Study of screening of mental health status of coronavirus disease-19 confirmed noncritical patients admitted at a tertiary care hospital and a coronavirus disease care center in Ahmedabad

Abstract

Background:

Despite coronavirus disease-19 (COVID-19) being a major health crisis in the current times, only a few studies have addressed its potential direct effect on mental health, especially among COVID-19 patients.

Aims:

This study was conducted to assess the mental health of COVID-19 patients.

Materials and Methods:

In cross sectional study, mental health status of 301 symptomatic and 200 asymptomatic COVID-19 participants was assessed using the General Health Questionnaire-28.

Results:

Around 8.78% COVID-19 patients were found to be psychologically distressed that was predominantly higher among symptomatic COVID-19 patients. Risk of psychological distress was significantly higher in females, living in nuclear families and having a history of addiction.

Conclusions:

COVID-19 patients suffer from psychological distress, which needs to be addressed to cope well with this pandemic situation.

INTRODUCTION

The coronavirus disease (COVID-19) was declared a pandemic by the WHO in 2020, being a public health emergency of international concern.[1] Since the global focus has largely been on physical health, the psychological outcomes of the pandemic have remained largely unaddressed, as evidenced by a paucity of studies targeting the same. Initial studies, when the pandemic was confined to China have found significant levels of depression (29.2%), anxiety (20.8%), and posttraumatic stress symptoms (96.2%) in COVID-19 patients in studies by Zhang et al. and Bo et al.[2,3] While a high prevalence of psychological themes of frustration, loneliness, helplessness, adjustment issues, and other mental health issues were also reported in patients by Rana et al.[4] Furthermore, they experienced anger of being infected, guilt of spreading the infection, self-stigma, and anticipation of consequent reaction of people after recovery as reported by Grover et al.[5] Indian studies have also reported high levels of psychological distress following COVID-19 pandemic in the general population, as for example, a study by Verma and Mishra reported statistically high levels of depression (25%), anxiety (28%), and stress (11.6%), while another study by Varshney et al. found 33.2% individuals in the community having psychological impact of COVID-19.[6,7] Younger age, being female and having a known physical comorbidity predicted higher psychological impact.[8] However, it is note-worthy that most of the Indian studies have not targeted mental health status of COVID-19 patients specifically.

The current study sheds light upon mental health status of COVID-19 positive patients in the initial stage of the first wave of the pandemic in India (May and June 2020), when no definite government guidelines for mental health were available. Hence, this study will not only help fill up the gap in the literature but shall also aid in formulating guidelines for improving mental health of these patients. With this background, our study was conducted with the aim of assessing as well as comparing mental health status and psychological distress among asymptomatic and noncritical symptomatic patients of COVID-19 and also establishing correlation of various sociodemographic and clinical parameters with their psychological distress.

MATERIALS AND METHODS

Study design and participants

A cross-sectional study was conducted for 2 months (May and June 2020) after approval from the Institutional Ethics Committee, which included 301 COVID-19 symptomatic noncritical patients (not requiring ventilatory/oxygen support) admitted in COVID designated tertiary care hospital and 200 asymptomatic patients admitted in COVID care center between the age group of 18 and 65 years and of both gender, while those having impaired judgement/inability to communicate due to serious medical conditions (like high grade fever or delirium) were excluded. Sampling was done by systematic randomization and every fourth consecutive patient (diagnosed with reverse transcription polymerase chain reaction) was selected, owing to a huge number of admitted patients. Survey was done face-to-face with usage of proper personal protective equipment and not by telephonic interview, which aids to our study's validity and reliability. Informed consent was obtained for each patient, either in written or audio-visual form, as considered appropriate owing to safety measures.

After obtaining basic sociodemographic details and clinical details, all the patients were assessed using General Health Questionnaire-28 (GHQ-28). The self-administered questionnaire GHQ-28 developed by Goldberg and Hillier in 1978 was designed to detect probable psychiatric disorders.[9] For scoring, binary (traditional/acute) scoring method is used with standardized cutoff value of 4 defining GHQ caseness (sensitivity 0.95), while cutoff for individual subscales is considered 1 (as per logical division).[10] High test-retest reliability (0.78–0 0.9) and excellent internal consistency (Cronbach's alpha = 0.95) for GHQ-28 were found in studies by Jackson, Robinson and Price, Failde et al.[10,11,12] An Indian study by Ray et al. has also used GHQ-28 for assessing psychiatric comorbidity with cutoff value of 4.[13]

Statistical analysis

Statistical analysis was performed using the IBM SPSS Statistics for Windows, version 20 Armouk, NY, USA.[14] Suitable parametric/nonparametric tests were applied, and multivariate logistic regression analysis was done for finding significant statistical differences.

RESULTS

Sociodemographic and clinical profile of COVID-19 patients

Both groups of patients, symptomatic as well as asymptomatic, comprised of similar sociodemographic profile and clinical characteristics. However, statistically higher percentage of symptomatic patients was aged more than 30 years (23.6%, P = 0.04685), were graduated (58.2%, P = 0.00006), Hindus (78.7%, P = 0.0016), and having comorbid medical illness (36.2%, P = 0.00002) as compared to asymptomatic patients.

Prevalence of psychological distress in COVID-19 patients

Psychological distress, as evaluated from the GHQ-28 questionnaire, was found in 44 (8.78%) of 501 COVID-19 patients screened. Higher psychological distress was found in symptomatic patients (13.29%) than asymptomatic patients (2%). Mean/standard deviation of symptomatic patients was 8.733 ± 5.458 and for asymptomatic patients was 5.981 ± 3 which was statistically significant with P = 0.0001, thereby suggesting statistically higher psychological distress among symptomatic patients.

Regression analysis

As shown in Table 1, which depicts independent association between sociodemographic and clinical variables and psychological distress, risk of psychological distress seems to be significantly less (P = 0.025) in males (OR = 0.468) than females. Furthermore, those living in extended families had 0.480 times less risk of distress than those belonging to nuclear families with a significant difference of P value 0.046. Those who have a history of addiction had 44.603 times more chances of psychological distress than those who have no addiction with significant difference of P = 0.0001.

Table 1.

Sociodemographic and clinical variables independently associated with psychological distress by logistic regression analysis in symptomatic and asymptomatic patients (n=501)

Independent variables	P	OR	95% CI
Age (1) (≥30 years)	0.887	1.062	0.461-2.445
Sex (1) (Female)	0.025	0.468	0.241-0.909
Marital status (1) (married)	0.604	0.791	0.325-1.992
Education (1) (graduation completed)	0.235	1.503	0.768-2.941
Occupation (1) (professional/semi-professional/skilled)	0.813	0.925	0.484-1.766
Family income (1) (<7332)	0.174	4.142	0.533-32.196
Religion (1) (Hindu)	0.603	1.304	0.479-3.549
Family type (1) (Nuclear)	0.046	0.48	0.233-0.988
Comorbid medical illness (1) (yes)	0.2	1.524	0.800-2.903
History of addiction (1) (No)	0.0001	44.603	17.444-114.044
History of psychiatric illness (1) (yes)	0.999	0.001	0.001-
Duration of hospital stay (1) (≥1 week)	0.598	0.832	0.419-1.651

Dependent variable - Final score which the presence of psychological distress; For all independent variables 1^st has been taken as reference (i.e., Age<30; Female; Unmarried; Not Graduated; Unskilled/semiskilled or unemployed; Income>7332; Other religion; Nuclear Family; Duration<1 week; No history of psychiatric illness). CI - Confidence interval, OR - Odds ratio. *P<0.05 is considered statistically significant

Comparison of ghq-28 subscales

As shown in Table 2, depressive symptoms were found in 19 (3.79%) patients, anxiety/insomnia symptoms in 54 (10.77%) patients, somatic symptoms in 68 (13.57%) patients, and social dysfunction in 45 (8.98%) patients out of 501 patients. The proportion of patients having anxiety/insomnia (P = 0.015), somatic symptoms (P = 0.001), and social dysfunction (P = 0.017) is statistically higher among symptomatic patients as compared to asymptomatic patients.

Table 2.

Comparison of general health questionnaire -28 subscales between symptomatic and asymptomatic patients

a. Subscale: Depression (general health questionnaire-28 questions 22-28)
	Symptomatic patients (n=301), n (%)	Asymptomatic patients (n=200), n (%)	χ 2	P	Mean depression score±SD
Present	17 (5.65)	2 (1)	2.386	0.124 (NS)	1.86600±1.76568
Absent	284 (94.35)	198 (99)
b. Subscale: Anxiety/insomnia (general health questionnaire-28 questions 8-14)
	Symptomatic patients (n=301)	Asymptomatic patients (n=200), n (%)	χ 2	P	Mean anxiety/insomnia score±SD
Present	44 (14.62)	8 (4)	5.815	0.015* (S)	3.010405±1.836182
Absent	257 (85.38)	192 (96)
c. Subscale: Somatic symptoms (general health questionnaire-28 questions 1-7)
	Symptomatic patients (n=301)	Asymptomatic patients (n=200), n (%)	χ 2	P	Mean somatic symptoms score±SD
Present	61 (20.26)	7 (3.5)	10.816	0.001* (S)	2.23395±1.81101
Absent	240 (79.73)	193 (96.5)
d. Subscale: Social dysfunction (general health questionnaire-28 questions 15-21)
	Symptomatic patients (n=301)	Asymptomatic patients (n=200), n (%)	χ 2	P	Mean social dysfunction score±SD
Present	40 (13.28)	5 (2.5)	5.598	0.017* (S)	2.23735±2.21822
Absent	261 (86.72)	195 (97.5)

*P<0.05 is considered statistically significant. NS - Not significant; S - Significant, SD - Standard deviation

Symptom profile

Sleep impairment is the most common symptom in both the groups (11.96% in symptomatic and 3% in asymptomatic). Other common symptoms in symptomatic patients were not feeling perfectly well (10.29%), feeling in need of a good tonic and feeling ill (8.97% both); while pain/tightness/pressure in head and dissatisfaction in performing tasks (2% all) among asymptomatic patients.

DISCUSSION

To our knowledge, this is one among very few studies aimed at exploring the mental health status of symptomatic and asymptomatic patients of COVID-19 by face-to-face interview in India.

In our present study, it was observed that psychological distress was present in 8.78% of patients. Those patients who showed the symptoms of COVID-19 were found to be more psychologically distressed (13.29%) as compared to asymptomatic patients (2%). Having symptoms of the infection could increase a patient's anxiety, anger, guilt, feeling of being isolated, and having to remain away from family and stress due to stigma among family members and relatives. Higher proportion of individuals aged more than 30 years, graduates, having comorbid medical illness found among the symptomatic patient group could also contribute to the increased psychological distress in them. Our results were in accordance with a China-based study by Zhang et al. which also reported a higher prevalence of depression (29.2%) and anxiety (20.8%) in COVID-19 patients than individuals in quarantine (9.8% and 10.2%).[2] Correlates of symptomatic cases of psychological distress included age more than 50 years and high school graduates in another study by Peng et al. following SARS outbreak in Taiwan, much similar to our study.[15]

After controlling confounding factors and assessing individual parameters, females, those belonging to nuclear families and those having a history of addiction had significantly higher risk of psychological distress as compared to their counterparts, i.e. males, those belonging to joint families and with no history of substance use. Similar profile was observed in studies by Li and Wang and Mazza et al., wherein females and younger people had higher distress after COVID infection.[16,17] This could be explained by increased responsibility of family duties among females, increased stress due to responsibility among nuclear families, and exacerbation of psychiatric symptoms due to acquiring infection and unavailability of medications in patients already suffering from psychiatric illness.

Symptom clusters of anxiety/insomnia, somatic symptoms, and social dysfunction were statistically higher in symptomatic patients (14.26%, 20.26%, and 13.28%) as compared to asymptomatic patients (4%, 3.5%, and 2.5%). Similar to our study, some Indian studies on general population, as that by Grover et al. have also found moderate levels of stress (70%), anxiety (38.2%) and depression (10.5%), and Gupta et al. too found increased levels of anxiety (11.7%) and depression (10.5%) following COVID-19.[18,19]

On assessing each symptom, sleep impairment was the most common symptom in both the groups. This was a consistent finding in many studies, which have shown that sleep disturbances are quite common in COVID-19 pandemic (10%–18.2%).[19,20]

Thus, it can be concluded from our study that there is a need for more systematic assessment of psychological needs of the population that can help in formulating needed psychological interventions for affected COVID-19 patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.