Psychological distress among survivors of moderate-to-critical COVID-19 illness: A multicentric prospective cross-sectional study

Abstract

Purpose:

Coronavirus disease-2019 (COVID-19) is predicted to have long-term sequelae on the physical and mental health of survivors. We aim to calculate the prevalence of psychological distress in moderate-to-critical survivors of COVID-19.

Materials and Methods:

The patients discharged from the hospital after moderate-to-critical COVID-19 were interviewed using e-mail at 30 and 60 days for anxiety, depression, and posttraumatic stress disorder (PTSD) using Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, and PTSD Check List-5 questionnaire, respectively.

Results:

In 103 patients (96% were immigrant workers), the prevalence rate of clinically significant anxiety, depression, and PTSD was 21.4%, 12.7%, and 8.7% at day 30 and 9.5%, 7.1%, and 4.7% at day 60, respectively. There was significantly higher anxiety in patients of Indian nationality and depression with preexisting chronic illness.

Conclusion:

There is a high prevalence rate of clinically significant psychological distress among COVID-19 survivors, and we propose a formal psychiatric assessment and long-term follow-up.

INTRODUCTION

The exponential growth of coronavirus disease-2019 (COVID-19) has caused unprecedented disruption in human lives in the last few months. The patients with COVID-19 admitted to the hospital are subject to psychological anguish by social isolation, boredom, and loneliness. The symptoms like, fever, cough, and respiratory distress and uncertainties about new disease further add to fear of life.[1] Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection may also cause neurological involvement as part of multi-organ illness.[2] In a registry of 125 patients with COVID-19 who presented with neurological symptoms, 23 (18%) patients were diagnosed with neuropsychiatric features (10 [43%] psychosis, 6 [26%] had neurocognitive syndrome, and 4 [17%] had affective disorder).[3] Severe respiratory infections and acute respiratory distress syndrome (ARDS) are known to cause posttraumatic stress disorder (PTSD) and cognitive sequelae among survivors.[4] Mental illnesses such as PTSD, anxiety, and depression were common among survivors of previous coronavirus outbreaks (2003 SARS and Middle East respiratory syndrome).[5,6,7] This was comparable to that after an earthquake or terrorist attack.[6,8] The experts have warned about the psychological impact of COVID-19 in survivors of acute illness.[9,10] We undertook this study to assess the prevalence and risk factors of psychological distress among survivors of COVID-19 at 30 and 60 days after hospital discharge.

MATERIALS AND METHODS

This prospective multicentric cross-sectional study was performed on discharged patients of COVID-19 from two tertiary care hospitals in Dubai between March and June 2020. The discharge criteria were clinical stability without any oxygen supplementation for 48 h and two consecutive negative reverse transcription–polymerase chain reaction samples for SARS-CoV-2, 24–48 h apart. The severity of the disease was defined as moderate (pneumonia and respiratory symptoms without hypoxemia), severe (pneumonia with hypoxemia, SpO₂<92%), and critical (ARDS, shock, or multi-organ failure) COVID-19. Patients with a diagnosis of moderate, severe, or critical COVID-19 were only included in this study. The exclusion criteria were patients who were transferred to other hospitals. The study was approved by the hospital ethics committee and Dubai Scientific Research Ethics Committee (DSREC-09/2020_33).

The patient demographics, the severity of the disease, and treatment were collected from the electronic medical record (EMR) of the hospital. The patients who agreed to participate in the study through the telephone completed the questionnaire through e-mail. The survey questionnaire (developed on Google forms™) was based on Generalized Anxiety Disorder (GAD)-7, PTSD checklist (PCL-5), and a Patient Health Questionnaire (PHQ)-9 for the screening of GAD, PTSD, and depression, respectively. Respondents filed a separate questionnaire on days 30 and 60 of discharge.

The GAD-7 score is validated to screen anxiety as per the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV). Anxiety can be classified as mild (0–9), moderate (10–14), and severe (15–21) based on the cumulative score of seven items on the Likert scale. Cutoff score of eight was used for clinically significant anxiety.[11] The PCL-5 was used to screen PTSD in line with DSM-5, and a cutoff score of 31 was used in our study for diagnosing clinically significant PTSD.[12] The PHQ-9 is a screening tool for depression, validated in different patients' population based on DSM-IV using a 4-point Likert scale.[13] Depression can be classified (on the cumulative score) into minimal (1–4), mild (5–9), moderate (10–14), moderate–severe (14–19), and severe (20–27).[12] PHQ-9 cutoff score of 10 was used for diagnosing clinically significant major depression.[14]

Statistical analysis

The categorical variables were expressed as frequency or percentages, and the continuous variables as means (standard deviation) and median (range). Categorical variables were compared using Fisher's exact or Chi-square test, while paired t-test was used for continuous variables. The data not available from the EMR were taken as missing and not imputed. P <0.05 was considered significant. IBM SPSS (version 26.0, IBM Corp., Armonk, NY, USA) software was used for statistical analysis.

RESULTS

Out of 262 hospitalized patients, 156 patients were of moderate-to-critical COVID-19. One hundred and twenty-three (78.9%) patients were discharged and 17 (6.4%) patients succumbed to the illness. One hundred and four (84.5%) patients agreed initially to participate in the study. However, 103 (99.0%) and 85 (81.7%) patients finally completed the survey questionnaire on day 30 and day 60 of discharge, respectively [Table 1].

Table 1.

Relation of psychological distress with patients’ demographics, place of stay in hospital, treatment, and the severity of the coronavirus disease-2019

	Frequency (%)	GAD-7 (%)	P	PHQ-9 (%)	P	PCL-5 (%)	P
Cutoff		8		10		31
Age
20-29	10 (9.7)	4 (17.4)	0.239	2 (15.4)	0.211	1 (11.1)	0.255
30-39	36 (34.9)	5 (21.7)		6 (46.2)		6 (66.7)
40-40	28 (27.3)	9 (39.1)		5 (38.5)		2 (22.2)
50-59	20 (19.4)	4 (17.4)		0		0
60-69	9 (8.7)	1 (4.3)		0		0
Gender
Male	69 (67.0)	19 (82.6)	0.071	8 (61.5)	0.754	6 (66.7)	1.000
Female	34 (33.0)	4 (17.4)		5 (38.5)		1 (25.0)
Nationality
Indian	49 (47.6)	10 (43.5)	0.003	7 (53.8)	0.215	4 (44.4)	0.369
Pakistan	18 (17.5)	0		1 (7.7)		1 (11.1)
Philippines	12 (11.7)	2 (8.7)		0		0
Arabs	14 (13.6)	8 (34.8)		4 (30.8)		3 (33.3)
Others	10 (9.7)	3 (13.0)		1 (7.7)		1 (11.1)
Comorbidity
Yes	58 (56.3)	12 (52.2)	0.650	4 (30.8)	0.047	3 (33.3)	0.174
No	45 (43.7)	11 (47.8)		9 (69.2)		6 (66.7)
Place of stay in hospital
ICU	17 (16.5)	5 (21.7)	0.516	2 (15.4)	1.000	2 (22.2)	0.633
Ward	86 (83.5)	18 (78.3)		11 (84.6)		7 (77.8)
Steroid
Yes	18 (17.5)	7 (30.4)	0.118	3 (23.1)	0.699	1 (11.1)	1.000
No	85 (82.5)	16 (69.6)		10 (76.9)		8 (88.9)
Oxygen
Yes	50 (48.5)	13 (56.5)	0.411	10 (76.9)	0.708	8 (88.9)	0.313
No	53 (51.5)	10 (43.5)		6 (46.2)		3 (33.3)
Ventilator
Yes	7 (6.8)	2 (8.7)	0.619	0	1.000	0	1.000
No	96 (93.2)	21 (91.3)		13 (100.0)		9 (100)
Severity of COVID-19
Moderate	86 (83.5)	17 (94.4)	0.202	12 (92.3)	0.689	7 (87.5)	0.641
Severe	10 (9.7)	0		0		0
Critical	7 (6.8)	1 (5.6)		1 (7.7)		1 (12.5)

P<0.05 is significant (marked in bold). COVID-19 – Coronavirus disease-2019; ICU – Intensive care unit; GAD – Generalized Anxiety Disorder; PHQ – Patient Health Questionnaire; PCL – Posttraumatic stress disorder check list

Out of 103, 69 (67%) patients were male with a median age of 40 (23–60) years. Almost 96% were immigrant workers, with 47.6% being Indian nationals. Moderate, severe, and critical COVID-19 was diagnosed in 86 (83.5%), 10 (9.7%), and 7 (6.8%) patients, respectively. Fifty-eight patients (56.3%) had preexisting chronic illnesses such as diabetes mellitus and hypertension. None of the patients had a diagnosed previous mental illness. Fifty (48.5%) patients required oxygen, 18 (17.5%) patients received corticosteroids, and 7 (6.8%) required invasive mechanical ventilation. The median hospital stay was 12 (6–39) days [Table 1].

Moderate and severe anxiety was present in 11 (10.7%) and 5 (4.9%) patients, respectively, on day 30 [Table 2]. On day 60, moderate and severe anxiety was present in 3.5% and 2.4% of patients, respectively. Depression was ubiquitous with some symptoms present in all the patients on day 30 and day 60. Moderate-to-severe depression (or clinically significant depression) was present in 13 (12.7%) and 6 (7.1%) patients on day 30 and day 60, respectively [Table 2]. PTSD was found in 9 (8.7%) and 4 (4.7%) patients at day 30 and day 60, respectively.

Table 2.

Psychological symptoms scores (posttraumatic stress disorder check list-5, Generalized anxiety disorder-7, Patient Health Questionnaire-9), and prevalence rate at day 30 and day 60 of discharge

Score	Day 30	Prevalence rate (%)	Day 60	Prevalence rate (%)
PCL-5
<31	94	91.3	81	95.3
≥31	9	8.7	4	4.7
GAD-7
None or mild (0-9)	87	84.4	80	94.1
Moderate (10-14)	11	10.7	3	3.5
Severe (15-21)	5	4.9	2	2.4
Clinically significant anxiety (≥8)	22	21.4	8	9.5
PHQ-9
Minimal depression (1-4)	66	64.0	72	84.7
Mild depression (5-9)	24	23.3	7	8.2
Moderate depression (10-14)	8	7.8	4	4.7
Moderate-severe depression (14-19)	4	3.9	2	2.4
Severe depression (20-27)	1	1.0	0	0.0
Clinically significant depression (≥10)	13	12.7	6	7.1

GAD – Generalized Anxiety Disorder; PHQ – Patient Health Questionnaire; PCL – Posttraumatic stress disorder check list

The psychological symptoms were more common in males and younger age groups (30–50 years). The Indian nationals were associated with a significantly higher prevalence of anxiety (P = 0.003) and preexisting chronic illnesses related to a higher rate of depression (P = 0.04) [Table 2]. The relationship of psychological distress to the severity of disease and treatment received was nonsignificant [Table 2].

DISCUSSION

To our knowledge, this is one of the first prospective observational studies on psychological distress among the COVID-19 expatriate population of the Middle East. There was clinically significant psychological distress among COVID-19 survivors at day 30 and day 60 of discharge.

Infectious disease epidemics are known for psychological disorders among survivors, health-care workers, and the general population.[5,6,7,8] Lee et al. found the prevalence of psychological distress among 10%–20% survivors of the 2003 SARS outbreak.[5] The COVID-19 is expected to have long-term implications on human beings, including mental illness.[3,9,10] In a recent study from China, the reported prevalence of clinically significant stress, anxiety, and depression among COVID-19 patients was 31%, 22.2%, and 38.1%, respectively.[15] We assessed various factors such as demographic details, the severity of the COVID-19, treatment received, and any preexisting chronic medical illnesses for any significant association to psychological distress. The COVID-19 patients of the younger age group (30–39 years) had a higher prevalence of psychological distress as compared to those aged (>40 years). However, there was no statistically significant difference in the prevalence rate of psychological distress based on the severity of COVID-19. The studies on non-COVID-19-related ARDS also reported younger age groups and female sex as independent risk factors as compared to illness severity.[15] Patients with Indian nationality had a significantly higher association with anxiety and preexisting chronic illnesses with a significantly higher rate of depression. The population of Dubai in 2019 consisted of 92.1% expatriates (majority from South Asia), 69.5% were male and 48% were young (25–39 years).[16] The depression rate reported in studies from the United Arab Emirates is higher (12.5%–28.6%) than the United States (6%–12%) and associated with preexisting chronic diseases.[17] Dervic et al. reported that suicide rates were seven times higher among the expatriate population, with 75% of those suicide were Indian nationals.[18] In our study we did not have clear incidence of preexisting mental illness as patients were first time presented to our hospital and none of them were on any psychiatric treatment. However, an undiagnosed mental illness could not be excluded, as found in other studies among expatriates.[18] The COVID-19 pandemic had significant implications on the expatriate population with movement restrictions by government sterilization (lockdown) program (for infection control), loss of employment, and departure to the home country.[19] We could not assess these factors and may have contributed to higher psychological distress and also a higher attrition rate at day 60 of the study.

There are several limitations to our study. First, around 18% of the patients could not complete the day 60 questionnaire, as many of these patients were immigrant workers and returned to their home country once international flights resumed. These patients may have contributed to statistical bias in reduced prevalence of clinically significant psychological distress at day 60 of discharge. Second, we could not collect the true incidence of preexisting mental illness. Third, a limited number of patients and follow-up of only 60 days may explain no significant correlation to many demographic and treatment factors. Finally, the online self-administered questionnaire has its limitations.

CONCLUSION

There is a high prevalence of clinically significant anxiety, depression, and posttraumatic stress among the survivors of moderate to critically COVID-19. We recommend formal evaluation by psychiatrists and long-term mental rehabilitation for survivors of COVID-19.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.