Psychiatric comorbidity in clinically stable COVID-19 patients

Abstract

Aims:

To identify prevalence of psychiatric comorbidity in clinically stable COVID-19 patients.

Materials and Methods:

A cross-sectional single point observational study was conducted among clinically stable 72 COVID-19 infected patients. Psychiatric comorbidity was assessed with the help of DSM-5 Self-Rated Level 1 CCSM—Adult scale.

Results:

The prevalence of psychiatric comorbidity was 76.4% (n = 55). Depression was the most common diagnosis in 44.44% (n = 32) followed by anxiety (34.72%, n = 25), somatic symptoms (26.39%, n = 19), sleep problems (23.61%, n = 17). Around 45 .83 % (n = 33) patients considered COVID-19 infection as potentially life-threatening and 23.62% (n=17) patients experienced discrimination and stigma after being diagnosed with COVID-19 infection. Using binary logistic regression, physical symptoms was identified as a risk factor for psychiatric comorbidity.

Conclusion:

Our study provides evidence of a significant impact of COVID-19 infection on mental health in COVID-19 patients.

INTRODUCTION

Several studies available on the past pandemic infection like severe acute respiratory syndrome has reported that infected patients may suffer from various mental health disorders even after the discharge from the hospital and the mental health of these patients should not be ignored.[1]

The COVID-19 is a disease caused by a Novel Corona virus. India, which has the second-largest population in the world, reported its first case in Kerala and thereafter, the reported cases have increased steadily to reach around 800000 cases, across the country as of July 11, 2020. This infection has spread now in almost every part of India.[2] The COVID 19 pandemic worldwide represents a dangerous and potentially traumatic event and it can be regarded as a mental health catastrophe.[3] Corona virus infection can affect the brain resulting in some neurological and psychiatric symptoms including a headache, dizziness, psychotic symptoms, PTSD, anosmia, altered sensorium, impaired consciousness, confusion and/or delirium. With the increasing number of cases, COVID-19 patients are facing several challenges including the stigma and discrimination. Furthermore, in the current situation, it seems that in COVID-19 sufferers, survival anxiety or fear could induce an increase of psychiatric disorders.[4]

The psychological impact of the covid-19 infection is a major global health concern, but yet to be assessed properly specially in the Indian context. Considering the paucity of literature on this topic issue, the present study was undertaken to address the current gap in the existing literature.

MATERIALS AND METHODS

Study design

Thiscross-sectional observational study was conductedto assess the psychiatric comorbidity in clinically stable patients diagnosed with COVID-19 infection by department of Psychiatry of a tertiary care hospital attached to a medical college and was duly approved by Institutional Ethics Committee. A purposive sampling strategy was used to recruit the participants.

Inclusion criteria

1. Age ≥18 Years

2. Participants of both genders who are able to read and write Hindi and English language.

3. Clinically stable patientsconsisting of asymptomatic/symptomatic patients classified as non-severe type of COVID-19 infection (as screened by patient’s case medical officer) with laboratory – confirmed COVID-19 infection either admitted in hospital or kept in isolation and taking treatment at home.

4. Willing to give consent.

Exclusion criteria

1. Patients suffering from any neurological illness.

2. Past history of psychiatric illness.

3. Symptomatic patients requiring ICU care.

Data collection

Clinically stable COVID-19 patients fulfilling the inclusionand exclusion criteria were invited for the study. Data was collected electronically using Google Form developed by Google. Participants were also asked about their opinion regarding perceived life threat, perceived discrimination and stigma because of suffering from COVID-19 infection.

• “Q.Do you think this infection is potentially life-threatening?” [Yes/No].

• “Q.Have you faced stigma or been mistreated / discriminated because of COVID-19 positive status?” [Yes/No].

Survey instrument

Recently conducted studies in COVID-19 patients for assessing psychiatric comorbidity have used a wide range of scales for measuring mental health, which included SAS, SDS, GHQ, PHQ, GAD-7, IES-R, HADS, HAMA, and HAMD.[4]

In this study, psychiatric comorbidity was assessed by using DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure (CCSM), (APA, 2014),[5] developed by American Psychiatric Association. This scale has a good test–retest reliability for using in research and clinical settings (Cronbach’s alpha = 0.90).[6] The DSM-5 Level 1 Cross-Cutting Symptom Measure has been translated in Hindi and found to have an excellent cross-language concordance, internal consistency, split-half reliability,and test-retest reliability in Indian population justifying it as a valid instrument in Indian population.[7]

Statistical analysis

Statistical analysis was done using SPSS Statistic 22.0 (IBM SPSS Statistics, New York, United States). A two-tailed P value of less than 0.05 was considered as statistically significant for all analysis.

RESULTS

The study sample included 72 patients consisting of 64% male (n= 47). Mean age of the participants was 38.95 (±14.69) years. Twenty-three (31.69 %) of participants had coexisting chronic medical illness. Around 73% (n = 53) patients had documented physical symptoms (fever, sore throat, cough, Headache, fatigue etc.). Nineteen (26.39%) patients were on steroid therapy. Approximately 68.10 % (n = 49) patients considered COVID-19 infection as potentially life-threatening while the prevalence of reported COVID-related discrimination in the participants was 48.60% (n = 35).

Psychiatric diagnosis (domain)

The prevalence of psychiatric comorbidity was 76.4% (n = 55). As shown in Table 1 and Figure 1, depression was the most common diagnosis observed in 44.44% (n = 32) of patients followed by anxiety (34.72%, n = 25), somatic symptoms (26.39%, n = 19), sleep problems (23.61%, n = 17), mania (15.25%, n = 11), anger (18.10%, n = 13), substance use (13.89%, n=10), personality functioning (12.50%, n = 9) and repetitive thoughts and behavior (9.72%, n = 7). Other commonly observed diagnosis was dissociation (06.94%, n = 5), memory problem (5.56%, n = 4), Psychosis in 4.17% (n = 3) and suicidal ideation in (5.56%, n = 4) of patients.

Table 1.

Psychiatric symptomatology (domain)

Domain	Number=n, (%)
Depression	32 (44.44)
Anxiety	25 (34.72)
Somatic symptoms	19 (26.39)
Sleep	17 (23.61)
Anger	13 (18.06)
Mania	11 (15.25)
Substance Use	10 (13.89)
Personality Functioning	09 (12.50)
Repetitive thoughts and behavior	07 (09.72)
Dissociation	05 (06.94)
Memory	04 (05.56)
Suicide	04 (05.56)
Psychosis	03 (04.17)

Figure 1.

Psychiatric comorbidity in clinically stable COVID-19 patients (Mental health domains)

Table 2 shows the binary logistic regression analysis of the factors associated with psychiatric comorbidity. In this study, the only risk factors for psychiatric comorbidity identified was presence of physical symptoms (β = −2.801, P < 0.001).

Table 2.

Binary logistic regression analysis showing the factors associated with psychiatric comorbidity

	B	S.E	Sig.	Exp (B)
Age (Age group)	‒0364.	0.570	0.524	0.695
Sex (female vs male)	‒3.16	0.602.	0.600	0.729
Perceived life threat due to COVID-19 infection (yes vs no)	‒0.155	0.605	0.798	0.856
Perceived discrimination and stigma due to COVID-19 infection (yes vs no)	1.058	0.597	0.077	2.880
Admission in hospital (yes vs no)	0.901	0.697	0.196	2.463
Presence of physical symptoms (yes vs no)	‒2.801	0.669	0.000**	0.061
Presence of medical comorbidity (yes vs no)	0.155	0.605	0.798	1.168
Steroid therapy (yes vs no)	‒0.567	0.599	0.344	0.567

**Significant at 1% level of significance. B – Coefficient for the constant; S.E. – Standard error for the coefficient for the constant; Sig. – Significance; Exp (B) - Exponentiation of the B coefficient

DISCUSSION

It is a well-established fact that several viruses are capable of invading our brain and can affect our nervous system.[8] There have been several reports about the COVID-19 virus potential to directly invade the nervous system and causing serious psychiatric disorders.[1] Very few studies, so far have been conducted to see the involvement of this virus in the development of new onset psychiatric disorders.[9] This study was designed to assess the psychiatric comorbidity among COVID-19 patients and is likely to be among the first such study in this regard in Indian context.

The mean age of participants in this study was 38.95 (± 14.69) years and the majority of the participants were male (64%, n = 47). Our findings were quite similar to the finding of similar study on COVID-19 patients.[10] Recently, an increasing trend in the morbidity and mortality has been noticed worldwide, which has led to widespread panic and fear reactions related to lethality of this disease.[11] Reflecting the above belief, the majority of participants (68.10%, n = 49) considered the COVID-19 infection as potentially life-threatening infection.

Analysis of the stigma and discrimination towards COVID-19 patients is essential for the effective control of this disease.[12] We tried to investigate experience of perceived discrimination related to COVID-19 infection among participants in this studyand 48.6% (n = 35) patients reported that they had faced discrimination and stigma after being labeled as COVID-19 patients. These finding are in resonance with the finding of one similar study.[13]

Currently, there is a paucity of data related to psychiatric symptoms in COVID-19 patients.[14] The prevalence of psychiatric comorbidity in our study was 76.4% (n = 55) which is comparatively higher than the findings of a similar study conducted on 402 COVID-19 patients and in which author reported 56% psychiatric comorbidity in COVID-19 patients after one month follow-up. The difference in findings could be because of methodological difference between the two studies.[15]

In our study, depression (44.4%), anxiety (34.72%) and somatic symptoms (26.39%) were the most frequenting symptoms reported by COVID-19 positive patients followed by sleeping problems (23.61%) and anger issues (18.10%) which were in resonance with the findings of similar study.[15] Additionally, high prevalence of other psychiatric symptoms such as mania, substance use, problems in personality functioning, repetitive thoughts and behavior, dissociative symptoms, memory problems and psychosis were also observed in the participants. It was also alarming that about 5.56% of participants acknowledged experiencing thoughts of actually hurting themselves. To the best of our ability, although we were not able to find descriptive studies from India so far on this issue, findings of our study are consistent with the finding of few other international studies which have also reported high prevalence of psychiatric symptoms in COVID-19 positive patients.[16,17]

A recent study found COVID-19 symptoms, steroid treatment, perceived discrimination as a risk factor for psychiatric comorbidity in COVID-19 patients,[18] in contrast, the only risk factor identified for psychiatric comorbidity in the present study was presence of physical symptoms in our study. The possible reason for the difference could be because of methodological difference.

Limitations

Some important study limitation include a purposive sampling from a single center. Another methodological issue is the reliance on a self-report measure of scales used which could lead to inaccuracies in the information reported. Recall bias and a response bias cannot be ruled out as the data was collected cross-sectionally.

CONCLUSION

Our study provides early evidence of a significant psychological impact of COVID-19 infection on patients.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of Interest

The authors declare that there are no conflicts of interest.