Abstract
Background:
Many studies across the globe have evaluated the adverse mental health consequences of COVID-19 in patients who suffered from COVID-19 infection. However, a comparative study of persons who suffered from COVID-19 infection and those who witnessed the COVID-19 infection in their close relatives is lacking.
Aims and Objectives:
This study aims to compare the psychiatric morbidity in persons who suffered from COVID-19 infections, and those who witnessed the illness in one of their close relatives.
Methods:
In this cross-sectional online survey, 2,964 adult participants completed the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) Scale, Fear of COVID-19 Scale (FCS-19), Brief Resilient Coping Scale (BRCS), The Brief Resilience Scale (BRS) and a self-designed questionnaire to evaluate other neuropsychiatric complications.
Results:
Compared to the close relatives who had witnessed COVID-19 infection, participants who developed COVID-19 infection had a significantly higher prevalence of depression (34.6%), anxiety disorder (32.3%), and fear of COVID-19 infection (18.8%), which was significantly higher than that noted in close relatives. However, BRS coping score was not significantly different between the two groups. Overall, about one-third of the participants who developed COVID-19 infection had depression and one-third had anxiety disorders. One-fifth of the participants reported high fear, post-traumatic symptoms, and obsessive-compulsive symptoms, whereas one-sixth reported other neuropsychiatric manifestations.
Conclusion:
Patients who suffered from COVID-19 have a higher prevalence of depression, anxiety, and fear as compared to those to witnessed COVID-19 in relatives.
Keywords: Anxiety, COVID-19, depression, fear, neuropsychiatric complications, resilience
INTRODUCTION
Currently, the world is facing one of the most difficult challenges for survival due to the ongoing pandemic of the coronavirus infection or COVID-19 outbreak. As a fighting strategy against COVID-19, most of the countries implemented lockdown and other public health measures such as social distancing, screening, and compulsory use of masks. However, despite this, the pandemic has affected a large proportion of the population across the globe and has led to significant mortality across the globe.
The different surveys carried out across the globe during the first wave of the pandemic suggested an increase in the prevalence of various psychiatric disorders such as depression, anxiety disorder, and insomnia in the general population, patients with acute COVID infection, and in the post-COVID infection patients. A meta-analysis of five studies, which included data of 9,074 persons, reported the prevalence of stress to be 29.6% (confidence interval [CI]: 24.3–35.4%). The same meta-analysis reported the prevalence of anxiety disorders in 17 studies involving 63,439 persons to be 31.9% (95% CI: 27.5–36.7) and that of depression in 14 studies involving 44,531 participants at 33.7% (95% CI: 27.5–40.6).[1]
Another meta-analysis of the data, which pooled data from 65 studies involving 97,333 health care workers from 21 countries, reported the pooled prevalence of depression to be 21.7% (95% CI, 18.3%–25.2%). The same meta-analysis reported pooled prevalence of anxiety to be 22.1% (95% CI, 18.2%–26.3%) and that of post-traumatic stress disorder (PTSD) to be 21.5% (95% CI, 10.5%–34.9%). In terms of countries, the prevalence rates for depression and anxiety were reported to be highest in studies from Middle-East (34.6% and 28.9%, respectively) countries.[2]
One more meta-analysis, which focused on psychiatric morbidity associated with the severe COVID-19 infection, included data from 65 published studies and 7 preprints, and reported that during the acute illness the prevalence of depressed mood was 32.6% (95% CI: 24.7–40.9) and that of anxiety was 35.7% (95% CI: 27.6–44.2). The prevalence of impaired memory was 34.1% (95% CI: 26.2–42.5) and that of insomnia was 41.9% (95% CI: 22.5–50.5).[3]
Emerging data from all parts of the world also suggest that there is an increase in the prevalence of psychiatric manifestations in the form of depression, anxiety, insomnia, PTSD, and fatigue in persons who have suffered from COVID-19 infection. A meta-analysis suggested that in the post-illness state, the prevalence of depressed mood was 10.5% (95% CI: 7.5–14.1), anxiety was 12.3% (95% CI: 7.7–17.7), irritability was 12.8% (8.7–17.6), memory impairment was 18.9% (95% CI: 14.1–24.2), fatigue was 19.3% (95% CI: 15.1–23.9%), traumatic memories was 30.4% (95% CI: 23.9–37.3%), and that of sleep disorder was 100% (95% CI: 88–100). Meta-analysis of the data suggested that the point prevalence of PTSD during the post-illness stage was 32.2% (95% CI: 23.7–42) and that of depression and anxiety were 14.8% (95% CI: 12.1–18.2) and 14.7% (95% CI: 11.1–19.4), respectively.[3] Another meta-analysis reported the pooled prevalence to be 45% (95% CI: 37–54) for depression, 47% (95% CI: 37–57%) for anxiety, and 34% (95% CI: 19–50) for sleep disturbances in patients with COVID-19 infection.[4]
Data from a large-scale study (n = 236,379) of patients diagnosed with COVID-19 infection revealed the estimated incidence of a neurological or psychiatric diagnosis in the 6 months follow-up period to be 33.62% and those admitted to an intensive care unit (ICU) had an incidence rate of 46.42%. Psychiatric diagnosis-specific outcomes as reported by the study suggested incidences of 0.67% for dementia, 17.39% for anxiety disorder, and 1.4% for psychotic disorder with higher rates in those admitted to the intensive care unit (ICU) during the acute illness.[5]
The high prevalence of psychiatric morbidity has been attributed to the direct effect of the virus on the brain, and the psychosocial factors. The emerging data also provides evidence for the direct effect of the SARS-CoV-2 on the human central nervous system leading to neuropsychiatric sequelae such as mood changes, psychosis, and neuromuscular dysfunction during the recovery period.[6]
Studies from India also suggest a high prevalence of depression and anxiety in the general population[7] and patients with COVID-19 infection[8] and also during the post-COVID-19 infection phase.[9]
However, the data on psychological morbidity during the post-COVID-19 infection phase are limited to occasional small sample size studies.[9] In the Indian context, despite understanding the high infectivity rate of COVID-19 infection, other family members have been closely involved in the care of the patient, either directly (taking care of their ill relatives during the home isolation) or indirectly (involved in the treatment decision-making or remaining in telephonic contact with the patient during the hospitalization). Due to this, they have also experienced significant distress because of the uncertainty of the outcome. In this background, this study aimed to evaluate the prevalence of psychiatric manifestations in persons who have suffered from COVID-19 infection and compare the same with persons who themselves did not suffer from COVID-19 infection, but witnessed the same in one of their relatives.
METHODOLOGY
This study was a cross-sectional internet-based study in which the data collection started on July 24, 2021, during the downslide of the second wave of the COVID-19 and was continued until September 24, 2021. The online trilingual (English, Hindi, and Gujarati) survey questionnaire using Google forms was circulated via WhatsApp, Email, text message, Facebook, and Instagram using the snowball sampling technique. The recipients of the survey link were also requested to forward the survey link to their known contacts. The link was designed in such a way that only one response could be generated by entering one phone number from a single device. The study was approved by an Independent Ethics Committee (IBIOME IEC ECR/40/INDT/GJ2013/RR1, IORG no. IORG0005548). The survey link mentioned that only those persons should complete the survey who had either suffered from the COVID-19 infection themselves (Group-A) or one of their close relatives (grandparents, parents, spouse, uncle, aunt, children, or sibling) had developed COVID-19 infection and they have been in close contact with them (Group-B). Additionally, the survey link mentioned that only persons who were aged 18 to 75 years should complete the survey. The survey invitation clearly stated that the participants will have the right not to participate in the survey and participation in the survey will imply providing informed consent. The participants were also informed that confidentiality of the data will be maintained and the data would anonymize for storage purposes. It was compulsory for participants to enter their phone numbers. We took care of duplicate entries by screening the IP addresses and the phone numbers of the responses.
The survey questionnaires included:
Sociodemographic details: The first section of the survey included sociodemographic variables with respect to age, gender, educational qualification, marital status, profession, place of residence, and religion.
Previous psychiatric illness-related data: The second section collected information related to previous psychiatric illness, medication continued, starting off a new psychiatric, and/or sleep medication, and post-COVID-19 sexual dysfunctions.
Medical illnesses and COVID-19-related data: The third section collected information related to medical comorbidities. Additional information collected included COVID-19 illness-related information, details of COVID-19 vaccine, confusion or fear associated with vaccination pattern, side effects of the vaccine, COVID-19 diagnosis, and testing status, home-based or hospital-based treatment for COVID-19, duration of hospital stay, need for oxygen support, and admission to the ICU.
Patient Health Questionnaire-9 (PHQ): PHQ-9 is a self-administered version of the PRIME-MD diagnostic instrument for screening depression. It has nine items, each of which focuses on the nine diagnostic criteria of depression as per the diagnostic and statistical manual, fourth revision criteria on a 4-point scale of “0” (not at all) to “3” (nearly every day). This questionnaire had been found to have excellent reliability and validity, sensitivity, and specificity for major depression. A cut score of more than or equal to 10 is considered to be an indicator of depression.[10] The Hindi-translated version of the scale has been validated in the past.[11]
Generalized Anxiety Disorder-7 (GAD-7) Scale: This is a 7-item anxiety scale with good reliability as well as the criterion, construct, factorial, and procedural validity. Cut-off points of 5, 10, and 15 are interpreted as representing mild, moderate, and severe levels of anxiety. There is good agreement between self-report and interviewer-administered versions of the scale.[12]
The Hindi-translated version of the scale has been validated in the past.[11]
Fear of COVID-19 Scale (FCV-19S): FCV-19S is a 7-item scale, each of which is rated on a 5-point Likert scale (strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree, strongly agree). Scores are categorized as low and high levels of fear based on the mean, which was taken as a cut-off. The scores less than or equal to the mean were considered as low fear and scores above the mean were considered as an indicator of high fear. This scale has been validated and tested for reliability in a few recent studies.[13] This scale was translated to Hindi and Gujrati using the standard World Health Organization (WHO) methodology for translation and back translation. However, a formal validation study was done to evaluate the psychometric properties of the translated version.
A self-designed questionnaire: A self-designed questionnaire was also included to document the effect of COVID-19 in the form of PTSD, panic attacks, obsessive-compulsive features, somatization, worry, psychotic symptoms, and loneliness. Neurological manifestations such as brain operating slowly, forgetfulness, difficulty in holding things, tremors, seizures, headache, and dizziness were assessed. Each item was rated on four anchor points (mot at all, several days, more than half of the days, nearly every day) over the last 4 weeks.
Brief Resilient Coping Scale (BRCS): It is a 4-item measure designed to capture tendencies to cope with stress in a highly adaptive manner. Its validity and reliability have also been tested in earlier studies. Each item is rated on a 5-point Likert scale (does not describe me at all, does not describe me, neutral, describes me, describes me very well), and the scores are categorized as low (score 4–13), medium (score 14–16), and high (score 17–20).[14]
The Brief Resilience Scale (BRS): The Brief Resilience Scale is a 6-item scale, each item rated on a 5-point Likert scale (strongly disagree, disagree, neutral, agree, and strongly agree). Some of the items were reverse-coded (items 2, 4, and 6). The scale has acceptable internal consistency in both samples, with Cronbach’s α values equal to 0.76 and 0.72, respectively.[15,16]
The FCV-19S, BRCS, BRS, and self-designed questionnaires were translated to Hindi and Gujrati using the standard WHO methodology for translation and back translation. However, a formal validation study was done to evaluate the psychometric properties of the translated version.
Statistical analysis was done using the software Statistical Package for Social Sciences, 14 versions. Continuous variables are expressed as mean and standard deviation (SD), whereas categorical variables are defined as a percentage. The Chi-square test was used for the comparison of categorical variables. The association between various variables was determined using Pearson’s correlation test or Spearman rank correlation. Statistical significance was accepted at the level of P < 0.05.
RESULTS
The survey included 2,964 subjects with 1,975 participants having suffered from COVID-19 infection (Group-A) and 989 participants although themselves did not suffer from COVID-19 infection; however, they witnessed the same in one of their relatives (Group-B). Compared to Group-B, a higher proportion of participants of Group-A were males, married, and from urban localities [Table 1].
Table 1.
Socio-demographic profile of the study participants
| Variables | Whole sample frequency (%)/mean (SD) n=2,964 | Persons who developed COVID 19 infection (Group A) Frequency (%)/mean (SD) (n=1,975) | Persons who witnessed COVID 19 infection. (Group B) Frequency (%)/mean (SD) (n=989) | Chi square test/t test value P Significant/non significant |
|---|---|---|---|---|
| Age (18 to 75) | 40.39±15.29 | 41.22±16.44 | 38.74±12.24 | <0.001*** |
| Age | ||||
| (18 to 45) | 2044 (69.0) | 1320 (64.6) | 724 (35.4) | 0.001*** |
| (45 to 60) | 681 (23.0) | 483 (70.9) | 198 (29.1) | |
| (60 to 75) | 239 (8) | 172 (72.0) | 67 (28.0) | |
| Sex | 0.060 | |||
| Male | 1915 (64.6) | 1253 (63.4) | 662 (66.9) | |
| Female | 1049 (35.4) | 722 (36.6) | 327 (33.1) | |
| Marital Status | ||||
| Currently married | 2306 (77.8) | 1570 (79.5) | 736 (74.4) | 0.001*** |
| Currently single | 658 (22.2) | 405 (20.5) | 253 (25.6) | |
| Educational Qualification | ||||
| Less than matriculation | 141 (4.8) | 82 (4.2) | 59 (6.0) | 0.031* |
| 10th Pass | 3 (0.1) | 1 (0.1) | 2 (0.2) | |
| Graduate | 2285 (77.1) | 1527 (77.3) | 758 (76.6) | |
| Post-graduate | 535 (18.0) | 365 (18.5) | 170 (17.2) | |
| Occupation | ||||
| Self-employed | 644 (21.7) | 473 (23.9) | 171 (17.3) | 0.08 |
| Employed | 497 (16.8) | 350 (17.7) | 147 (14.9) | |
| Home maker | 587 (19.8) | 386 (19.5) | 201 (20.3) | |
| Unemployed | 130 (4.4) | 92 (4.7) | 38 (3.8) | |
| Retired | 168 (5.7) | 103 (5.2) | 65 (6.6) | |
| Student | 299 (10.1) | 126 (6.4) | 173 (17.5) | |
| Others | 639 (21.55) | 445 (22.53) | 194 (19.61) | |
| Locality | ||||
| Urban | 1955 (66.0) | 1329 (67.3) | 626 (63.3) | 0.031* |
| Semi-urban | 374 (12.6) | 242 (12.3) | 132 (13.3) | |
| Rural | 635 (21.4) | 404 (20.5) | 231 (23.4) | |
| Religion | ||||
| Hindu | 2743 (92.5) | 1837 (93.0) | 906 (91.6) | 0.271 |
| Muslim | 169 (5.7) | 104 (5.3) | 65 (6.6) | |
| Others | 52 (1.75) | 34 (1.72) | 18 (1.82) |
*P<0.05; ***P<0.001
Out of the total participants, 15.96% had a history of previous psychiatric illness, and most of them had suffered from COVID-19 infection (Group-A). Out of 473 participants having a previous history of psychiatric illness, only 108 participants (22.83%) had continued their psychiatric medication during the COVID-19 lockdown/illness, with a significantly higher prevalence of non-adherence among those who suffered from COVID-19 infection (Group-A) [Table 2].
Table 2.
Psychiatric illness, medication continued, new psychiatric, and/or sleep medication started
| Variables | Whole sample frequency (%)/mean (SD) n=2,964 | Persons who developed COVID-19 infection (Group-A) Frequency (%)/mean (SD) (n=1,975) |
Persons who witnessed COVID-19 infection (Group-B) Frequency (%)/Mean (SD) (n=989) |
P |
|---|---|---|---|---|
| Did you fear of getting inflicted with mucormycosis after you recovered/witnessed from COVID-19? | 0.001*** | |||
| Yes | 244 (8.23%) | 185 (75.82%) | 59 (24.18%) | |
| No | 2720 (91.77%) | 1790 (65.81%) | 930 (34.19%) | |
| Did you have any psychiatric illness in the past? | <0.001*** | |||
| Yes | 473 (15.96%) | 369 (78.01%) | 104 (21.99%) | |
| No | 2491 (84.04%) | 1606 (64.47%) | 885 (35.52%) | |
| Did you continue your psychiatric medication during COVID-19 lockdown/illness? | (n=473) | (n=108) | (n=108) | <0.001*** |
| Yes | 108 (22.83%) | 24 (22.22%) | 84 (77.78%) | |
| No (Not applicable will be in no only) | 365 (77.17%) | 345 (94.52%) | 20 (5.48%) | |
| Did you start any new medication for your psychiatric conditions after you recovered/witnessed from COVID-19 illness? (n=2,964) | <0.001*** | |||
| Yes | 561 (18.9) | 438 (22.17%) | 123 (12.44%) | |
| No | 2403 (81.1) | 1537 (77.83%) | 866 (87.56%) | |
| Are you given any new sleeping medication after you recovered/witnessed from COVID-19 illness? | <0.001*** | |||
| Yes | 899 (30.3) | 666 (74.08%) | 233 (25.92%) | |
| No | 2065 (69.7) | 1309 (63.39%) | 756 (36.61%) | |
| After you recovered/witnessed COVID-19 illness, did you have persistent sexual difficulty? | <0.001*** | |||
| Yes | 461 (15.55) | 420 (21.27) | 41 (4.15) | |
| No | 2503 (84.45) | 1555 (78.73) | 948 (95.85) | |
| If Yes, what was the kind of sexual problem you had? (n=461) | ||||
| Failure to obtain/achieve erection during sexual activity with partner. | 244 (52.93%) | 227 (54.05%) | 17 (41.46%) | 0.126 |
| Ejaculation before/shortly after vaginal penetration | 74 (16.05%) | 66 (15.71%) | 8 (19.51%) | 0.412 |
| “Discrepancy in sex desire” -Lower desire than your partner in sexual activity | 59 (12.8%) | 51 (12.14%) | 8 (19.51%) | 0.839 |
| Marked delay in/or inability to achieve ejaculation | 3 (0.65%) | 3 (0.71%) | 0 | |
| Difficulty in experiencing orgasm and/or markedly reduced intensity of orgasmic sensation | 10 (2.17%) | 8 (1.90%) | 2 (4.88%) | <0.001*** |
| More than one problems | 70 (15.18%) | 64 (15.234%) | 6 (14.64%) | 0.918 |
| Fear of pain | 1 (0.22%) | 1 (0.24%) | 0 | |
| Substance/medication induced sexual dysfunction | 0 | 0 | 0 |
***P<0.001
About one-fifth of the participants (18.9%) started new psychotropic and sleep medication after the start of the pandemic, with a significantly higher prevalence among those who had suffered from COVID-19 (Group-A) [Table 2]. Similarly, there was a significantly higher prevalence of sexual difficulty among those who suffered from COVID-19 infection (Group-A). The fear of mucormycosis was also higher among those who had suffered from COVID-19 infection (Group-A) [Table 2].
Compared to those who had only witnessed COVID-19 infection (Group-B), those who had developed COVID-19 infection (Group-A) had a significantly higher prevalence of any medical comorbidity [Table 3].
Table 3.
Medical comorbidities, vaccination pattern, confusion or fear, and side-effect of vaccinations and home or hospital treatment received
| Variables | Whole sample frequency (%)/mean (SD) n=2,964 | Persons who developed COVID-19 infection (Group-A) | Persons who witnessed COVID-19 infection (Group-B) | Chi-square test/t test value |
|---|---|---|---|---|
| Frequency (%)/mean (SD) (n=1,975) | Frequency (%)/mean (SD) (n=989) | P | ||
| Do you have any medical illness? (apart from COVID-19) | <0.001*** | |||
| Yes | 805 (27.2) | 609 (30.8) | 196 (19.8) | |
| No | 2159 (72.8) | 1366 (69.2) | 793 (80.2) | |
| More than one | 305 (37.89%) | 255 (41.87%) | 50 (25.51%) | <0.001*** |
| Asthma | 12 (1.49%) | 9 (1.48%) | 3 (1.53%) | 0.958 |
| Benign prostatic hyperplasia | 2 (0.25%) | 2 (0.33%) | 0 | 0.422 |
| Cancer | 2 (0.25%) | 1 (0.16%) | 1 (0.51%) | 0.024 |
| Chronic kidney disease | 5 (0.62%) | 1 (0.16%) | 4 (2.04%) | 0.422 |
| Chronic obstructive pulmonary disease | 2 (0.25%) | 1 (0.16%) | 1 (0.51%) | 0.349 |
| Diabetes | 115 (14.29%) | 83 (13.64%) | 32 (16.33%) | 0.693 |
| Dyslipidemia or hypercholesterolemia | 15 (1.86%) | 12 (1.97%) | 3 (1.53%) | 0.541 |
| Epilepsy | 7 (0.87%) | 6 (0.99%) | 1 (0.51%) | 0.083 |
| Hypertension | 189 (23.47%) | 134 (22%) | 55 (28.07%) | 0.114 |
| Hypo or Hyperthyroidism | 54 (6.71%) | 36 (5.91%) | 18 (9.18%) | 0.633 |
| Ischemic Heart Disease | 11 (1.37%) | 9 (1.48%) | 2 (1.02%) | 0.035 |
| Obesity | 23 (2.86%) | 13 (2.13%) | 10 (5.10%) | 0.422 |
| Stroke | 1 (0.12%) | 0 | 1 (0.51%) | 0.459 |
| Tuberculosis | 2 (0.25%) | 1 (0.16%) | 1 (0.51%) | 0.460 |
| Others | 19 (2.36%) | 13 (2.13%) | 6 (3.06%) | |
| Not applicable | 41 (5.09%) | 33 (5.43%) | 8 (4.08%) | |
| Vaccinated | 0.029* | |||
| Yes | 2343 (79.0) | 1584 (80.2) | 759 (76.7) | |
| No | 621 (21.0) | 391 (19.8) | 230 (23.3) | |
| Confusion and fear of vaccination | 0.202 | |||
| Yes | 464 (15.7) | 332 (16.8) | 132 (13.3) | |
| No | 1873 (63.2) | 1250 (63.3) | 623 (63.0) | |
| Not Applicable | 627 (21.2) | 393 (19.9) | 234 (23.7) | |
| Side effect of vaccine | (n=2,343) | (n=1,584) | (n=759) | <0.001*** |
| Yes | 1394 (59.5) | 886 (55.93) | 508 (66.93) | |
| No | 949 (40.5) | 698 (44.07) | 251 (33.07) | |
| Diagnosis of COVID | NA | |||
| RTPCR | 1098 (55.59%) | |||
| Rapid antigen test | 451 (22.84%) | |||
| CT-thorax | 14 (0.71%) | |||
| more than 1 test | 382 (19.34%) | |||
| Not Applicable | 30 (1.52%) | |||
| HOME treatment for COVID-19 | 1532 (77.57%) | NA | ||
| Hospitalization for COVID-19 | 358 (18.13%) | |||
| Required oxygen support during the COVID-19 infection | 175 (8.86%) | |||
| Hospitalization to ICU due to COVID-19 infection | 46 (2.33%) | |||
| Duration of stay in the hospital (n=358) | ||||
| Less than a week | 89 (24.86%) | NA | ||
| Between 1 and 2 weeks | 211 (58.94%) | |||
| Between 2 and 4 weeks | 55 (15.36%) |
*P<0.05; ***P≤0.001
A significantly higher proportion of those who had developed COVID-19 infection (Group-A) had received one dose of the vaccine, had fear of the vaccine, and a lower proportion of them experienced side-effects with the vaccine. The majority of the participants who had developed COVID-19 infection (Group-A) received home-based treatment [Table 3].
Compared to those who had witnessed the COVID-19 infection (Group-B), a significantly higher proportion of those who had suffered from COVID-19 infection (Group-A) reported intense recollection or flashbacks of illness when in dreams or awakened states, avoiding memories, thoughts, or feelings related to the stressful experience, panic attacks, increase in obsession with cleanliness, obsession with cleanliness troubled other people; repetitive washing routines, repetitive checking behavior, uncomfortable religious and sexual thoughts/recurrent intrusive thoughts/impulses/images; concerned about the bodily symptoms (e.g., body aches and pains, feel of lump in throat, feel of choking, and jerky breathing), worry that your loved ones will die at the hands of COVID-19, experience of any elevated mood or euphoria for at least 1 week, increased energy or constant urge to do many things, feeling alone or left out, brain operating slowly, forgetfulness, persistent headache, and experience sudden onset dizziness (head spinning) [Table 4].
Table 4.
Other Neuropsychiatric issues among those with COVID-19 infection and those who witnessed the COVID-19 infection in a relative
| Variables | Whole sample frequency (%)/mean (SD) n=2964 | Persons who developed COVID-19 infection (Group-A) Frequency (%)/mean (SD) (n=1,975) |
Persons who witnessed COVID-19 infection (Group-B) Frequency (%)/mean (SD) (n=989) |
Chi-square test/t test value P Significant/non significant |
|---|---|---|---|---|
| Intense recollection or flashbacks of illness when in dreams or awakened states | ||||
| Not at all | 2361 (79.7) | 1502 (76.1) | 859 (86.86) | <0.001*** |
| Several Days | 254 (8.6) | 188 (9.5) | 66 (6.67) | |
| More than half of the days | 259 (8.7) | 213 (10.8) | 46 (4.65) | |
| Nearly everyday | 90 (3.0) | 72 (3.6) | 18 (1.82) | |
| Repeated, disturbing, and unwanted memories of the stressful experience | ||||
| Not at all | 2319 (78.2) | 1477 (74.8) | 842 (85.1) | <0.001*** |
| Several Days | 294 (9.9) | 222 (11.2) | 72 (7.3) | |
| More than half of the days | 254 (8.6) | 199 (10.1) | 55 (5.6) | |
| Nearly everyday | 97 (3.3) | 77 (3.9) | 20 (2.0) | |
| Avoiding memories, thoughts, or feelings related to the stressful experience | ||||
| Not at all | 2309 (77.9) | 1470 (74.4) | 839 (84.8) | <0.001*** |
| Several Days | 291 (9.8) | 224 (11.3) | 67 (6.8) | |
| More than half of the days | 253 (8.5) | 196 (9.3) | 57 (5.8) | |
| Nearly everyday | 111 (3.7) | 85 (4.3) | 26 (2.6) | |
| Panic attacks (sudden, intense anxiety that lasts for a short length of time) | ||||
| Not at all | 2511 (84.7) | 1626 (82.3) | 885 (89.5) | <0.001*** |
| Several Days | 248 (8.4) | 194 (9.8) | 54 (5.5) | |
| More than half of the days | 162 (5.5) | 120 (6.1) | 42 (4.2) | |
| Nearly everyday | 43 (1.5) | 35 (1.8) | 8 (0.8) | |
| Increase in the obsession with cleanliness | ||||
| Not at all | 2273 (76.7) | 1473 (74.6) | 800 (80.9) | 0.006** |
| Several days | 349 (11.8) | 259 (13.1) | 90 (9.1) | |
| More than half of the days | 264 (8.9) | 194 (9.8) | 70 (7.1) | |
| Nearly everyday | 78 (2.6) | 49 (2.5) | 29 (2.9) | |
| Obsession with cleanliness troubled other people | ||||
| Not at all | 2478 (83.6) | 1605 (81.3) | 873 (88.3) | <0.001*** |
| Several days | 304 (10.3) | 232 (11.7) | 72 (7.3) | |
| More than half of the days | 144 (4.9) | 111 (5.6) | 33 (3.3) | |
| Nearly everyday | 38 (1.3) | 27 (1.4) | 11 (1.1) | |
| Repetitive washing routines, repetitive checking behavior, uncomfortable religious and sexual thoughts/recurrent intrusive thoughts/impulses/images | ||||
| Not at all | 2422 (81.7) | 1561 (79.0) | 861 (87.1) | <0.001*** |
| Several days | 291 (9.8) | 218 (11.0) | 73 (7.4) | |
| More than half of the days | 199 (6.7) | 154 (7.8) | 45 (4.6) | |
| Nearly everyday | 52 (1.8) | 42 (2.1) | 10 (1.0) | |
| Concerned about the bodily symptoms (e.g., body aches and pains, feeling of a lump in the throat, feeling of choking, and jerky breathing) | ||||
| Not at all | 2381 (80.3) | 1510 (76.5) | 871 (88.1) | <0.001*** |
| Several days | 238 (8.0) | 185 (9.4) | 53 (5.4) | |
| More than half of the days | 244 (8.2) | 194 (9.8) | 50 (5.1) | |
| Nearly everyday | 101 (3.4) | 86 (4.4) | 15 (1.5) | |
| Worry that your loved ones will die at the hands of COVID-19 | ||||
| Not at all | 2070 (69.8) | 1310 (66.3) | 760 (76.8) | <0.001*** |
| Several days | 286 (9.6) | 193 (9.8) | 93 (9.4) | |
| More than half of the days | 424 (14.3) | 321 (16.3) | 103 (10.4) | |
| Nearly everyday | 184 (6.2) | 151 (7.6) | 33 (3.3) | |
| Experience of any elevated mood or euphoria for at least 1 week | ||||
| Not at all | 2434 (82.1) | 1549 (78.4) | 885 (89.5) | <0.001*** |
| Several days | 168 (5.7) | 116 (5.9) | 52 (5.3) | |
| More than half of the days | 169 (5.7) | 129 (6.5) | 40 (4.0) | |
| Nearly everyday | 193 (6.5) | 181 (9.2) | 12 (1.2) | |
| Increased energy or constant urge to do many things | ||||
| Not at all | 2421 (81.7) | 1544 (78.2) | 877 (88.7) | <0.001*** |
| Several days | 160 (5.4) | 104 (5.3) | 56 (5.7) | |
| More than half of the days | 179 (6.0) | 138 (7.0) | 41 (4.1) | |
| Nearly everyday | 204 (6.9) | 189 (9.6) | 15 (1.5) | |
| Feeling alone or left out | ||||
| Not at all | 2362 (79.7) | 1513 (76.6) | 849 (85.8) | <0.001*** |
| Several days | 213 (7.2) | 149 (7.5) | 64 (6.5) | |
| More than half of the days | 240 (8.1) | 183 (9.3) | 57 (5.8) | |
| Nearly everyday | 149 (5.0) | 130 (6.6) | 19 (1.9) | |
| Brain operating slowly | ||||
| Not at all | 2460 (83.0) | 1594 (80.7) | 866 (87.6) | <0.001*** |
| Several days | 246 (8.3) | 181 (9.2) | 65 (6.6) | |
| More than half of the days | 189 (6.4) | 141 (7.1) | 48 (4.9) | |
| Nearly everyday | 69 (2.3) | 59 (3.0) | 10 (1.0) | |
| Forgetfulness | ||||
| Not at all | 2384 (80.4) | 1537 (77.8) | 847 (85.6) | <0.001*** |
| Several days | 263 (8.9) | 188 (9.5) | 75 (7.6) | |
| More than half of the days | 240 (8.1) | 187 (9.5) | 53 (5.4) | |
| Nearly everyday | 77 (2.6) | 63 (3.2) | 14 (1.4) | |
| Felt that it was hard to hold things, write or button your shirt | ||||
| Not at all | 2761 (93.2) | 1835 (92.9) | 926 (93.6) | 0.184 |
| Several days | 109 (3.7) | 73 (3.7) | 36 (3.6) | |
| More than half of the days | 67 (2.3) | 43 (2.2) | 24 (2.4) | |
| Nearly everyday | 27 (0.9) | 24 (1.2) | 3 (0.3) | |
| Recent onset shaking of hands | ||||
| Not at all | 2727 (92.0) | 1811 (91.7) | 916 (92.6) | 0.224 |
| Several days | 125 (4.2) | 83 (4.2) | 42 (4.2) | |
| More than half of the days | 84 (2.8) | 60 (3.0) | 24 (2.4) | |
| Nearly everyday | 28 (0.9) | 21 (1.1) | 7 (0.7) | |
| New-onset fits (seizures or epilepsy) | ||||
| Not at all | 2824 (95.3) | 1884 (95.4) | 940 (95.0) | 0.452 |
| Several days | 67 (2.3) | 37 (1.9) | 30 (3.0) | |
| More than half of the days | 54 (1.8) | 37 (1.9) | 17 (1.7) | |
| Nearly everyday | 19 (0.6) | 17 (0.9) | 2 (0.2) | |
| Persistent headache | ||||
| Not at all | 2497 (84.2) | 1622 (82.1) | 875 (88.5) | <0.001*** |
| Several days | 260 (8.8) | 195 (9.9) | 65 (6.6) | |
| More than half of the days | 171 (5.8) | 130 (6.6) | 41 (4.1) | |
| Nearly everyday | 36 (1.2) | 28 (1.4) | 8 (0.8) | |
| Experience sudden onset dizziness (head spinning) | ||||
| Not at all | 2514 (84.8) | 1627 (82.4) | 887 (89.7) | <0.001*** |
| Several days | 271 (9.1) | 203 (10.3) | 68 (6.9) | |
| More than half of the days | 140 (4.7) | 114 (5.8) | 26 (2.6) | |
| Nearly everyday | 39 (1.3) | 31 (1.6) | 8 (0.8) |
***P≤0.001
In terms of psychiatric morbidity, a significantly higher proportion of those who developed COVID-19 infection had depression, anxiety, and fear of COVID-19 infection. Compared to those who did not develop COVID-19 infection themselves (Group-B), a lower proportion of those who developed COVID-19 (Group-A) demonstrated fear of COVID-19, and a higher proportion of them reported a higher level of resilient coping [Table 5].
Table 5.
Psychiatric Morbidity among those who suffered COVID-19 infection and those who witnessed the COVID-19 infection in a relative
| Psychiatric morbidity | Whole sample frequency (%)/mean (SD) n=2964 | Persons who developed COVID-19 infection (Group-A) Frequency (%)/mean (SD) (n=1975) |
Persons who witnessed COVID-19 infection (Group-B) Frequency (%)/mean (SD) (n=989) |
Chi-square test/t test value/P
Significant/Non – significant |
|---|---|---|---|---|
| Mean PHQ-9 score | 6.80±6.9 | 7.41±7.09 | 6.56±6.15 | <0.001*** |
| Mean GAD-7 score | 6.07±6.13 | 5.58±6.59 | 5.10±5.97 | <0.001*** |
| Depression present (PHQ-9 score ≥10) | 905 (30.5) | 684 (34.6) | 221 (22.3) | <0.001*** |
| Severity of depression | ||||
| Minimal depression | 1390 (46.9) | 838 (42.2) | 552 (55.8) | <0.001*** |
| Mild depression | 669 (22.6) | 453 (22.9) | 216 (21.8) | |
| Moderate depression | 430 (14.5) | 327 (16.6) | 103 (10.4) | |
| Moderately severe depression | 319 (10.8) | 246 (12.5) | 73 (7.4) | |
| Severe depression | 156 (5.3) | 111 (5.6) | 45 (4.6) | |
| Anxiety disorder present (GAD-7 score ≥10) | 861 (29.0) | 637 (32.3) | 224 (22.6) | <0.001*** |
| Severity of anxiety | ||||
| Minimal anxiety | 1404 (47.4) | 851 (43.1) | 553 (55.9) | <0.001*** |
| Mild anxiety | 699 (23.6) | 487 (24.7) | 212 (21.4) | |
| Moderate anxiety | 557 (18.8) | 419 (21.2) | 138 (14) | |
| Severe anxiety | 304 (10.3) | 218 (11.0) | 86 (8.7) | |
| Fear of COVID-19 scale score | 11.04±6.35 | 11.32±6.45 | 10.48±6.12 | 0.001 |
| Low | 2463 (83.1) | 1604 (81.2) | 859 (86.9) | <0.001*** |
| High | 501 (16.9) | 371 (18.8) | 130 (13.1) | |
| Brief Resilience Scale (BRS) score | ||||
| Low | 556 (18.8) | 369 (18.7) | 187 (18.9) | <0.001*** |
| Normal | 1646 (55.5) | 1026 (51.9) | 620 (62.7) | |
| High | 762 (25.7) | 580 (29.4) | 182 (18.4) | |
| Brief Resilient Coping Scale score | ||||
| Low | 1534 (51.8) | 982 (49.7) | 552 (55.8) | 0.606 |
| Normal | 796 (26.9) | 563 (28.5) | 233 (23.6) | |
| High | 634 (21.4) | 430 (21.8) | 204 (20.6) |
***P≤0.001
A correlation analysis was carried out to assess the factors associated with psychiatric manifestations [Table 6]. Age was associated with significantly higher PHQ-9 score, GAD-7 score, FCV-19S score, and lower resilience score among those who had developed COVID-19 infection (Group-A). Among both the groups (Group-A and Group-B), higher depression scores were associated with higher severity of anxiety, higher fear of COVID-19 infection, and lower resilience score. Additionally, higher severity of anxiety was associated with higher fear of COVID-19 infection and lower resilience score [Table 6].
Table 6.
Association between Age, PHQ-9, GAD-7, FCV-19S, BRS, BRCS, variables in participants who suffered COVID 19 infection (Group-A) (n=1,975)
| Variables (Group-A) | Age | PHQ-9 Score | GAD-7 Score | FCV 19S Score | BRS Score |
|---|---|---|---|---|---|
| Correlations among those who suffered from COVID-19 infection | |||||
| PHQ-9 Score | 0.136 (<0.001***) | ||||
| GAD-7 Score | 0.123 (<0.001***) | 0.609 (<0.001***) | |||
| FCV-19S score | 0.080 (<0.001***) | 0.407 (<0.001***) | 0.473 (<0.001***) | ||
| BRS Score | -0.141 (<0.001***) | -0.393 (<0.001***) | -0.412 (<0.001***) | -0.327 (<0.001***) | |
| BRCS Score | -0.100 (<0.001***) | -0.290 (<0.001***) | -0.307 (<0.001***) | -0.211 (<0.001***) | 0.434 (<0.001***) |
| Correlations among those who witness COVID-19 infection in relatives | |||||
| PHQ-9 Score | 0.03 (0.348) | ||||
| GAD-7 Score | 0.071 (0.026*) | 0.801 (<0.001***) | |||
| FCV-19S score | -0.029 (0.365) | 0.438 (<0.001***) | 0.455 (<0.001***) | ||
| BRS Score | 0.053 (0.098) | -0.381 (<0.001***) | -0.362 (<0.001***) | -0.264 (<0.001***) | |
| BRCS Score | 0.016 (0.613) | -0.292 (<0.001***) | -0.261 (<0.001***) | -0.058 (<0.001***) | 0.466 (<0.001***) |
Spearman’s correlation coefficient; ***P≤0.001
DISCUSSION
The current survey aimed to evaluate the psychological and neuropsychiatric impact of going through the COVID-19 infection (Group-A) and compared the same with the group of people who themselves did not develop the COVID-19 infection, but witnessed the same in one of their relatives (Group-B).
The study data on psychological, neurological, neuropsychiatric, and psychosocial outcomes in patients who suffered and recovered from COVID-19 infection (Group-A) is emerging. The long-term psychiatric, neuropsychiatric, and neurological sequels are being reported from different parts of the globe.[1,2,3,4,5,17,18,19,20,21] Moreover, studies suggest a bidirectional relationship between COVID-19 and psychiatric disorders.[22,23] However, the research on specific psychiatric and neuropsychiatric manifestations, post-COVID sexual dysfunction, fear of mucormycosis and COVID-19 vaccine, resilience, and coping in this period of uncertainty of COVID-19 infection is very limited. In this background, the current study findings add to the data on psychiatric, neuropsychiatric, fear, sexual dysfunctions, and resilience outcomes.
The present study demonstrates the prevalence of depression and anxiety in one-third of those who developed COVID-19 infection (Group-A) and the prevalence of same and the severity of the same was significantly higher among those who developed COVID-19 infection (Group-A) compared to those who witnessed the COVID-19 infection (Group-B). Similarly, fear of COVID-19 infection was also higher among those who developed COVID-19 infection (Group-A) compared to those who witnessed the COVID-19 infection (Group-B). When we compare the findings of the present study with the existing literature available across the globe, the findings of the present study are in consonance with the existing literature from other parts of the world. This suggests that to provide care to people with post-COVID or long COVID symptoms, reorganization of mental health services is the need of the hour. Moreover, this finding suggests that the mental health professional should be an integral part of the multi-disciplinary teams involved in the care of patients with long COVID. Similar to the data available from different parts of the world, the findings of the present study also suggest a high prevalence of features of PTSD, OC symptoms, sexual dysfunction, and other psychiatric and neuropsychiatric symptoms during the post-COVID-19 phase.[17,18,24,25,26,27,28,30,31] The present study also shows that the prevalence of all these was higher among those who developed COVID-19 infection (Group-A) compared to those who witnessed COVID-19 infection (Group-B). These finding also suggest that the clinicians involved in the care of the patients with COVID-19 after the acute phase should regularly screen these patients for PTSD, OC symptoms, panic attacks, sexual dysfunction particularly erectile dysfunction in males, somatic symptoms, and other psychiatric and neuropsychiatric features. Similarly, the psychiatrists should regularly inquire about COVID-19 infection in persons presenting with recent onset psychiatric manifestations and also about symptoms of PTSD in these patients and also consider the possible underlying psychiatric and neuropsychiatric complications in the patients, which may be contributing to the recent onset psychiatric manifestations. The findings of sexual dysfunctions mainly erectile dysfunction suggest that COVID-19 has a uniquely harmful impact on men’s health and erectile function. As the pandemic wanes, strategies to identify long-term effects and additional health care support may be needed to adequately mitigate the impact of COVID-19 on men’s health.
The findings of the present study also support the emerging literature on the impact of COVID-19 on cognitive functions.[17,18,27,32] This suggests the need to improve awareness of the common people about these complications and public health measures need to be implemented to minimize the negative effect of COVID-19 illness on cognitive functions.
We are well aware of the limitations of the current study. Some of these include an Internet-based cross-sectional survey based on the snow-ball sampling method on a limited number of participants, the use of a screening questionnaire to assess psychiatric and medical comorbidities before the onset of the COVID-19 infection, and psychiatric and neuropsychiatric morbidities after COVID-19 infection in place of evaluating the patients clinically for the evidence of pre- and post-COVID morbidities. The study relied upon self-reported responses given by the participants. The present study did not evaluate the post-COVID or long COVID symptoms involving other body organs, which can have a significant impact on psychiatric morbidity. We suggest future research with a longitudinal study design on a larger sample to estimate the prevalence, course, and outcome of psychiatric and neuropsychiatric morbidities in patients who suffered or witnessed the COVID-19 infection.
CONCLUSION
To conclude, the present study reveals that a significant proportion of patients after recovering from COVID-19 infection experience psychological morbidity (nearly one-third experience anxiety and depression, nearly one-fifth report high fear, PTSD symptoms, OC symptoms, concerned about bodily symptoms, loneliness, and forgetfulness; nearly one-sixth report panic attacks, increased energy, brain operated slowly, headache, and dizziness. This suggests that to provide care to people with post-COVID or long COVID symptoms, there is a need for reorganization of mental health services and also that the mental health professional should be an integral part of the multi-disciplinary teams involved in the care of patients with long COVID. We further conclude that the clinicians involved in the care of the patients with COVID-19 after the acute phase should regularly screen these patients for PTSD, OC symptoms, panic attacks, sexual dysfunction particularly erectile dysfunction in males, somatic symptoms, and other psychiatric and neuropsychiatric features. Similarly, the psychiatrists should regularly inquire about COVID-19 infection in persons presenting with recent onset psychiatric manifestations and also about symptoms of PTSD in these patients and also consider the possible underlying psychiatric and neuropsychiatric complications in the patients, which may be contributing to the recent onset psychiatric manifestations.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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