Depression and anxiety in patients recently recovered from coronavirus disease (COVID‑19)

Introduction

Since the outbreak of coronavirus disease 2019 (COVID-19) in December 2019, we have been witnessing the greatest pandemic in recent years. As of May 25, 2021, over 167 million global cases have been reported (World­ometer 2021). COVID-19 is associated with a substantial risk of hospitalization and death (Wang et al. 2020). The pandemic created a previously unknown reality symbolized by facemasks, lockdown and social distancing. All these issues significantly affect the psychosocial dimension of life (Torales et al. 2020) as well as mental health in the general population (Xiong et al. 2020) and vulnerable groups (Suwalska et al. 2021; Tasnim et al. 2021). The meta-analysis conducted in 2020 shows that the estimated pooled prevalence of depression increased from 3.44% in 2017 to 25% in 2020 (Bueno-Notivol et al. 2021). Moreover, according to a recently published study, 18% of COVID-19 patients developed a psychiatric disorder up to 3 months after their diagnosis (Taquet et al. 2021). Following the acute phase of the disease, COVID-19 may have chronic consequences. Indeed, patients who have recovered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may present various sequelae (Al-Aly et al. 2021).
Previous studies showed that chronic diseases, such as diabetes mellitus, cancer, or heart disease, are related to higher rates of depression and anxiety (Berge et al. 2019; Cohen et al. 2019; Pitman et al. 2018). At present, however, the severity of anxiety and depression in post-COVID-19 patients remains largely unknown. The Beck Depression Inventory (BDI) is a well-established tool for assessing depressive symptoms (Beck et al. 1961). Likewise, the State-Trait Anxiety Inventory (STAI) is a commonly used instrument for measuring trait and state anxiety (Spielberger et al. 1983). Both of these inventories are commonly used when assessing patients with different diseases. The BDI was previously used to assess depressive symptoms in patients with various neurological diseases such as multiple sclerosis and in cancer patients (Cvetkovic and Nenadovic 2016; Tauil et al. 2018). The STAI was previously used when assessing anxiety in patients with chronic stroke or suffering from cancer (Chun et al. 2017; Eskelinen and Ollonen 2011).

Aim of the study

The present study evaluated the severity of anxiety and depression in patients who had recovered from COVID-19 using the Beck Depression Inventory and State-Trait Anxiety Inventory.

Material and methods

Study design and patients

The study was designed as a single-center, cross-sectional study. This substudy, designed to assess the severity of depression and anxiety, was a part of a more extensive research project evaluating post-COVID-19 sequelae. We defined post-COVID-19 sequelae (or post-acute COVID-19 syndrome) as persistent symptoms and/or delayed or long-term complications of SARS-CoV-2 infection beyond four weeks from the diagnosis of COVID-19 (Nalbandian et al. 2021). The examination of patients was conducted in the 2nd Department of Cardiology, St. John Paul II HCP Hospital in Poznan. Primary care physicians in Poznan recruited ambulatory patients who had recently recovered from COVID-19. The reason for referral was the evaluation after the COVID-19 infection. The assessment of patients took place between February 9 and April 16, 2021. Inclusion criteria were as follows: age > 18 years, confirmed COVID-19 infection by SARS-CoV-2 real-time PCR using nasopharyngeal swabs at least 28 days before the assessment. We included patients either treated at home or hospitalized due to COVID-19. We set the following exclusion criteria: severe mental disorders (dementia, schizophrenia, bipolar disorders, schizoaffective disorders), auditory and visual disability. In order to assess post-acute COVID-19 symptoms, we developed a questionnaire based on the National Institute for Health and Care Excellence (NICE) guidelines (NICE 2020). The questionnaire consisted of 24 questions (“yes/no” answers) regarding the current symptoms. Patients completed the questionnaire on their own.

Self-reported symptoms of anxiety

Anxiety was measured with the Polish adaptation of the State-Trait Anxiety Inventory (STAI) (Sosnowski et al. 2011). The STAI is a 40-item self-assessment scale measuring the presence and severity of current symptoms of anxiety and a generalized propensity to be anxious. The STAI is divided into two subscales; each of them contains 20 items. First, the State Anxiety Scale (S-Anxiety or STAI 1) evaluates the current state of anxiety, asking how respondents feel “right now”. It uses items that measure subjective feelings of apprehension, tension, nervousness, worry, and activation/arousal of the autonomic nervous system. The second subscale – the Trait Anxiety Scale (T-Anxiety or STAI 2) – evaluates relatively stable aspects of “anxiety proneness”, including general states of confidence, calmness and security. Responses for the S-Anxiety scale assess the intensity of current feelings “at this moment”: 1) not at all, 2) somewhat, 3) moderately so, and 4) very much so. Responses for the T-Anxiety scale assess the frequency of feelings “in general”: 1) almost never, 2) sometimes, 3) often, and 4) almost always. The STAI has been used in several chronic medical conditions (Julian 2011).

Assessment of depressive symptoms

We used the Polish adaptation of the Beck Depression Inventory (BDI) (Parnowski and Jernajczyk 1977) to assess depressive symptoms. The BDI is a self-reported, 21-question test for measuring the presence and severity of symptoms of depression in the preceding two weeks. The BDI contains 21 items on a 4-point scale from 0 (symptom absent) to 3 (severe symptoms). It covers affective, cognitive, somatic and vegetative symptoms of depression, reflecting the criteria for major depression. Higher scores indicate greater symptom severity (Jackson-Koku 2016). All patients signed informed consent before entering the study. The Bioethics Commission of Poznan University of Medical Sciences approved the study. The study complies with the requirements of the Declaration of Helsinki.

Statistical analysis

The distribution of data was tested for normality using the Shapiro-Wilk test. Continuous data are presented as mean and standard deviation (SD) or median and interquartile range (IQR) when data were non-normally distributed. Categorical variables are expressed as numbers and percentages. Student’s t-test or the Mann-Whitney U-test was applied for the group comparison. Correlations were evaluated by the Pearson or Spearman correlation coefficient. Statistical significance was considered for values of p < 0.05. We performed all analyses using the data analysis software system Statistica, version 13 (TIBCO Software Inc., 2017).

Results

Characteristics of the study group are shown in Table 1. We excluded three patients from the initially included 105 patients: one patient did not complete the STAI questionnaire correctly, one patient had the examination 120 days after COVID-19, and one patient had a BDI result of 41 and was referred to a psychiatrist. Finally, the analyzed group consisted of 102 patients, 55 women (55.9%), with a mean age of 51.9 ±13.4 years. 24 (23.6%) hospitalized patients had moderate to severe COVID-19 disease (Rochwerg et al. 2020). However, none of the patients was in a critical stage of COVID-19, requiring admission to the intensive care unit, intubation or heart-lung machine or extracorporeal membrane oxygenation (ECMO) support. The average time (±SD) from the diagnosis of COVID-19 was 55 ±18 days. Table 2 shows the occurrence of post-COVID-19 symptoms. Fatigue (82.4%), cognitive impairment (52.9%), breathlessness (42.2%) and cough (42.2%) were most frequently reported. The median number of the reported symptoms was six (IQR = 6, min = 0, max = 16). Women reported significantly more symptoms than men (8, IQR = 5 vs. 5, IQR = 4, respectively, p = 0.007). BDI and STAI 1 results were non-normally distributed. BDI results were left-skewed; STAI 1 results were slightly right-skewed. The median BDI score for the whole group was 7 (IQR = 10), the median STAI 1 score was 38 (IQR = 13), and the median STAI 2 score was 40.5 (IQR = 14). Women had significantly higher scores of BDI, STAI 1 and STAI 2 (Table 3). Categorized BDI results are shown in Table 4. A BDI score ≤ 11 was observed in 72 (70.6%) patients. In this group, only four patients reported no symptoms suggestive of depression (BDI score = 0). The median score in this group was 5 (IQR = 5). Twenty-nine (28.4%) had a score corresponding to mild depression (BDI score ≥ 12 and ≤ 26), and one patient (1%) had symptoms of moderate to severe depression (BDI score > 26). BDI, STAI 1 and STAI 2 scores showed high correlation (Table 5, Spearman’s ρ > 0.75, p < 0.001). There were a moderate correlation between the number of post-COVID-19 symptoms and BDI, STAI 1 and STAI 2 results (Table 6). Hospitalized patients had significantly higher BDI scores. There was no significant difference regarding STAI 1 and STAI 2 in hospitalized vs. non-hospitalized patients (Table 7).

Discussion

To the best of our knowledge, this is the first study assessing the severity of depression and anxiety in Polish patients who have recovered from COVID-19. Our results show that almost 30% of patients present symptoms related to mild depression (BDI score ≥ 12 and ≤ 26). Moreover, in the group in which the BDI score was below 12, only four patients reported no symptoms. The median score in this group was 5 (IQR = 5). The median BDI score was significantly higher in women (Table 3). This finding corresponds with previous studies before the COVID-19 outbreak. According to a systematic review and meta-analysis of post-COVID-19 symptoms (Lopez-Leon et al. 2021), 13% of those patients suffer from depression, and 12% complain of anxiety. In the recently published paper by de Sá Junior et al. (2019) women had higher scores of BDI-II than men.
We also found a correlation between the number of symptoms and higher BDI scores. Furthermore, hospitalized patients had higher BDI scores than non-hospitalized ones. These findings could be related to the content of the BDI. Some of the items of the BDI concern the symptoms observed after COVID-19. For example, questions about being annoyed or about difficulties in decision-making can be connected with COVID-19-related neurological changes described as brain fog (Nakamura et al. 2021). The BDI questionnaire concerns issues related to physical problems such as pain, upset stomach, and constipation. Again, all these problems are common three months after being diagnosed with COVID-19 (Al-Aly et al. 2021). Differences regarding BDI scores in hospitalized and non-hospitalized patients may reflect the distress resulting from the strict isolation for a long time. Furthermore, many patients feel uncertain about the state of their health and the future.
To evaluate the anxiety level, we used the STAI 1 and STAI 2 inventory. The median STAI 1 score was 38 (IQR = 13), and the median STAI 2 score was 40.5 (IQR = 14). These results indicate that patients had a moderate level of anxiety. The results were similar or even lower than mean results in the population during the COVID-19 pandemic, where the mean result was 50.3 ±7.4 (Madkor et al. 2021). Our study showed that females had greater anxiety level than males. Hishinuma et al. (2000) also observed such a difference, where female and male students were tested. The limitation of our study is its cross-sectional design. To assess whether experiencing COVID-19 can affect depression and anxiety level, the study should be prospective. Our study cannot exclude the background increase of anxiety and depression related to the COVID-19 pandemic. A recent study by Solomou and Constantinidou (2020) revealed that during the pandemic, 23.1% of responders reported moderate-to-severe anxiety symptoms. Concerning depression, 48% reported mild and 9.2% moderate-to-severe depression symptoms.

Conclusions

Patients recently recovered from COVID-19 present elevated anxiety and depressive symptoms. In this regard, women are more affected. From the clinical point of view, physicians should be aware of the depressive and anxiety symptoms of the post-COVID-19 syndrome. It is necessary to address (identify and treat) them, minimize the risk of progression to the chronic state, and help re-establish the pre-COVID-19 health status.

Disclosure

The authors declare no conflict of interest.

References