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Introduction

COVID-19 caused a huge mortality and morbidity. WHO declared it as a pandemic in March 2020 [1]. People who survived the acute infection are still complaining of various symptoms even after several months of acute infection. This phenomenon is happening around the world. Post COVID-19 symptoms are pertaining to almost all the systems of the body [2]. Various names were given to describe such symptoms like chronic COVID-19, post COVID-19 syndrome, Long Hauler syndrome [3, 4].

Many studies are underway to see the post COVID effects across the world. Very few studies have focussed exclusively on anxiety and depression. They are even less in India. India harbours nearly 19% of world’s population and the burden of infection was enormous. Patients who recovered from the disease are still fearful and complain of symptoms pertaining anxiety, depression and other neurocognitive disorders.

This study was conducted to see the prevalence of anxiety and depression in the patients who had COVID-19 in the past and attended various outpatient Departments (OPDs) of a Medical College.

Material and methods

We estimated the prevalence of anxiety and depression in the patients who were Reverse Transcription Polymerase Chain Reaction (RTPCR) positive for COVID-19. The study was conducted on patients attending various OPDs of GS Medical College & Hospital, Pilkhuwa. It is a prospective observational cross – sectional study and it was conducted from July 2021 to August 2022.

Inclusion criteria

All patients coming to various OPDs with symptoms of anxiety or depression with past history of COVID-19 infection, in whom RTPCR for COVID-19 was positive more than three months earlier, were included in this study.

Exclusion criteria

(a) Patients who had history suggestive of anxiety, depression or any other neurocognitive disorders like Alzheimer’s disease, Parkinson’s disease etc., in the past before contacting COVID-19 infection, (b) Patients having any death in the family or long hospitalization (other than COVID-19) in the last one year, (c) Any history of seizures disorder, head injury.

Methodology

A questionnaire [Hospital Anxiety and Depression Scale (HADS) - Appendix -I] was used to determine the presence, absence and severity of Anxiety, Depression and Neuro-cognitive impairment.

Scoring (Table 1)

Total Score: Depression (D)------- Anxiety (A) -----------

0-7= Normal

8-10= Borderline abnormal (borderline case)

11-21= Abnormal (case)

A staff nurse was trained in explaining the questionnaireto patients. She helped patients in understanding the questionnaire and filling the form properly. The patients were divided in two groups:

Group-I: Those patients who were not admitted and treated at home for COVID-19 in past were considered to be mild to moderate category patients.

Group-II: Those patients who were admitted to the hospital for COVID-19 in past were considered as severe category patients.

Table 1: Hospital anxiety and depression scale (Scoring sheet).

Note: Anxiety 2, 4, 6, 8, 11, 12, 14; Depression 1, 3, 5, 7, 9, 10, 13; Scoring 3, 2, 1, 0 (For items 7 & 10 the scoring is reversed). Grading: 0 - 7 = Non-case/ 8 – 10 = Borderline case/ 11+ = Case.

Results

After applying inclusion and exclusion criteria 1044 patients were considered for the study. Out of them 612 (58.62%) were male and 432 (41.33%) were female (Table 2). AS per the age group consideration maximum number 357 (34.19%) was in the age group 21-30 years, followed by age group 31-40 years in which we had 283 (27.10%) patients (Table 3). As is obvious younger population had a more severe psychological impact as compared to elderly.

Table 2: Distribution of patients according to sex.

 Table 3: Distribution of patients according to age group.  

COVID-19 disease severity wise distribution showed that 612 (58.62%) patients belonged to mild to moderate group i.e. Group-I and 432 patients fell into Group-II i.e. who were admitted in different hospitals (Table 4).

Table 4: Distribution of patients according to disease severity of COVID-19.  

When depression part was analysed, it was seen in 22 males and 18 females i.e. in a total of 40 (3.83%) patients in Group-I; whereas 52 males and 20 females amounting to 72 (6.89%) patients in Group-II showed depression (Table 5).

Table 5: Prevalence of depression according to disease severity of COVID-19.  

Similarly anxiety cases were also less in Group-I i.e.12 males and 10 females making a total of 22(2.10%) had anxiety whereas; in Group-II 62 males and 33 females making a total of 95(9.09%) had anxiety (Table 6).

Table 6: Prevalence of anxiety according to disease severity of COVID-19.  

Over all 34 males and 28 females making a total of 62 (10.13%) suffered from either depression or anxiety in Group I and 114 males and 53 females making a total of 167 (38.65%) suffered from either of the two in Group-II.

Both depression as well as anxiety were more common in males in both the Groups, but these were more pronounced in Group II. Depression was seen in 52 out of 237 (22.94%) in males as compared to 20 female out of 195 (10.25%) in Group-II. Similarly anxiety was also more common in males, 62 out of 237 (26.18%) in males than females 33 out of 195 (16.92%) in Group-II.

It was tried to ascertain any association with occupation or with associated diseases. Maximum number of patients 427 (40.90%) enrolled in the study were in the group of students/ homemakers/ unemployed who did not have their personal income (Table 6). Post tuberculosis squeal was associated in 65 (6.22%) patients (Table 7) which is almost similar to their prevalence in the population. No significant statistical correlation emerged as is obvious from Tables 7 and 8.

Table 7: Distribution of patients according to occupation.  

Table 8: Distribution of patients according to associated diseases.  

Discussion

There has been no widely accepted definition of long COVID [5]. The National Institute for Health and Care Excellence (NICE) and WHO defined Long COVID as when the signs and symptoms continued or reappeared till twelve weeks of acute COVID illness [6], If the signs and symptoms continued or reappeared beyond twelve weeks it was termed as post COVID [7, 8]. The Centre for Disease Control and Prevention (CDC) defined long COVID as a post COVID condition with a wide range of new, returning or ongoing health problems, people can experience four or more weeks after being infected with the virus that causes COVID-19 [9].

Although COVID-19 primarily attacks the respiratory system and major cause of death due to COVID was respiratory failure, post COVID symptoms were recorded from almost every organ system. There have been complaints of cough, breathlessness, chest pain, anosmia and palpitation [10]. Central nervous system (CNS) [11] as well as peripheral nervous system (PNS) [12] were also involved and the patients presented with various symptoms like headache, dizziness, nausea, vomiting, malaise, myalgia etc. The mechanism of involvement of nervous system has been thought to be via entry through olfactory nerve, vascular endothelium or leukocyte migration across the blood- brain barrier [13]. Hyper inflammation and hypercoagulability have also been incriminated [14].

Fear and anxiety are common psychological response during disastrous situations like COVID-19 as suggested by Dong and Bouey [15]. Anxiety and depression were the most common mental health problems post COVID-19 as described by Shanbehzadeh et al [16]. Therefore, we conducted the study focusing only on this parameter of post COVID-19 complications. Anxiety ranged 6.5% to 63% and depression ranged 4% to 31% in that study. In our study anxiety ranged from 2.10% to 9.09% and depression ranged from 3.83% to 6.89% which is more or less comparable. Greater levels of anxiety and depression were reported in females in that study, whereas in our study more anxiety and depression was seen in males. Anxiety was reported in 74 out of 612 (12.09%) males and 43 out of 432 (9.95%) females. Whereas depression was reported in 74 out of 612 (12.09%) males and 38 out of 432 (8.79%) females.

Goyal et al [17] explained that undue prolonged stress with social isolation can act as a niche for developing a pathological mental state. We could see this in our study as well. Those patients who got hospitalised had far more anxiety and depression than those who were not hospitalised. Hospitalised patients had more financial burden and also fear of loss of job which lead to more anxiety and depression as shown by Mann et al [18]. The loss of job overnight also leads to anxiety and depression as explained by Maaravi et al [19]. This may partly explain why more males suffered from anxiety and depression as seen in our study.

Strength of study

The study was conducted only on RTPCR confirmed patients and HADS score was used to detect anxiety and depression induced by post COVID stress after excluding any pre-existing psychiatric ailments.

Limitations of study

It was done in patients who attended OPDs of only one Medical College and hence may not reflect true affliction of community post COVID stress reaction.

Conclusion

A significant number of patients suffered from mental disorders like anxiety and depression even months after recovering from initial COVID-19 infection. Those patients who had to get hospitalised suffered more than those who were treated at home. Male suffered more than the females which might be related to financial issues.

Conflicts of interest

Authors declare no conflicts of interest.