID-19 has been reported in some areas in Vietnam.^15,16 Trang et al. collected data from 427 patients with COVID-19 in centralized isolation at medical camps in Bac Giang Province, in the northern region of Vietnam, from 5 June to 15 June 2021. The authors reported a prevalence of 40.7% for both depression and anxiety. ¹⁵ In another study conducted from July to October 2021, Nguyen et al. collected data from 1544 patients with COVID-19 in field hospitals throughout all provinces of Vietnam, including in Ho Chi Minh City. Those authors reported that the prevalence of depression, anxiety, and stress was 17.4%, 11.2%, and 22.4%, respectively. ¹⁶ However, to date, no previous studies have reported on mental health symptoms among patients with COVID-19 who were in a centralized isolation facility in the community in Ho Chi Minh City, particularly in communities with a prolonged complete lockdown.

In the present study, we investigated the prevalence and associated factors of depression, anxiety, and stress among patients with COVID-19 in a centralized quarantine facility in the Go Vap District in Ho Chi Minh City, where a partial or full lockdown was in effect from 31 May to 1 October 2021. The results of the present study will be helpful in managing the mental health of patients with COVID-19 in centralized quarantine sites, particularly in areas where full lockdown measures are imposed for an extended duration.

Methods

Study areas and participants

Ward 10 in the Go Vap District is located in the center of Ho Chi Minh City. The district experienced a complete lockdown from 31 May to 14 June and from 9 July to 1 October 2021^4,5,17–21 as well as a partial lockdown. ²² This area was one of the regions where a full lockdown was imposed for the longest period during the fourth wave of the COVID-19 pandemic in Vietnam.^4,5,17–21

In this retrospective and cross-sectional study, we examined patients’ medical records to gather data from individuals with COVID-19 at a dedicated isolation facility in the community within Ward 10, Go Vap District, Ho Chi Minh City, spanning from September 2021 to November 2021. Patients with COVID-19 were diagnosed using positive reverse transcriptase-polymerase chain reaction. The criteria for recruitment were i) age 18 years or more and ii) no previous history of psychiatric disorders.

Information was collected from all participants, including age, sex, education, income, smoking, alcohol consumption, the number of COVID-19 vaccine doses administered, medical disease history, marital status, current living status, and occupation. Participants’ physical parameters, including weight, height, and body mass index (BMI) were measured.

The current study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. ²³ All procedures involving human participants were conducted according to the principles of the Helsinki Declaration of 1975, as revised in 2013. This study was conducted according to the ethical standards of the Institutional Ethics Committee and per the guidelines developed and approved by the Vietnam Military Medical University and 10 commune health centers belonging to Ho Chi Minh City (No. 4881/QD-HVQY, date: 22 October 2021). Written informed consent was obtained from the individual participants included in this study, and all patient details were de-identified.

Assessment of depression, anxiety, and stress symptoms

The Depression Anxiety Stress Scale-21 (DASS-21) evaluates three related negative emotional states, namely, depression, anxiety, and stress. The reliability and validity of the scale have been previously demonstrated and it has been used in various countries to evaluate patients with COVID-19.^24–27 The DASS-21 was translated from English to Vietnamese and has been suggested to be reliable and suitable for the Vietnamese population in previous studies.^28,29 In the present investigation, medical staff explained the DASS-21 and asked patients to complete the questionnaire. The scale comprises 21 items with three subscales addressing depression, anxiety, and stress. Each subscale includes seven items, and each item is rated on a 4-point Likert scale (0 = never a problem, 1 = sometimes a problem, 2 = often a problem, and 3 = almost always a problem). The total score for each domain ranges from normal to extremely severe. The levels of each domain are categorized as normal (0–9), mild (10–12), moderate (13–20), severe (21–27), and extremely severe (28–42) for the depression subscale; normal (0–6), mild (7–9), moderate (10–14), severe (15–19), and extremely severe (20–42) for the anxiety subscale; and normal (0–10), mild (11–18), moderate (19–26), severe (27–34), and extremely severe (35–42) for the stress subscale.^28–30

Data analysis

We used IBM SPSS ver. 21 (IBM Corp., Armonk, NY, USA) for data analysis. The Shapiro–Wilk test was used to check normality of the distribution of all variables. The appropriate methods were then applied in data analysis. Correlations between depression, anxiety, and stress scores as well as demographic variables including age (years), education (years), income (million Vietnamese dong), weight (kg), height (cm), and BMI (kg/m²) were calculated using Pearson’s correlation coefficient. An independent samples t-test was used to compare depression, anxiety, and stress scores among different groups based on demographic factors, including sex (male/female), smoking (yes/no), alcohol consumption (yes/no), COVID-19 vaccination status (yes/no), comorbid diseases (yes/no), and living with family (yes/no). Furthermore, participants were divided into three groups according to BMI category (<18.5, 18.5–22.9, >22.9 kg/m²) and age (<40, 40–60, >60 years). Means scores for depression, anxiety, and stress were compared among the three groups using one-way analysis of variance, followed by the Scheffe test for comparisons between the three groups. The significance level was p < 0.05 for all tests.

Results

Characteristics of participants

A total of 125 patients with confirmed COVID-19 were enrolled in the present study. The demographic characteristics of participants are shown in Table 1. Participants’ average age and years of education were 45.6 and 10.0 years, respectively. The mean body mass index (BMI) was 23.0 kg/m², with 25.6% of participants having a BMI higher than the normal range (BMI > 24.9 kg/m²). The proportion of men in our study population was 44.8%, with 13.6% and 12.0% of all participants reporting smoking and alcohol consumption, respectively. Most participants (75.2%) were married, and 3.2% were living alone. Additionally, 13.6% of participants had not received any doses of COVID-19 vaccine; 52.8% and 32.8% had received one and two doses of COVID-19 vaccine, respectively. Comorbid health conditions were observed in 24.8% of participants. In total, 24% of patients were working, with officers, homemakers, and business people constituting 20.8%, 17.6%, and 8.8% of participants, respectively. The mean duration from the date of receiving positive test results for COVID-19 infection to the day of examination was 4.0 days. No significant difference between men and women was found in demographic factors, except for weight, height, smoking status, and alcohol consumption (Table 1).

Table 1.

Characteristics of study participants.

Characteristics	Unit	Mean (n)	SD (%)
Age	Years	45.6	14.4
Education	Years	10.0	4.5
Income	VND million/month	7.0	4.8
Weight	kg	59.1	10.3*
Height	cm	160.3	7.5*
BMI	kg/m2	23	3.4
Smoking status	Yes	(17)	(13.6)*
Alcohol consumption	Yes	(15)	(12.0)*
Vaccination against COVID-19	Yes
No		(17)	(13.6)
One dose		(66)	(52.8)
Two doses		(41)	(32.8)
Medical history of diseases	Yes	(45)	(34.6)
Living with family	No	(4)	(3.2)
Marital status	Yes	(94)	(75.2)
Employment
Working		(30)	(24.0)
Officer		(26)	(20.8)
Homemaker		(22)	(17.6)
Businessperson		(11)	(8.8)
Other		(36)	(28.8)
Duration from date of positive COVID-19 test to the examination day	Day	4.0	2.4

SD, standard deviation; BMI, body mass index; VND: Vietnamese dong.

*p < 0.05 in a comparison of demographic variables between men and women using an independent samples t-test.

Prevalence of depression, anxiety, and stress among patients with COVID-19

The prevalence of depression, anxiety, and stress among patients with COVID-19 is displayed in Figure 1. The prevalence among participants of symptoms of depression was 14.4%, with 8.0% experiencing mild symptoms, 3.2% having moderate symptoms, and 1.8% exhibiting severe and extreme symptoms. The prevalence among participants of anxiety and stress symptoms was 20.8% and 20.0%, respectively. Among all patients, those with mild and extreme symptoms of anxiety accounted for a combined 4.0% whereas 9.6% and 3.2% experienced moderate and severe anxiety symptoms, respectively. For stress symptoms, 14.4% of participants experienced mild symptoms and 3.2% had severe symptoms. Only 1.6% and 0.8% of participants experienced moderate and extremely severe symptoms (Figure 1).

Figure 1.

Prevalence of depression, stress, and anxiety among patients with COVID-19.

Relationship of demographic factors with depression, anxiety, and stress scores

Table 2 shows the correlations between depression, anxiety, and stress scores using the DASS-21 scale and the demographic variables education, monthly income, weight, height, and BMI.

Table 2.

Correlation between depression, anxiety, and stress scores using the DASS-21 scale and demographic variables using Pearson’s correlation.

	DASS-21 scores
Demographic factors	Depression		Anxiety		Stress
	r	p	r	p	r	p
Age	0.168	0.061	0.109	0.225	0.183	0.041
Education	−0.091	0.313	0.008	0.931	0.036	0.687
Monthly income	0.002	0.980	−0.059	0.510	0.015	0.866
Weight	0.140	0.119	0.006	0.947	0.125	0.164
Height	−0.079	0.378	−0.124	0.167	0.050	0.578
BMI	0.202	0.024	0.087	0.334	0.106	0.239

BMI, body mass index; DASS-21, Depression Anxiety Stress Scale-21.

Depression scores were significantly and positively correlated with BMI (r = 0.202; p = 0.024). Stress scores were significantly and positively correlated with age (r = 0.183; p = 0.041). There was no significant correlation between any of the DASS-21 scores and participants’ monthly income, education, weight, and height (Table 2).

Based on the results in Table 2, we compared depression scores among the three groups according to BMI category, including underweight (BMI < 18 kg/m²), normal weight (18 to ≤22.9 kg/m²), and overweight (BMI > 22.9 kg/m²) (Figure 2a). Depression scores in participants with normal weight and overweight were significantly higher than those in participants who were underweight (Figure 2a). Given the significant correlation between the stress score and age (Table 3), we divided participants into three groups based on age (<40, 40–60, >60 years) and compared stress scores among these three groups (Figure 2b). Stress scores in the group comprising participants over 60 years of age were significantly higher than those in participants younger than 40 years age (Figure 2b).

Figure 2.

(a) Comparison of depression scores among groups according to body mass index and (b) Comparison of stress scores among groups according to age. BMI, body mass index.

Table 3.

Comparison of DASS-21 scores according to demographic factors using independent samples t-test.

		Depression			Anxiety			Stress
Demographic factors	N	Mean	SD	p	Mean	SD	p	Mean	SD	p
Sex
Male	56	4.1	7.0	0.921	4.0	5.4	0.308	5.8	7.1	0.486
Female	69	3.8	6.4		5.3	7.3		5.3	7.8
Smoking status
Yes	17	3.8	7.6	0.660	4.4	6.4	0.421	4.2	7.5	0.266
No	108	3.9	6.5		4.8	6.6		5.7	7.5
Alcohol consumption
Yes	14	2.3	2.8	0.886	2.4	2.6	0.259	4.1	5.2	0.852
No	111	4.1	6.9		5.0	6.9		5.7	7.7
Vaccination against COVID-19
Yes	108	4.0	6.8	0.638	4.8	6.8	0.862	3.9	6.5	0.941
No	17	3.3	5.6		4.4	4.9		3.8	7.6
Medical history of disease
Yes	45	3.7	4.9	0.203	5.4	6.1	0.203	6.7	6.8	0.051
No	80	4.0	7.4		4.4	6.8		4.9	7.8
Living with family
Yes	121	3.9	6.7	0.964	4.7	6.6	0.355	5.5	7.5	0.207
No	4	3.5	5.7		6.0	4.9		7.5	5.3

SD, standard deviation; DASS-21, Depression Anxiety Stress Scale-21.

We compared DASS-21 scores among different groups based on demographic factors, including sex, smoking, alcohol consumption, COVID-19 vaccination status, medical history of diseases, and living with family. The results are presented in Table 3. Stress scores in participants with comorbid diseases were borderline significantly higher than those in participants without comorbid diseases. No significant differences were found for any DASS-21 scores among the different groups according to other factors (Table 3).

Discussion

In the present study, we investigated the prevalence of depression, anxiety, and stress among patients with COVID-19 in a centralized quarantine facility in Ho Chi Minh City, Vietnam, where a full lockdown was imposed for a long period during the fourth wave of the COVID-19 pandemic. The prevalence of depression, anxiety, and stress was 14.4%, 20.8%, and 20%, respectively. The prevalence of depression, anxiety, and stress among patients with COVID-19 has been previously reported in Vietnam (Supplementary Table 1). Trang et al. collected data via a social media app and reported a prevalence of depression and anxiety of 40.7% among patients with COVID-19 in medical camps located in northern Vietnam. However, the authors did not provide individual prevalence rates for depression or anxiety, and the prevalence of stress was not reported. Moreover, the study was performed during the early stage of the fourth COVID-19 epidemic wave (5 June to 15 June 2021) in Bac Giang Province, Vietnam where a full lockdown was imposed for a much shorter duration than that in Ho Chi Minh City. ¹⁵ An online cross-sectional study assessed psychological symptoms among patients with COVID-19 in field hospitals throughout all provinces of Vietnam, including Ho Chi Minh City, during the fourth wave of the COVID-19 pandemic from July to October 2021. Nguyen et al. reported a prevalence of depression, anxiety, and stress of 17.4%, 11.2%, and 22.9%, respectively ¹⁶ (Supplementary Table 1). In an investigation into the prevalence of depression, anxiety, and stress in the general Vietnamese population during the early stage of the pandemic, Le et al. reported that 4.9% of participants were depressed, 7.0% were anxious, and 3.4% experienced stress. ⁶ Taken together with our results, these findings suggest an increased prevalence of depression, anxiety, and stress among patients with COVID-19 in Vietnam.

In the present study, the most prevalent health issue was anxiety, which affected 20.8% of participants. This value is nearly two to three times higher than that reported in field hospitals and the general population in Vietnam during the COVID-19 pandemic^15,16 and nearly eight times higher than that reported in the general population of Vietnam. ³¹ It should be noted that our study was conducted at the peak of the COVID-19 pandemic, when the full lockdown in Go Vap District, Ho Chi Minh City, lasted for nearly 5 months and the number of deaths was increasing rapidly in the community. This situation may have contributed to an increase in symptoms of anxiety among patients with COVID-19. Moreover, in our past study (unpublished data), anxiety symptoms were significantly greater among middle-aged patients (40–60 years old) compared with younger patients. Nguyen et al. reported that 21.7% of all participants were aged between 40 and 60 years, ¹⁶ which is lower than the 39.2% in our current study. This difference may also partly contribute to variations in the prevalence of anxiety among patients with COVID-19 in the present and in previous studies in Vietnam.

Following anxiety, stress was found to be a common mental health issue in our study. A similar finding was observed in a cross-sectional study in Afghanistan in which the authors reported anxiety, stress, and depression symptoms in 79.5%, 48.6%, and 41.2% of respondents, respectively. ³² Dey et al. also reported that 23% of patients had anxiety, 12% had stress, and 9% had depression among individuals with COVID-19 who were admitted to isolation facilities in the Maldives. ³³ In a cross-sectional study of patients with COVID-19 in Iran, Servatyari et al. reported that the most common issue was anxiety, affecting 64.3% of respondents, followed by depression and stress at 61.4% and 51.7%, respectively. ³⁴ Similarly, Adhikari et al. observed that the prevalence of anxiety among home-isolated patients with COVID-19 in Karnali Province, Nepal was 11.2%, followed by depression and stress, which accounted for 8.0% and 4.0%, respectively. ³⁵ In examining the relationships between risk factors and stress, we observed a significant correlation between increased stress levels and increased age, particularly in patients older than 60 years. However, this finding is inconsistent with those of previous reports^36,37 showing a higher psychological impact on individuals younger than 30 years, ³⁶ with no age differences in COVID-19-related stress levels. ³⁷ Older people are more susceptible to COVID-19 ³⁸ and are at greater risk for severe illness, developing complications, and death owing to COVID-19 than younger and middle-aged adults. ³⁹ Additionally, the fourth wave of the COVID-19 pandemic in Vietnam led to an overload of the country’s health care system, which might have caused more stress among older than younger people. Another finding of the current research is that BMI was significantly and positively correlated with depression, which is consistent with the results of a cross-sectional study conducted in a secondary hospital in the Littoral Region of Cameroon, which demonstrated a strong association between depression and obesity. ⁴⁰ It has also been reported that obesity has a strong positive correlation with depression, increasing the crude mortality rate in patients with COVID-19. ⁴¹ Therefore, to reduce the risk of depression, recommendations include encouraging and assisting individuals to engage in physical activity, especially during the COVID-19 pandemic. ⁴⁰ This approach should be applied in centralized quarantine facilities.

In the current study, no significant relationship was observed between sex, education, monthly income, living with family, or comorbid conditions, and depression, anxiety, or stress. In contrast, some studies have reported that these factors are related to mental health problems in patients with COVID-19.^15,16,34,40 The difference in results may be attributed to variations in study populations, methodological analyses, and the timing of studies conducted since the onset of the COVID-19 pandemic.

Anxiety and depression frequently co-exist in many patients with mental health conditions. This co-existence has been reported in patients with COVID-19 during the acute phase ⁴⁰ and in those with long-term sequelae of the disease. ⁴² In the present study, 24.8% of participants had at least one symptom of anxiety, depression, or stress. Nearly half (11.2% of participants) demonstrated the co-existence of anxiety and depression. Additionally, 6.4% of participants had co-existence of depression and stress, 7.2% had co-existence of anxiety and stress, and 6.4% had co-existence of anxiety, depression, and stress (Supplementary Table 2). Therefore, interventions focusing on bridging the symptoms of depression, anxiety, and stress might reduce these co-existing conditions among patients with COVID-19. However, bridge and central symptoms are not consistent among studies. ⁴³ Therefore, the network structures of depression, anxiety, and stress should be analyzed in patients with COVID-19 in Vietnam in the future.

Considering the high prevalence of depression, anxiety, and stress, as indicated by the increased DASS-21 scale scores observed in the present study, it is imperative to implement mental health strategies to reduce psychological impacts in patients with COVID-19. Several intervention methods, including physical activity, mindfulness meditation with sound therapy, as well as verbal and written encouragement, have been reported to have a positive impact on reducing psychological outcomes in patients with COVID-19. ⁴⁴ Furthermore, to reduce the spread of COVID-19, online interventions like internet-based cognitive behavioral therapy (CBT) have enabled people to practice social distancing and also reduce psychiatric symptoms during the COVID-19 pandemic.^45,46 These interventions are recognized for their time efficiency and cost-effectiveness, ⁴⁷ making them particularly useful during the pandemic.^44,45 There are no studies regarding the effectiveness of online interventions, including internet-based CBT, in Vietnamese patients with COVID-19. Therefore, further research is needed to evaluate the role of online-based interventions in improving psychological outcomes among patients with COVID-19 in Vietnam.

Limitations

The findings of this study should be interpreted within the context of some limitations. First, the number of participants was small; therefore, our results might not be representative of all patients with COVID-19 in the general population during the fourth wave of the COVID-19 pandemic in Vietnam. In addition, other risk factors, such as sources of infection and knowing someone who died owing to COVID-19, might have an impact on the mental health of patients with COVID-19 ¹⁶ ; however, these factors were not investigated in this study.

Conclusion

An increased prevalence of depression, anxiety, and stress was observed among patients with COVID-19 in a centralized isolation facility during the fourth wave of the COVID-19 pandemic in Vietnam. Overweight and older age were identified as risk factors for adverse mental health impacts among our patients with COVID-19. The present findings suggest that psychological intervention programs should be established in centralized isolation facilities for patients with COVID-19, particularly in overweight and older patients, during the implementation of social distancing measures.

Data availability statement

The datasets used and analyzed in the current study are available from the corresponding author upon reasonable request.