Anxiety and Depression Symptoms in ICU Survivors After COVID‐19

ABSTRACT

Background

Post‐intensive care syndrome includes physical, cognitive and psychological impairments that may persist after discharge from the intensive care unit (ICU), with anxiety and depression among the most commonly reported symptoms. Evidence on these symptoms beyond the first year after discharge remains limited, particularly in patients admitted for COVID‐19.

Aim

To determine the prevalence and characteristics of anxiety and depression symptoms among patients previously admitted to the ICU for COVID‐19 within three years after discharge, and to examine differences according to sociodemographic and clinical variables.

Study Design

A multicentre, descriptive cross‐sectional study was conducted among ICU survivors in Spain using clinical records and structured telephone interviews. Sociodemographic, clinical and patient‐reported outcomes were obtained. The Hospital Anxiety and Depression Scale (HADS) was used to assess symptoms of anxiety (HADS‐A) and depression (HADS‐D).

Results

A total of 106 participants were included. Mean anxiety (HADS‐A) and depression (HADS‐D) scores were 6.5 (SD ±3.9) and 6.7 (SD ±3.8), respectively. Female sex was linked to higher anxiety (β = 1.73; 95% CI, 0.32–3.13; p = 0.016), while memory problems were associated with higher anxiety (β = 1.49; 95% CI, 0.14–2.83; p = 0.031) and depression (β = 1.65; 95% CI, 0.43–2.86; p = 0.009). Depression was also higher in participants with greater pain (β = 0.50; 95% CI, 0.15–0.84; p = 0.006). Higher quality of life (β = −0.07; 95% CI, −0.11 to −0.03; p < 0.001) was associated with lower depression scores.

Conclusions

Anxiety and depression were common among individuals with a history of ICU admission due to COVID‐19 up to three years after discharge. Psychological symptoms should be considered alongside physical and cognitive aspects.

Relevance to Clinical Practice

Incorporating psychological assessment into the long‐term follow‐up may facilitate identifying individuals who may benefit from further support.

Impact Statements

• What is known about this topic

  • ○
    Patients admitted to intensive care units (ICUs), particularly due to COVID‐19, may experience long‐term physical, cognitive and psychological symptoms, including anxiety and depression.
  • ○
    However, evidence beyond the first year after discharge remains limited.
• What this paper adds?

  • ○
    This study reports a high prevalence of anxiety and depressive symptoms up to three years after ICU discharge.
  • ○
    Perceived memory difficulties were consistently associated with both anxiety and depression, while the latter was also associated with greater pain intensity and lower quality of life and was associated with higher depression.
  • ○
    These findings support the need to consider psychological outcomes as part of the long‐term assessment of ICU survivors.

1. Introduction and Background

Although survival after admission to intensive care units (ICUs) has improved, many patients experience significant challenges in recovering their previous state of health after the acute phase of illness [1, 2, 3]. Interest in the long‐term consequences of ICU admission is not new; however, the concept of post‐intensive care syndrome (PICS) has been more recently standardised to describe the physical, psychological and cognitive impairments that may develop during ICU stay and persist after discharge [4, 5].

The physical domain of PICS commonly includes muscle weakness, functional impairment and reduced exercise capacity. Cognitive impairments frequently involve deficits in memory, attention and executive function, affecting up to 80% of adult ICU survivors, with symptoms that may persist for years despite partial recovery [1, 6, 7, 8]. In addition, psychological symptoms, particularly anxiety, depression and post‐traumatic stress disorder, are highly prevalent. Approximately 29%–32% of people report symptoms of anxiety or depression within the first 2–3 months after discharge, and these rates remain relatively stable for up to 12 months [9].

Despite increasing recognition of PICS, its psychological dimension is still insufficiently understood [10, 11]. Previous studies have identified several factors associated with psychological outcomes in patients previously admitted to the ICU, including a history of mental health disorders, older age, female sex and aspects related to the experience such as inadequate communication [3, 12]. These conditions represent a significant public health concern, as they are associated with reduced quality of life, increased healthcare utilisation and long‐term morbidity in both patients and their families [3, 7, 8, 10, 12, 13].

Current interventions targeting PICS focus on physical rehabilitation, psychological support, medication adjustments and nutritional therapy, typically delivered by multidisciplinary teams [14]. From a nursing perspective, early identification of the symptoms through screening together with interventions such as structured follow‐up, patient education, emotional support, delirium prevention, early mobilisation and family involvement are considered key strategies to mitigate the impact of PICS [11, 13]. Furthermore, interventions such as ICU diaries, pre‐discharge education and post‐ICU recovery programmes have shown potential benefits for improving psychological symptoms; however, their long‐term effectiveness is still uncertain due to heterogeneity and limited extended follow‐up [15, 16].

Although the short‐ and medium‐term effects after ICU admission have been widely described, evidence beyond the first year after discharge remains limited, particularly among patients admitted due to COVID‐19. Moreover, psychological outcomes in this population may be influenced by multiple post‐discharge factors, making their long‐term characterisation complex.

In this context, assessing the prevalence and characteristics of anxiety and depression among ICU survivors is essential to better characterise their health status in the years following critical illness.

2. Aims and Objectives

The aim of this study was to determine the prevalence and characteristics of anxiety and depression symptoms among patients previously admitted to the ICU for COVID‐19, assessed at a single time point within three years after discharge. The specific objectives were to examine differences in anxiety and depression according to sociodemographic and clinical variables.

3. Design and Methods

3.1. Study Design

A quantitative, cross‐sectional, multicentre study was conducted.

3.2. Setting and Sample

The study population comprised patients who met the following inclusion criteria: diagnosis of severe COVID‐19 pneumonia requiring admission to an ICU for at least seven days during the pandemic period (October 2020 to June 2021); ages between 18 and 65 years; requirement for invasive mechanical ventilation (IMV) for more than 48 h during ICU stay; and voluntary agreement to participate.

Patients who did not meet these criteria were excluded. Additional exclusion criteria included ICU admissions not related to COVID‐19 respiratory infection (e.g., oncological conditions, immunocompromised status or transplant surgery), patients requiring only non‐invasive mechanical ventilation or IMV for less than 48 h, individuals who were still hospitalised at the time of data collection, and those unable to complete the assessment due to cognitive or physical impairment.

Data were collected in two Spanish tertiary referral hospitals during the COVID‐19 pandemic. One hospital served a catchment population of approximately 68 000 inhabitants and had a single general ICU with 12 beds, whereas the other served approximately 320 000 inhabitants and comprised seven ICUs, including two specialised cardiac surgery units and five general medical–surgical ICUs, with a total capacity of 70 beds. During the study period, all units provided care for patients with COVID‐19.

The minimum required sample size was calculated based on the annual number of ICU admissions for respiratory causes. An a priori power analysis for Pearson correlations, assuming a 95% confidence level (α = 0.05), a medium effect size (r = 0.30) and 80% power (1‐ β = 0.80), indicated a minimum sample size of 84 participants.

3.3. Data Collection and Measures

Sociodemographic and clinical data were collected from two sources. First, clinical records were reviewed to obtain information on sex, age, time since ICU discharge, presence of at least one cardiovascular risk factor (hypertension, diabetes mellitus, dyslipidaemia or obesity), nutritional status (defined as normal weight if body mass index [BMI] 18.5–24.9 kg/m², overweight if BMI 25–29.9 kg/m² and obesity if BMI ≥ 30 kg/m²), smoking status (never, current or former smoker), alcohol consumption, polypharmacy (defined as the chronic use of five or more medications) and prior psychiatric history. These clinical variables were verified in the medical records as being present both at the time of ICU admission and at the time of data collection.

Second, patient‐reported data were collected through telephone interviews. These included perceived memory difficulties compared to pre‐ICU status, the presence of intrusive thoughts, images or memories (defined as unwanted, recurrent experiences perceived as distressing); subjective experiences related to the ICU stay (including emotional responses and perceptions of the experience); perceived recovery of pre‐admission health status; quality of life assessed using the visual analogue scale of the EQ‐5D‐5L (EQ VAS) [17, 18], which ranges from 0 to 100 and reflects the participant's perceived health status at the time of assessment; and pain intensity at the time of assessment, measured on a verbal numerical rating scale (0–10) [19].

To evaluate symptoms of anxiety and depression, the Hospital Anxiety and Depression Scale (HADS), developed by Zigmond and Snaith [20] and validated for the Spanish population by Herrero et al. [21] was used. The HADS is a self‐reported instrument consisting of 14 items divided into two subscales: anxiety (HADS‐A) and depression (HADS‐D), each comprising seven items. Each item is scored on a 4‐point Likert scale (0–3), resulting in a total score ranging from 0 to 21 for each subscale, with higher scores indicating greater symptom severity. A score above 8 was used to indicate the presence of symptoms of anxiety and/or depression. For analytical purposes, scores were further categorised into three groups: absence of symptoms (0–7), mild symptoms [8, 9, 10] and scores compatible with a clinical case (≥ 11), in accordance with the literature [20, 21].

In the Spanish validation study, the HADS demonstrated high internal consistency, with a Cronbach's alpha of 0.90 for the total scale, 0.85 for the anxiety subscale and 0.84 for the depression subscale [22].

Participants were identified through hospital databases following approval from the Research Ethics Committee and the appropriate institutional authorisations. An independent information technology professional, not involved in the research team, provided a list of all patients admitted to the ICU during the period defined in the inclusion criteria (n = 912). Subsequently, a single investigator screened these records to determine eligibility, resulting in an initial accessible population of 375 patients. Of these, 56.3% met the predefined inclusion and exclusion criteria. Ultimately, 50.2% of eligible patients agreed to participate. To reduce selection bias and potential losses, no random sampling procedure was applied; instead, all patients in the initial database were screened.

Data collection was conducted through telephone interviews between May and June 2024, with a maximum of three contact attempts per patient. Individuals who could not be reached after three attempts were classified as non‐responders. Potentially eligible patients were contacted by telephone and invited to participate. During the call, the study was explained in detail, including its objectives, procedures and conditions of participation, and verbal informed consent was obtained. Participants were given the opportunity to ask questions and were not required to make an immediate decision, allowing time to consider participation if needed.

Participation was entirely voluntary, and individuals were assured that declining or withdrawing at any time would not affect their current or future healthcare. To avoid any potential perception of coercion, recruitment was conducted by members of the research team not directly involved in the participants' clinical care.

3.4. Data Analysis

Statistical analyses were performed using R software (R Development Core Team, version 4.4.2) [23] Categorical variables were described using absolute and relative frequencies, while continuous variables were summarised using mean and standard deviation or median and interquartile range, as appropriate. The normality of continuous variables was assessed to determine the use of parametric tests. The chi‐square test (or Fisher's exact test, when appropriate) was used to assess relationships between categorical variables. Differences in continuous variables between two groups were analysed using Student's t‐test for independent samples, while Pearson's correlation coefficient was used to assess associations between continuous variables.

For comparisons involving the three‐level categorisation of HADS scores (absence of symptoms, mild symptoms and scores compatible with a clinical case), ANOVA or the Kruskal–Wallis test was applied, depending on the distribution of the data. When statistically significant differences were identified, post hoc pairwise comparisons were performed using Dunn's test with appropriate adjustment for multiple comparisons.

Separate multivariable linear regression models were constructed to assess the association between independent variables and each HADS dimension, using the HADS‐A and HADS‐D total scores as continuous outcomes.

3.5. Ethical and Institutional Approvals

The study was approved by the Research Ethics Committee on 20 012023 (approval code 2022.424) and was conducted in accordance with the Declaration of Helsinki [24].

All participants received detailed information about the study objectives, procedures and conditions of participation and provided verbal informed consent prior to data collection.

Personal data were processed in accordance with applicable data protection regulations and were pseudonymised to ensure confidentiality. Identifiable information was accessible only to authorised members of the research team and was stored securely in compliance with the General Data Protection Regulation (EU 2016/679) [25] and Spanish Organic Law 3/2018 on data protection [26].

4. Results

The sample included 106 participants, of whom 43.4% were female, with a mean age of 59.2 years (SD ±9.6). The mean time since hospital discharge was 3.3 years (SD ±1.1) (Table 1). Overall, 33% of participants were on polypharmacy, and 87.7% had at least one cardiovascular risk factor; specifically, 53.8% were obese, 17% reported alcohol consumption, and 12.3% were active smokers.

TABLE 1.

Sociodemographic, clinical and patient‐reported characteristics of the study sample (n = 106).

		N	%
Sex	Male	60	56.6
	Female	46	43.4
Age		Mean 59.2	SD 9.6
Categorised age	< 40	6	5.7
	40–55	22	20.8
	> 55	78	73.6
Cardiovascular risk factor	Yes	93	87.7
	No	13	12.3
Polypharmacy	Yes	35	33
	No	71	67
Nutritional status	Normal weight	12	11.3
	Obesity	57	53.8
	Overweight	37	34.9
Alcohol consumption	Yes	18	17
	No	88	83
Smoking status	Never	59	55.7
	Current smoker	13	12.3
	Former smoker	34	32.1
Prior psychiatric history	Yes	19	17.9
	No	87	82.1
Time since ICU discharge		Mean 3.3	SD 1.1
Intrusive thoughts	Yes	79	74.5
	No	27	25.5
Perceived recovery of pre‐admission health status	Yes	34	32.1
	No	72	67.9
Subjective experiences	Limited recall of the ICU experience	11	10.4
	Fear	19	17.9
	Reluctance to talk	13	12.3
	Loneliness	23	21.7
	Emotional distress	10	9.4
	Dissociation	16	15.1
	Feeling supported	14	13.2
Pain (0–10)	Mean 1.6	SD 2.0
Perceived memory difficulties	Yes	47	44.3
	No	59	55.7
Quality of life (EQ VAS)		Mean 69.1	SD 18.1
Anxiety (HADS‐A total score)		Mean 6.5	SD 3.9
Anxiety symptoms HADS‐A categorised	Absence of symptoms	46	43.5
	Mild symptoms	43	40.6
	Clinical case	17	16
Depression (HADS‐D total score)		Mean 6.7	SD 3.8
Depression symptoms (HADS‐D categorised)	Absence of symptoms	49	46.2
	Mild symptoms	36	34
	Clinical case	21	19.8

Intrusive thoughts were reported by 74.5% of participants. A psychiatric history was present in 17.9% of the sample, mainly affective disorders, and 44.3% reported memory problems. A considerable proportion of participants reported negative emotional experiences during ICU admission, including feelings of loneliness (21.7%) and fearfulness (17.9%). Nevertheless, 67.9% of participants indicated that their lives had not returned to their pre‐admission state (Table 1).

The mean HADS‐A (anxiety) score was 6.5 (SD ±3.9), and the mean HADS‐D (depression) score was 6.7 (SD ±3.8), indicating overall symptom severity within the mild range. Based on the predefined cut‐off points, 56.6% of participants presented symptoms of anxiety (HADS‐A ≥ 8), while 53.8% showed scores compatible with a clinical level of depressive symptomatology (HADS‐D ≥ 11) (Table 1).

In the bivariate analysis, several variables showed statistically significant differences in HADS scores. Female sex was associated with higher scores in both anxiety (p = 0.004) and depression (p = 0.007). Memory problems were also linked to higher HADS‐A and HADS‐D scores (both p < 0.001) (Figure 1; Table S1). In addition, higher pain levels and poorer perceived quality of life were related to increased scores in both HADS dimensions (p < 0.001) (Table S1).

FIGURE 1.

Bivariate analysis of anxiety and depression scores (HADS‐A and HADS‐D) according to sex and memory impairment.

In the categorical analysis of HADS, similar patterns were observed, with female sex and memory problems more frequently identified among individuals presenting symptoms and scores compatible with clinical cases (Table S2).

Other variables did not show statistically significant differences and are presented in detail in Tables S1 and S2.

In the multivariable analysis for the HADS‐A total score (anxiety), the final model was statistically significant (p < 0.001) and explained 34.7% of the variance (adjusted R ² = 0.347). After adjustment, female sex (β = 1.73; 95% CI, 0.32–3.13; p = 0.016) and the presence of memory problems (β = 1.49; 95% CI, 0.14–2.83; p = 0.031) were independently associated with higher anxiety scores (Table 2).

TABLE 2.

Multivariable linear regression models for anxiety and depression.

		Anxiety (HADS‐A total score)		Depression (HADS‐D total score)
		β (95% CI)	p	β (95% CI)	p
Sex	Male	—
	Female	1.73 (0.32 to 3.13)	0.016
Age	< 55	—
	> 55	−1.41 (−2.84 to 0.01)	0.052
Cardiovascular risk factor	No			—
	Yes			1.69 (−0.12 to 3.50)	0.067
Polypharmacy	No			−1.31 (−2.59 to −0.03)	0.045
	Yes			—
Subjective experiences	Reluctance to talk	—
	Fear‐loneliness‐emotional distress	1.22 (−0.68 to 3.12)	0.205
	Dissociation‐limited recall of ICU exp	−0.37 (−2.43 to 1.69)	0.723
	Feeling supported	−2.10 (−4.44 to 0.25)	0.079
Alcohol consumption	No	—
	Yes	1.25 (−0.49 to 3.00)	0.157
Pain (0–10)		0.35 (−0.03 to 0.72)	0.068	0.50 (0.15 to 0.84)	0.006
Intrusive thoughts	No			1.26 (−0.13 to 2.65)	0.075
	Yes			—
Perceived memory difficulties	No	—		—
	Yes	1.49 (0.14 to 2.83)	0.031	1.65 (0.43 to 2.86)	0.009
Quality of life (EQ VAS)		−0.03 (0.08 to 0.01)	0.137	−0.07 (−0.11 to −0.03)	< 0.001

Note: Stepwise variable selection was used to obtain the final models. The bold values indicate statistically significant differences (p < 0.05).

Similarly, the final model for the HADS‐D total score (depression) was statistically significant (p < 0.001) and explained 40.8% of the variance (adjusted R ² = 0.407). After adjustment, higher pain levels (β = 0.50; 95% CI, 0.15–0.84; p = 0.006) and the presence of memory problems (β = 1.65; 95% CI, 0.43–2.86; p = 0.009) were associated with higher depression scores (Table 2). In contrast, polypharmacy (β = −1.31; 95% CI, −2.59 to −0.03; p = 0.045) and higher quality of life scores (β = −0.07; 95% CI, −0.11 to −0.03; p < 0.001) were associated with lower HADS‐D scores (Table 2).

5. Discussion

This study provides a cross‐sectional assessment of anxiety and depression among individuals with a history of ICU admission due to COVID‐19, evaluated within three years after discharge. A high prevalence of these symptoms was observed, along with differences according to demographic and clinical variables. The results are consistent with previous studies in ICU survivors, although variations may reflect differences in follow‐up duration, assessment methods or sample characteristics [22, 27, 28, 29].

Anxiety and depression have been widely described in the early phases after ICU discharge; however, data on longer‐term outcomes are still scarce [30, 31]. In line with existing evidence, our findings suggest that these symptoms may persist over time in a proportion of patients, with patterns where anxiety tends to improve while depressive symptoms may remain more stable or even worsen [31, 32]. A small proportion of participants (18%) presented pre‐existing mental health conditions before ICU admission; however, these conditions were not significantly associated with the primary variables related to anxiety and depression.

Regarding demographic variables, female participants showed higher anxiety scores, which is consistent with previous literature [22, 27, 30, 33]. However, this association was not observed for depressive symptoms after adjustment, suggesting that differences according to sex may vary depending on the psychological dimension assessed.

Perceived memory difficulties emerged as a consistent factor associated with both anxiety and depressive symptoms, in both bivariate and multivariable analyses. This finding aligns with available evidence in patients with similar clinical characteristics [34, 35]. Importantly, this variable may also be interpreted as an indirect indicator of the cognitive domain of post‐intensive care syndrome (PICS), underscoring the multidimensional nature of recovery after critical illness and the need for integrated assessment approaches [36].

Physical and psychological domains of PICS are closely interconnected, with functional impairments potentially contributing to emotional distress. Additionally, poorer perceived health‐related quality of life has been associated with higher levels of depression [9, 29, 35, 36].

In the bivariate analysis, additional variables such as perceived recovery of pre‐admission health status and subjective experiences during ICU stay were also linked to anxiety and depressive symptoms. However, these associations were not retained in the multivariable models, suggesting that their effects may be mediated by other factors.

Patients reported a wide range of subjective experiences related to their ICU stay, including fear, loneliness and loss of reality, but also positive perceptions such as feeling supported. These responses reflect the complexity of psychological adaptation following critical illness and are consistent with previous literature describing both distress and adaptive responses after ICU discharge [37, 38]. In addition, many patients report difficulties returning to normal daily activities and social participation, which may contribute to the persistence of anxiety and depressive symptoms over time [10].

The context of COVID‐19 may also be considered when interpreting these findings, as broader contextual factors such as social isolation, restricted communication and increased healthcare system burden may influence psychological outcomes. These aspects underscore the need to consider environmental and societal factors when analysing long‐term health status in individuals with a history of critical illness.

Previous studies suggest that emotional and social support during and after hospitalisation may be associated with lower psychological symptoms [38, 39]. The use of validated instruments such as the HADS may facilitate a more comprehensive assessment of patient needs.

Post‐ICU recovery programmes represent a relevant approach to addressing the complex sequelae of critical illness. These programmes are typically based on a multidisciplinary framework and include structured follow‐up, physical and cognitive rehabilitation and psychological support [36, 38, 39]. Interventions such as ICU diaries, early mobilisation and family involvement have been associated with improved adaptation after discharge, although their long‐term effectiveness remains heterogeneous [36, 40].

Overall, our findings support the use of integrated approaches that consider both physical and psychological dimensions of recovery after critical illness.

6. Limitations

Several limitations should be considered when interpreting the results of this study. Its descriptive cross‐sectional design prevents causal inferences and does not permit longitudinal evaluation of symptom progression over time. Additionally, the absence of a control group limits definitive conclusions regarding whether the negative affect observed three years after discharge is specifically associated with ICU survivorship.

In addition, the absence of baseline data on prior cognitive status limits the interpretation of reported memory problems, as it is not possible to distinguish between pre‐existing conditions and symptoms identified after ICU discharge. Moreover, although 18% of participants reported previous mental health conditions, the lack of detailed pre‐ICU psychological assessment limits the ability to determine the extent to which anxiety and depressive symptoms were attributable to pre‐existing disorders versus ICU survivorship.

Furthermore, significant confounding factors, such as post‐discharge life events and social conditions, were not fully controlled and may have influenced the findings.

Data collection through telephone interviews may have introduced recall bias, particularly given the time elapsed since discharge and may have limited the depth of the information obtained. Moreover, emotional experiences during ICU stay were assessed retrospectively using dichotomous questions, which may have reduced the sensitivity of these measures.

7. Implications for Practice and Further Research

The findings of this study emphasise the importance of considering psychological symptoms, including anxiety and depression, as part of the overall assessment of this population. These aspects should be incorporated into comprehensive follow‐up approaches that extend beyond physical recovery.

Previous literature suggests that early recognition of these symptoms may facilitate targeted interventions and improve functional adaptation after discharge [14, 16, 20]. In this context, patients reporting negative emotional experiences during their ICU stay may represent a group requiring closer follow‐up within multidisciplinary care frameworks, with active involvement of nursing professionals [21, 33].

Nursing plays a central role in continuity of care across the ICU stay and the post‐discharge period, contributing to supportive environments that facilitate communication, symptom recognition and coordinated follow‐up. The incorporation of structured approaches aimed at improving communication and patient‐centred care may be relevant in addressing the psychological needs identified.

From a research perspective, further studies are needed to better characterise the persistence of psychological symptoms beyond the first year after ICU discharge, particularly in populations admitted due to COVID‐19. Future research should also explore the individual and contextual factors associated with anxiety and depression in individuals following critical illness, as well as evaluate the feasibility and effectiveness of follow‐up strategies that integrate psychological assessment within routine care.

8. Conclusion

A high prevalence of anxiety and depression was identified among individuals with a history of ICU admission due to COVID‐19, assessed up to three years after discharge. Female participants showed higher levels of anxiety, while perceived memory difficulties and pain intensity were consistently associated with both outcomes. with both outcomes. Depression was also associated with greater pain intensity and lower quality of life.

These results indicate that psychological symptoms remain present in a proportion of ICU survivors and highlight the relevance of considering both physical and cognitive aspects as part of their overall health status, supporting the incorporation of psychological assessment into long‐term follow‐up. However, given the cross‐sectional design and the potential influence of post‐discharge factors, these observations should be interpreted with caution.

Funding

The authors have nothing to report.

Ethics Statement

The study was submitted for assessment and approved by the Ethics Committee of the Principality of Asturias, with approval granted on January 20, 2023. (CEIm2022.424 code).

Consent

Participants in this research must sign an Informed Consent. To this end, they will be duly informed about the justification, methodology, main objective, type of participation that will be required from the individual and the confidentiality of the data.

Compliance with the ethical principles of the Declaration of Helsinki was maintained throughout the research process. All personal data were handled with strict confidentiality and anonymity and stored in a database in accordance with Regulation (EU) 2016/679 of the European Parliament, Organic Law 3/2018 of 5 December on the Protection of Personal Data and the guarantee of digital rights, as well as Law 14/2007 of 3 July on Biomedical Research.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: Bivariate analysis of anxiety and depression scores (HADS‐A and HADS‐D).

Table S2: Bivariate analysis of categorised anxiety and depression symptoms (HADS‐A and HADS‐D).

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.