The coronavirus disease (COVID-19) was declared a pandemic by the WHO in 2020, being a public health emergency of international concern. 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. 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. 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. 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. Younger age, being female and having a known physical comorbidity predicted higher psychological impact. 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. 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). 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. An Indian study by Ray et al. has also used GHQ-28 for assessing psychiatric comorbidity with cutoff value of 4.
Statistical analysis was performed using the IBM SPSS Statistics for Windows, version 20 Armouk, NY, USA. Suitable parametric/nonparametric tests were applied, and multivariate logistic regression analysis was done for finding significant statistical differences.
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.
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.
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.
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.
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%). 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.
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. 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.
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%).
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
Conflicts of interest
There are no conflicts of interest.
We would like to thank Yatna Patel (School of Medicine, University of California, Riverside) and Dipesh Patel (Penn State University Park) for their able guidance and regarding statistical analysis and technical support in completing this research article.
1. Q and A on coronaviruses (COVID-19). World Health Organization. World Health Organization.Last accessed on 2020 Sep 21 Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses
2. Zhang J, Lu H, Zeng H, Zhang S, Du Q, Jiang T, et al The differential psychological distress
of populations affected by the COVID-19 pandemic Brain Behav Immun. 2020;87:49–50
3. Bo HX, Li W, Yang Y, Wang Y, Zhang Q, Cheung T, et al Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China Psychol Med. 2021;51:1052–3
4. Rana W, Mukhtar S, Mukhtar S. Mental health of medical workers in Pakistan during the pandemic COVID-19 outbreak Asian J Psychiatr. 2020;51:102080
5. Grover S, Dua D, Sahoo S, Mehra A, Nehra R, Chakrabarti S. Why all COVID-19 hospitals should have mental health professionals: The importance of mental health in a worldwide crisis! Asian J Psychiatr. 2020;51:102147
6. Verma S, Mishra A. Depression, anxiety, and stress and socio-demographic correlates among general Indian public during COVID-19 Int J Soc Psychiatry. 2020;66:756–62
7. Varshney M, Parel JT, Raizada N, Sarin SK. Initial psychological impact of COVID-19 and its correlates in Indian Community: An online (FEEL-COVID) survey PLoS One. 2020;15:e0233874
8. Wilson W, Raj JP, Rao S, Ghiya M, Nedungalaparambil NM, Mundra H, et al Prevalence and predictors of stress, anxiety, and depression among healthcare workers managing COVID-19 pandemic in India: A nationwide observational study Indian J Psychol Med. 2020;42:353–8
9. Chan DW. The two scaled versions of the Chinese General Health Questionnaire: A comparative analysis Social Psychiatry and Psychiatric Epidemiology. 1995;30:85–91
10. Jackson C. The general health questionnaire Occup Med. 2007;57:79
11. Robinson RG, Price TR. Post-stroke depressive disorders: A follow-up study of 103 patients Stroke. 1982;13:635–41
12. Failde I, Ramos I, Fernandez-Palacín F. Comparison between the GHQ-28 and SF-36 (MH 1-5) for the assessment of the mental health in patients with ischaemic heart disease Eur J Epidemiol. 2000;16:311–6
13. Ray PK, Ray Bhattacharya S, Makhal M, Majumder U, De S, Ghosh S. Prevalence of psychiatric co-morbidity among patients attending dental OPD and the role of consultation-liaison psychiatry in dental practice in a tertiary care general hospital Indian J Dent. 2015;6:32–6
14. IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY IBM Corp
15. Peng EY, Lee MB, Tsai ST, Yang CC, Morisky DE, Tsai LT, et al Population-based post-crisis psychological distress
: An example from the SARS outbreak in Taiwan J Formos Med Assoc. 2010;109:524–32
16. Li LZ, Wang S. Prevalence and predictors of general psychiatric disorders and loneliness during COVID-19 in the United Kingdom Psychiatry Res. 2020;291:113267
17. Mazza C, Ricci E, Biondi S, Colasanti M, Ferracuti S, Napoli C, Roma P. A nationwide survey of psychological distress
among Italian people during the COVID-19 pandemic: immediate psychological responses and associated factors Int J Environmental Res and Public Health. 2020;17:3165
18. Grover S, Sahoo S, Mehra A, Avasthi A, Tripathi A, Subramanyan A, et al Psychological impact of COVID-19 lockdown: An online survey from India Indian J Psychiatry. 2020;62:354–62
19. Gupta R, Grover S, Basu A, Krishnan V, Tripathi A, Subramanyam A, et al Changes in sleep pattern and sleep quality during COVID-19 lockdown Indian J Psychiatry. 2020;62:370–8
20. Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: A web-based cross-sectional survey Psychiatry Res. 2020;288:112954