1. Background
To date, studies have examined coronavirus disease 2019 (COVID-19)-related mental health outcomes among the general population and healthcare workers. However, evidence for the psychological consequences of hospitalized patients with COVID-19 has not been extensively studied (1, 2). Most recent studies are cross-sectional and reported that patients with COVID-19 had high levels of mental health burden, such as depression, anxiety, and posttraumatic stress disorder (PTSD), associated with the pandemic disease during hospitalization (3, 4). Importantly, these studies did not evaluate the psychological consequences of patients with COVID-19 after discharge from the hospital. Studies during previous pandemics reported that infected hospitalized patients have high rates of PTSD and mental distress (5, 6).
2. Objectives
This study aimed to evaluate the mental health status of COVID-19 patients one month after discharge from the hospital and determine the risk factors associated with anxiety, depression, and PTSD after hospitalization.
3. Methods
3.1. Study Design and Participants
This cross-sectional study was performed on all confirmed COVID-19 patients who had been hospitalized at Rasoul-Akram Medical Center, Tehran, Iran, within March 20, 2020, to September 21, 2020, and one month had passed since their discharge from the hospital. It should be noted that patients under 17 years of age or with cognitive or communication barriers were excluded from the study. Finally, 400 eligible patients were contacted by telephone and were informed about the purpose of the study. A total of 158 patients (39.5%) agreed to participate in the study. Then, the questionnaires were sent to them online. The participants answered the questionnaire anonymously on the Internet if they consented. The participants were asked to answer the questionnaire based on their experience with COVID-19 infection and hospitalization and show how much each problem bothered them.
3.2. Ethical Statement
This study was approved by the Ethics Committee of the Iran University of Medical Sciences, Tehran, Iran (code: 1399.594). Firstly, the respondents were asked to read the purpose of the study, give informed consent again, and participate in the survey if they agreed.
3.3. Measures
3.3.1. Demographic Information
Demographic information included the data, such as age, gender, education, occupation, marital status, underlying disease or physical illness under medical treatment, history of smoking or/and use of other substances (e.g., opioids, cannabinoids, methamphetamine, or alcohol), history of psychiatric disorders, hospitalization history in the intensive care unit (ICU), and duration of hospital stay due to COVID-19 infection.
3.3.2. Hospital Anxiety and Depression Scale (HADS)
The HADS questionnaire is a 14-item tool to measure depression and anxiety in inpatient, outpatient, and community settings. Each item is ranked on a 4-point Likert scale with a maximum score of 21 for anxiety and depression. Scores of 0-7 are considered normal on the relevant scales, with 8 - 10 as borderline and 11 or more as significant distress (7). This scale has been validated in Iran with good reliability and validity for Iranian society (8).
3.3.3. Posttraumatic Stress Disorder Checklist for the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders (PCL-5)
The PCL-5 is a 20-item self-report questionnaire that assesses the severity of PTSD symptoms over the past month and is based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. This scale has four subscales (i.e., intrusion, avoidance, negative alterations in cognition/mood, and alterations in arousal/reactivity), and respondents on a 5-point Likert scale from 0 (not at all) to 4 (extremely) rated how much a problem described in the statement bothered them last month. The PCL-5 scores showed strong internal consistency (α = 0.94), test-retest reliability (r = 0.82), and convergent (rs = 0.74 to 0.85) and discriminant (rs = 0.31 to 0.60) validity (9). Scores on the PCL-5 range from 0 to 80, and a preliminary cut-off score of 33 is recommended as indicating PTSD caseness (10). The PCL-5 has been validated in Iran with good reliability and validity for Iranian society (11).
3.3.4. Statistical Analysis
Firstly, the central tendency and dispersion parameters, including mean and standard deviation, for quantitative variables and the frequency and percentage for categorical variables were reported. Secondly, multivariable logistic regression modeling was performed to explore the effect of demographic and clinical factors on anxiety, depression, and PTSD. All the analyses were conducted in SPSS software (version 24.0). P-values of less than 0.05 were considered statistically significant (two-tailed tests).
4. Results and Discussion
The patients were within the age range of 17 - 69 years, and the mean age value was 42.02 ± 10.56 years. Most participants were male (58.2%) and married (79.1%) and the mean value of hospital stay duration was 9.08 ± 7.26 days (range: 5 - 35 days). In this study, 16 (10.1%) participants were healthcare workers, and 20 (12.7%) subjects had a positive history of psychiatric illness. Moreover, 21 (13.3%) patients were substance abusers. Additionally, 34 (21.5%) participants were admitted to the ICU during hospitalization.
Based on the results of the HADS, the prevalence rates of borderline anxiety and depression were 19.6% (n = 31) and 27.2% (n = 43), respectively. The prevalence rates of abnormal anxiety and depression in discharged patients were 20.3% (n = 32) and 13.3% (n = 21), respectively. According to the cut-off points of the PCL-5 questionnaire, 28.5% (n = 45) of COVID-19 patients discharged from the hospital had PTSD.
This study also evaluated the relationship between demographic data and all HDAS subscales and PCL-5 using both univariate and multivariate logistic regressions. In the multivariable logistic regression models, the female participants were more prone to hospital anxiety [adjusted odds ratio (AOR) = 2.571, 95% confidence interval (CI): 0.914 - 7.228], hospital depression (AOR = 2.282, 95% CI: 0.767 - 6.789), and PTSD (AOR = 1.513, 95% CI: 0.492 - 4.657) than male participants, although they were not statistically significant (P > 0.05). In addition, the participants with a positive history of psychiatric disorders and substance abuse were more likely to develop hospital depression and PTSD in the multivariate logistic regression (P < 0.05). A positive history of smoking was also a potential influencing factor associated with anxiety, depression, and PTSD in the univariate model (P < 0.05). Further details are presented in Tables 1 and 2.
| Variables | Hospital Anxiety | Hospital Depression | ||||||
|---|---|---|---|---|---|---|---|---|
| Unadjusted | Adjusted | Unadjusted | Adjusted | |||||
| 95% CI | P-Value | 95% CI | P-Value | 95% CI | P-Value | 95% CI | P-Value | |
| Age (y) | 1.015 (0.985 - 1.047) | 0.326 | 1.011 (0.963 - 1.061) | 0.656 | 1.008 (0.978 - 1.039) | 0.593 | 1.038 (0.985 - 1.093) | 0.165 |
| Gender | ||||||||
| Male | - | - | - | - | - | - | - | - |
| Female | 1.490 (0.782 - 2.840) | 0.226 | 2.571 (0.914 - 7.228) | 0.073 | 1.765 (0.925 - 3.366) | 0.085 | 2.282 (0.767 - 6.789) | 0.138 |
| Marital status | ||||||||
| Single | - | - | - | - | - | - | - | |
| Married | 1.211 (0.513 - 2.857) | 0.662 | 1.562 (0.517 - 4.715) | 0.429 | 0.599 (0.260 - 1.381) | 0.229 | 0.458 (0.150 - 1.398) | 0.170 |
| Divorced/widowed | 0.340 (0.035 - 3.340) | 0.355 | 0.197 (0.014 - 2.692) | 0.224 | 0.186 (0.019 - 1.808) | 0.147 | 0.020 (0.001 - 0.453) | 0.014 |
| Education level | ||||||||
| Under diploma | - | - | - | - | - | - | - | - |
| Diploma/Associate degree | 0.839 (0.372 - 1.897) | 0.674 | 1.183 (0.417 - 3.356) | 0.753 | 0.683 (0.303 - 1.573) | 0.357 | 0.985 (0.334 - 2.902) | 0.978 |
| Bachelor’s/Master’s degree | 0.803 (0.339 - 1.906) | 0.619 | 0.609 (0.189 - 1.960) | 0.406 | 0.543 (0.227 - 1.298) | 0.170 | 0.320 (0.090 - 1.130) | 0.077 |
| PhD and higher | 0.739 (0.186 - 2.945) | 0.669 | 0.902 (0.123 - 6.603) | 0.920 | 0.877 (0.229 - 3.359) | 0.848 | 1.189 (0.158 - 8.925) | 0.867 |
| Employment | ||||||||
| Unemployment | - | - | - | - | - | - | - | - |
| Housewife | 0.533 (0.169 - 1.680) | 0.283 | 0.208 (0.041 - 1.049) | 0.057 | 0.517 (0.164 - 1.636) | 0.262 | 0.253 (0.045 - 1.419) | 0.118 |
| Student | 1.778 (0.254 - 12.449) | 0.562 | 1.809 (0.148 - 22.141) | 0.643 | 0.700 (0.108 - 4.538) | 0.708 | 0.158 (0.011 - 2.313) | 0.178 |
| Part-time employee | 1.111 (0.294 - 4.205) | 0.877 | 0.572 (0.124 - 2.634) | 0.473 | 0.700 (0.184 - 2.664) | 0.601 | 0.285 (0.055 - 1.459) | 0.132 |
| Full-time employee | 0.404 (0.136 - 1.201) | 0.103 | 0.419 (0.116 - 1.511) | 0.184 | 0.342 (0.114 - 1.025) | 0.055 | 0.188 (0.046 - 0.763) | 0.019 |
| Retired | 0.556 (0.128 - 2.412) | 0.433 | 0.204 (0.031 - 1.356) | 0.100 | 0.311 (0.068 - 1.427) | 0.133 | 0.087 (0.011 - 0.715) | 0.023 |
| Occupation | ||||||||
| Healthcare worker | - | - | - | - | - | - | - | - |
| Nonhealthcare worker | 1.118 (0.385 - 3.246) | 0.838 | 1.683 (0.379 - 7.085) | 0.509 | 0.492 (0.173 - 1.396) | 0.183 | 0.570 (0.126 - 2.578) | 0.465 |
| History of psychiatric disorder | ||||||||
| Negative | - | - | - | - | - | - | - | - |
| Positive | 3.269 (1.224 - 8.728) | 0.018 | 3.064 (0.971 - 9.670) | 0.056 | 5.449 (1.868 - 15.894) | 0.002 | 6.468 (1.735 - 24.119) | 0.005 |
| History of smoking | ||||||||
| Negative | - | - | - | - | - | - | - | - |
| Positive | 3.298 (1.442 - 7.542) | 0.005 | 2.411 (0.876 - 6.635) | 0.088 | 2.674 (1.184 - 6.040) | 0.018 | 1.925 (0.650 - 5.703) | 0.237 |
| History of other substance abuse | ||||||||
| Negative | - | - | - | - | - | - | - | - |
| Positive | 1.441 (0.573 - 3.626) | 0.438 | 0.938 (0.295 - 2.978) | 0.913 | 3.480 (1.317 - 9.195) | 0.012 | 3.804 (1.135 - 12.750) | 0.030 |
| Comorbidity of hypertension and/or cardiovascular diseases | ||||||||
| No | - | - | - | - | - | - | - | - |
| Yes | 1.802 (0.783 - 4.149) | 0.166 | 1.624 (0.501 - 5.266) | 0.419 | 1.215 (0.527 - 2.804) | 0.647 | 0.575 (0.160 - 2.068) | 0.397 |
| Comorbidity of diabetes mellitus | ||||||||
| No | - | - | - | - | - | - | - | - |
| Yes | 1.813 (0.659 - 4.982) | 0.249 | 1.534 (0.420 - 5.601) | 0.517 | 2.302 (0.827 - 6.407) | 0.111 | 1.827 (0.471 - 7.084) | 0.383 |
| Hospitalization days | 1.008 (0.965 - 1.053) | 0.723 | 1.016 (0.962 - 1.073) | 0.571 | 0.990 (0.947 - 1.035) | 0.667 | 1.025 (0.967 - 1.087) | 0.400 |
| Hospitalized in intensive care unit | ||||||||
| No | - | - | - | - | - | - | - | - |
| Yes | 0.800 (0.371 - 1.723) | 0.569 | 0.837 (0.304 - 2.305) | 0.731 | 1.324 (0.602 - 2.914) | 0.485 | 2.226 (0.707 - 7.008) | 0.171 |
Binary Logistic Regression of Factors Affecting Hospital Anxiety or Depression in Coronavirus Disease 2019 Survivors
| Variables | PTSD | |||
|---|---|---|---|---|
| Unadjusted | Adjusted | |||
| OR (95% CI) | P-Value | OR (95% CI) | P-Value | |
| Age (y) | 1.017 (0.984 - 1.051) | 0.316 | 1.031 (0.974 - 1.091) | 0.295 |
| Gender | ||||
| Male | - | - | - | - |
| Female | 1.500 (0.748 - 3.009) | 0.254 | 1.513 (0.492 - 4.657) | 0.470 |
| Marital status | ||||
| Single | - | - | - | - |
| Married | 0.635 (0.265 - 1.523) | 0.309 | 0.362 (0.106 - 1.236) | 0.105 |
| Divorced/Widowed | 0.340 (0.035 - 3.340) | 0.355 | 0.069 (0.002 - 2.048) | 0.122 |
| Education level | ||||
| Under diploma | - | - | - | - |
| Diploma/Associate degree | 0.690 (0.292 - 1.632) | 0.398 | 0.712 (0.229 - 2.213) | 0.558 |
| Bachelor’s/Master’s degree | 0.483 (0.185 - 1.257) | 0.136 | 0.233 (0.057 - 0.952) | 0.042 |
| PhD and higher | 1.020 (0.254 - 4.104) | 0.977 | 0.669 (0.074 - 6.079) | 0.721 |
| Employment | ||||
| Unemployment | - | - | - | - |
| Housewife | 0.910 (0.260 - 3.187) | 0.883 | 0.922 (0.151 - 5.613) | 0.930 |
| Student | 4.800 (0.655 - 35.198) | 0.123 | 6.164 (0.411 - 92.374) | 0.188 |
| Part-time employee | 2.400 (0.596 - 9.670) | 0.218 | 2.340 (0.420 - 13.027) | 0.332 |
| Full-time employee | 0.554 (0.164 - 1.871) | 0.342 | 0.538 (0.117 - 2.466) | 0.425 |
| Retired | 1.067 (0.221 - 5.145) | 0.936 | 0.831 (0.105 - 6.554) | 0.860 |
| Occupation | ||||
| Healthcare worker | - | - | - | - |
| Nonhealthcare worker | 0.631 (0.215 - 1.853) | 0.402 | 0.844 (0.153 - 4.668) | 0.846 |
| History of psychiatric disorder | ||||
| Negative | - | - | - | - |
| Positive | 4.773 (1.798 - 12.671) | 0.002 | 3.760 (1.082 - 13.065) | 0.037 |
| History of smoking | ||||
| Negative | - | - | - | - |
| Positive | 2.738 (1.202 - 6.238) | 0.017 | 1.999 (0.669 - 5.972) | 0.215 |
| Comorbidity of hypertension and/or cardiovascular diseases | ||||
| No | - | - | - | - |
| Yes | 1.613 (0.675 - 3.858) | 0.282 | 0.972 (0.262 - 3.614) | 0.967 |
| Comorbidity of diabetes mellitus | ||||
| No | - | - | - | - |
| Yes | 1.897 (0.674 - 5.342) | 0.225 | 0.967 (0.224 - 4.186) | 0.965 |
| Hospitalization days | 0.983 (0.935 - 1.033) | 0.501 | 0.987 (0.923 - 1.055) | 0.694 |
| Hospitalized in intensive care unit | ||||
| No | - | - | - | - |
| Yes | 1.136 (0.483 - 2.672) | 0.769 | 1.371 (0.411 - 4.575) | 0.608 |
Binary Logistic Regression of Factors Affecting Scores of Posttraumatic Stress Disorder Checklist for the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders in Coronavirus Disease 2019 Survivors
Survivors of critical illnesses might experience a variety of psychological problems after hospitalization. Few studies have evaluated the mental health of COVID-19 patients after discharge from the hospital. The current study reported that 20.3% and 13.3% of COVID-19 patients experienced abnormal anxiety and depression after discharge from the hospital, respectively. In addition, 28.5% of the participants experienced PTSD.
Psychological problems might occur in COVID-19 survivors for a variety of reasons, such as the high rates of mortality and prolonged quarantine, which separates the patients from family and community (12-14). Furthermore, most ordinary individuals receive information about COVID-19 through social media, often exaggerating the consequences of the disease and leading to panic and anxiety in patients (15). On the other hand, the symptoms that remain after discharge, worry about recurrence, and worry about infecting others might cause anxiety and depression in survivors (16).
In a similar study conducted in Mashhad, Iran, within March 20 to April 3, 2020, on 188 COVID-19 survivors to assess mental health using the 42-item Depression-Anxiety-Stress Scale and HADS, the prevalence rates of depression, anxiety, and stress were 43.1%, 12.8%, and 39.4%, respectively (17). The depression rate reported in the current study is in line with that of the aforementioned study; however, the rate of anxiety was higher in the aforementioned study. Because the aforementioned study was conducted when COVID-19 had just appeared in Iran, a high level of anxiety was expected when the disease was unknown, and there was insufficient treatment in the early stages of COVID-19.
One study in Italy that investigated psychiatric symptoms in 402 adult COVID-19 survivors one month after hospitalization using clinical interviews and a battery of self-report questionnaires showed that a significant proportion of participants evaluated themselves within the range of psychopathology, including 28%, 31%, and 42% for PTSD, depression, and anxiety, respectively (18). Conversely, one study in China showed that approximately 10% of COVID‐19 survivors reported anxiety and depression, which was lower than the present study (16). The aforementioned reports might indicate that the prevalence of mental disorders in COVID-19 survivors is different in various countries and even in different provinces; however, it is not certain due to differences between studies, such as measuring instruments, study time, and duration, and the number of participants.
According to the risk factor associated with psychopathology, consistent with previous research, the current study showed that the female participants and patients with a positive history of psychiatric illness and substance use disorder suffered more in all psychopathological dimensions (1, 18). Based on the aforementioned results, it might be concluded that COVID-19 survivors, especially the aforementioned groups, need more targeted interventions regarding psychological health during and after discharge to avoid COVID-19-related psychiatric injuries.
In addition to the main limitation, which is the cross-sectional nature of the study that does not allow the interpretation of causation, this study had some limitations. Firstly, because the sample size was relatively small and all participants were from the same hospital in Iran, it was impossible to generalize the results to other areas. Secondly, PTSD was assessed using a self-report inventory tool instead of a clinical assessment of PTSD; therefore, the degree of direct association of symptoms with the COVID-19 epidemic could not be determined. Thirdly, since this study did not have a control group of nonCOVID-19 hospitalized patients, it cannot be concluded which of the findings, if at all, are specific to COVID-19 patients.
