Prevalence of anxiety during the COVID-19 pandemic in patients diagnosed with subglottic stenosis

Abstract

Objectives

In the wake of the novel coronavirus disease (COVID-19), patients with subglottic stenosis (SGS) have a new, seemingly ubiquitous, respiratory disease to contend with. Whether real or perceived, it is likely that patients with SGS will feel exposed during the current pandemic. This study seeks to determine whether patients with SGS have increased rates of anxiety during the COVID-19 pandemic relative to healthy controls, as well as how much of an impact the pandemic itself plays in the mental health of this population.

Methods

Retrospective review of 10 patients with a confirmed SGS diagnosis and 21 control patients were surveyed via telephone. Patients of all ages that had an in-person or virtual visit within 3 months of the survey start date were included.

Results

A total of 30 patients were surveyed in this study, of whom 67.8 % were in the control group and 32.2 % were comprised of patients diagnosed with SGS. SGS patients reported a significantly higher level of anxiety on the GAD-7 scale with severe anxiety in 20 % of patients, moderate anxiety in 50 % of patients, mild anxiety in 20 %, and 10 % reporting no anxiety. Overall, the average reported GAD-7 score of the SGS patients and control patients were 10.8 ± 4.96 and 6.67 ± 2.96 respectively (p < 0.05).

Conclusions

This study is the first of its kind to analyze the rates and causes of anxiety within the context of the COVID-19 pandemic on patients diagnosed with subglottic stenosis. SGS patients were found to have a significantly higher anxiety based on the GAD-7 survey in comparison to patients without SGS.

Level of evidence: IV.

1. Introduction

Subglottic stenosis (SGS) is a rare disease with a difficult pathology to diagnosis and treat [1], [2], [3]. This highly complex disease continues to be poorly understood with a long list of etiologies [1], [4], [5]. The treatment of SGS also proves to be a significant therapeutic challenge because of its complex pathology and intricate location. Depending on the severity of the stricture, endoscopic therapeutic options such as laser division and balloon dilation may not be viable due to a high probability of recurrence [4], [6], [7]. Surgical resection may be required in advanced cases but this may also be complicated depending on the involvement of neighboring structures [4], [8]. As such, each case of SGS is highly variable with its own set of unique challenges and requires an extensive amount of effort from the physician and patient for effective work up and management.

In the wake of the novel coronavirus disease (COVID-19), patients with SGS have a new, seemingly ubiquitous, respiratory disease to contend with. Whether real or perceived, it is likely that patients with SGS will feel exposed during the current pandemic. Stress and anxiety are known to be associated with poor health outcomes, especially in individuals with pre-existing comorbidities [9], [10], [11]. Elsner et al. conducted a study to investigate the influence of anxiety on health outcomes of patients with COPD and found that patients with higher anxiety had poorer health outcomes with higher risk of COPD exacerbation [10]. It remains largely unknown how mental health status can affect SGS outcomes in patients.

A diagnostic interview data study done by the National Comorbidity Study Replication showed that an estimated 19.1 % of adults in the United States had any type of anxiety disorder in the past year with an estimated 31.1 % of all US adults experiencing any anxiety disorder at some point in their lives [12]. While the impact of the COVID-19 pandemic on this prevalence has not yet been investigated, the pandemic has been shown to increase mental health burden in various locations and certain patient populations [13], [14]. Similar effects of the pandemic in patients with SGS have not yet been explored. This study seeks to determine whether patients with SGS have increased rates of anxiety during the COVID-19 pandemic relative to healthy controls, as well as how much of an impact the pandemic itself plays in the mental health of this population.

2. Methods

This study was approved by the Rush University Medical Center Institutional Review Board. Informed consent was obtained verbally at the beginning of each survey session. The current study consists of a prospective survey conducted with patients from the senior author's (I.H.) laryngology practice. Ten patients with a confirmed SGS diagnosis and 21 control patients were surveyed via telephone. Patients of all ages that had an in-person or virtual visit within 3 months of the survey start date were included. Patient demographic data (age, sex, weight, height, comorbidities) were extracted from the medical record system.

The GAD-7 survey is a well-established 7-item scale used to measure the level of anxiety in patients and assess for generalized anxiety disorder (GAD) [15]. Willing participants were asked to complete this survey along with 3 additional questions that were designed by the authors to investigate the impact of COVID-19 specifically on an individual's current concerns. The questions were as follows (with corresponding labels for subsequent reference): “How has your worrying regarding your health changed since the onset of the COVID-19 pandemic” (Q1), “Relative to the average person, how likely do you believe you are to become infected with the COVID-19 virus” (Q2), and “If you become infected with the COVID-19 virus, how likely do you believe you are to have a complication such as hospitalization, intubation, or death, compared to the average person” (Q3). For Q1, patients were asked to rate their response ranging from much worse (0), to no worrying (6). For Q2 and Q3, the responses ranged from more likely (0), average likelihood, and less likely (2).

After responses were compiled for each group, independent t-test was performed for the compiled mean scores of the GAD-7 survey and each of the additional 3 COVID-19-related questions. Differences in means with p-values <0.05 were considered to have a significant difference.

3. Results

3.1. Demographics

Demographic statistics are presented in Table 1 . A total of 30 patients were surveyed in this study, of whom 67.8 % were in the control group and 32.2 % were comprised of patients diagnosed with SGS. Overall, females accounted for 61.3 % of the study group. The mean age of control patients was 55.8 in comparison to 44.1 years in patients with SGS. There was no notable difference in comorbidities between the two groups.

Table 1.

Demographic characteristics of all patients included in this study.

Covariate	No. (%)
Age, mean
SGS	51.7
Control	55.8
Sex – SGS cohort
Male	4 (23.5)
Female	13 (76.5)
Sex - control
Male	9 (42.9)
Female	12 (57.1)

3.2. Survey results

SGS patients reported a significantly higher level of anxiety on the GAD-7 scale with severe anxiety in 20 % of patients, moderate anxiety in 50 % of patients, mild anxiety in 20 %, and 10 % reporting no anxiety. This is in comparison to the patients in the control arm of whom 0 % reported severe anxiety, 22.7 % with moderate anxiety, 45.4 % with mild anxiety, and 27.3 % with none. Overall, the average reported GAD-7 score of the SGS patients and control patients were 10.8 ± 4.96 and 6.67 ± 2.96 respectively (p < 0.05).

Three additional questions were surveyed to further assess anxiety in regards to the COVID-19 pandemic. The first question (Q1) had a slightly higher average of 1.80 for SGS patients in comparison to the average of 1.57 for control patients, however this difference did not reach statistical significance (p = 0.69). Q2 approached statistical significance (p = 0.08), with SGS patients reporting an average of 0.9 and control patients with an average of 1.29. Finally, Q3 also did not demonstrate a significant difference between the two cohorts (p = 0.55; SGS mean = 0.80, Ctrl mean = 1.00).

4. Discussion

To our knowledge, this is the first investigation of generalized anxiety in patients diagnosed with SGS during the COVID-19 pandemic in the US. This study provides valuable insight into anxiety levels in patients with SGS that may better equip physicians and mental health providers in recognizing and treating patients who are at higher risk for mental health challenges during the current pandemic.

The survey results partially confirmed our hypotheses. Patients with SGS reported a much higher level of generalized anxiety with a significantly higher mean score when compared to the control arm. It is recognized that underlying respiratory conditions can increase a patient's risk of illness from the COVID-19 virus with varying levels of evidence. These findings have been well-publicized by public health entities such as the CDC and WHO [16], [17], [18], [19], [20], [21]. All respondents with SGS were undergoing active management for their symptoms with follow-up visits within three months of the survey and were aware of their diagnoses. Other cohorts of patients with pre-existing conditions have similarly demonstrated disproportionately high mental health burdens. Marbaniang et al. reported that patients with HIV experienced a significantly higher mental burden during the pandemic than non-immunosuppressed patients [22]. These findings support the premise of the study that respondents are aware of the increased risk that their diagnoses pose in developing illness from the COVID-19 virus. It is then plausible that their diagnoses of SGS may play a role in the observed increased mental health burden.

The remainder of the questions yielded variable results. Although patients with SGS reported a substantial increase in their infection likelihood of COVID-19, this did not reach statistical significance. Additionally, patients did not believe their worry regarding health outcomes to have changed significantly since the onset of the pandemic nor that they were at increased risk of a complication in the event that they were infected with the COVID-19 virus. Much about the virus remains unknown. Therefore, the effects of the pandemic may not be uniform for every individual. These variable responses also highlight the fact that patients are facing an overwhelming number of stressors including social distancing, financial difficulties, grief, and other medical issues [23], [24], [25]. Further identification of these stressors is critical in understanding how to better manage the physiological and psychosocial burden of this disease.

Altogether there is a pressing need for further evidence to be gathered regarding the mental burden that this pandemic is placing on patients with pre-existing conditions such as SGS. This study represents a start in understanding how physicians and patients can better navigate the disease management process in the wake of a pandemic that has demonstrated weaknesses within the US healthcare system.

The current study suffers from limitations that warrant consideration. The number of participants were limited in order to survey patients who were undergoing active management of SGS during the pandemic. Due to the rarity of this disease and the resultant relative low power of the study, trends related to the COVID-19-specific questions are difficult to assess. Subsequent studies utilizing larger size samples can help confirm the results. Similarly, the small sample size limited matching of cohorts. Additional demographic information may serve to elucidate potential confounders. Third, this survey was carried out via telephone, potentially excluding certain populations such as those who do not have access to a telephone.

5. Conclusion

This study is the first of its kind to analyze the rates and causes of anxiety within the context of the COVID-19 pandemic on patients diagnosed with subglottic stenosis. SGS patients were found to have a significantly higher anxiety based on the GAD-7 survey in comparison to patients without SGS. Additional questions specific to the COVID-19 pandemic did not show a significant difference between the two groups.

Declaration of competing interest

EV: No conflict of interest. No financial disclosures.

JK: No conflict of interest. No financial disclosures.

ME: No conflict of interest. No financial disclosures.

PL: No conflict of interest. No financial disclosures.

IH: No conflict of interest. No financial disclosures.