Assessment of Level of Depression and Associated Factors among COVID-19-Recovered Patients: a Cross-Sectional Study

ABSTRACT The coronavirus disease 2019 (COVID-19) pandemic has psychological consequences such as increased risk of depression, anxiety, and stress problems, exacerbating human health disparities. This study aimed to analyze depression and its causes in COVID-19-recovered patients in Bangladesh. A cross-sectional study was conducted on COVID-19-recovered patients who attended follow-up visits after 14 days to 3 months at Dhaka Medical College Hospital (DMCH) and Dhaka North City Corporation Hospital (DNCCH), Dhaka, Bangladesh, from 1 January to 31 December 2021. Respondents were face-to-face interviewed with a semistructured questionnaire after written agreement. The Patient Health Questionnaire (PHQ-9) was used to assess respondents’ depression, and data were analyzed using SPSS version 23, with a P value of <0.05 indicating statistical significance. A total of 325 COVID-19-recovered patients aged from 15 to 65 years (mean, 44.34 ± 13.87 years) were included in this study, the highest proportion (23.1%) of them were aged 46 to 55 years, and the majority (61.5%) of them were male. There were 69.5% of respondents who had no signs of depression while 31% of them did have signs, with 26.7% being mildly depressed, 2.5% being extremely depressed, and 1.2% being severely depressed. Diabetes mellitus, hospitalization duration, social distancing, social media posts on COVID-19, loss of employment, family damage, and fear of reinfection were significantly associated with depression level of respondents. This study gives us a glimpse into the psychological health of COVID-19-recovered patients, and its findings highlight the imperative of alleviating their psychological anguish in Bangladesh. IMPORTANCE The COVID-19 pandemic had a significant psychological impact on healthy populations, with increased depression, perceived stress, posttraumatic stress disorder, and insomnia reported. The COVID-19 pandemic affects people’s mental health by instilling fear of infection and depression. In the post-COVID-19 syndrome, depressive symptoms and clinically significant depression may have serious consequences for quality-of-life outcomes. To combat the spread of COVID-19, the Bangladesh government has implemented a number of measures, including lockdown, social distancing, self-isolation, and quarantine. Given the negative consequences, it is critical to investigate potential factors and mechanisms that may shed light on mental health improvement. The purpose of the study is to determine the level of depression in patients 3 months after recovering from acute COVID-19. The study’s findings highlight the need for COVID-19-infected people in Bangladesh to receive health education and interventions.

stress, insomnia, depression, anxiety, and even suicidality. After discharge, many of these patients' mental disturbances persisted and continued for a long time (4,5).
The COVID-19 pandemic has a significant psychological impact on healthy populations, with an increase in depression, perceived stress, posttraumatic stress, and insomnia being reported (6). The COVID-19 pandemic situation is fast-changing with worldwide case counts of crisis, suicide, domestic violence, mental disorder, anxiety, and depressive disorders (7). To combat the spread of COVID-19, the Bangladesh government has implemented a number of measures, including lockdown, social distancing, self-isolation, and quarantine (8). Besides, recent findings have demonstrated prevailing acute psychiatric symptoms among patients while being treated in isolation, lacking interaction with friends, family, or loved ones, being admitted to intensive care units (ICUs), and requiring mechanical ventilation (9). Extreme fear, when accompanied with social and economic implications (e.g., job loss, reduced earnings, relationship problems), has the potential to encourage individuals to engage in irrational thinking, which can lead to psychological discomfort (10).
In prior lethal viral epidemics, fear of death, loneliness, boredom, anxiety, sadness, social isolation, contagion, and (in severe situations) thoughts of suicide might result in long-term psychological repercussions among the general population (11). In the present COVID-19 pandemic, depression and anxiety problems are more activated. A recent systematic review reported that the pooled prevalence of depression and anxiety among COVID-19 patients was 45% and 47%, respectively (12).
Patients with COVID-19 have different degree of psychological pain such as anxiety and depression, which may worsen their prognosis by negatively affecting the patients' immunity. As a result, clinically significant depression could have serious consequences for quality of life (13). Despite its increasing significance, present estimates on the prevalence of psychological distress, such as anxiety and depressive symptoms, among COVID-19 patients are uncertain (12).
In the aftermath of a natural disaster, a high rate of mental health suffering (i.e., a prevalence rate of 65% depression, much higher than rates reported elsewhere) was previously reported and appears to reflect the vulnerability of the Bangladeshi population to mental health suffering in a pandemic situation such as COVID-19 (14). During pandemics, public health officials and the media are more concerned with the biological and physical consequences of the outbreak than with mental health difficulties. With an increasing number of reports indicating that the COVID-19 outbreak is causing an increase in mental health burden, there have been greater calls for steps to improve mental health support for the public (15).
To date, scant findings on COVID-19 have been reported regarding the prevalence and associated factors of depression among COVID-19=recovered patients in Bangladesh. Therefore, this study aimed to comprehensively assess the level of depression and explore the factors associated with depressive symptoms 3 months after recovery from COVID-19 infection.

RESULTS
Sociodemographic characteristics of respondents. This study comprised a total of 325 respondents, whose ages ranged from 15 to 65 years. The respondents' mean age was 44.34 years, with standard deviation (SD) of 613.87 years, and the highest proportion (23.1%) were between 46 and 55 years old. The majority of respondents (61.5%) were men, 75.7% were married, 92% were Muslims, 21.2% were graduates, 31.4% were business owners, 81.5% belonged to nuclear families, 61.5% resided in urban areas, 89.2% of them had only one family member who was financially contributing, 37% of respondents did not complete vaccination against COVID-19, and hypertension was found to be the most prevalent chronic disease ( Table 1).
Association of prevalence of depression with variables of respondent. The variables of educational qualification, diabetes mellitus history, duration of hospitalization, distress due to social distancing, being affected by posts on social media about COVID-19, fear of job loss, feeling harmful to family members, fear of reinfection, taking an antidepressant drug, and interruption of personal life were significantly associated with the prevalence of depression (P , 0.05) ( Table 5).

DISCUSSION
This study found that among 325 respondents, 31% had depression symptoms, with 26.8% exhibiting mild symptoms, 2.5% exhibiting moderate symptoms, and 1.2% exhibiting severe symptoms. Several studies were undertaken in Bangladesh following  (18). The increased prevalence of depression could be attributed to the virus's ongoing transmission, the increasing number of new cases, the death of a loved one, and the fear of infection during the early stages of the COVID-19 outbreak, when individuals were challenged by mandatory quarantine, unexpected unemployment, and uncertainty associated with the outbreak (16,18). According to certain research, depressive symptoms were recorded at lower prevalence rates than in the present study, such as 16.5% of the Chinese population (19), 11.4% of Japanese people (20), 17.3% of Italians (3), 3.7% of Portuguese people (21), and 26% of Iranian people (22). Prevalence rates varied between studies, which could be explained by differences in government preparedness, the availability of medical supplies and facilities, the effective communication of information about COVID-19, or international/cultural variances affecting the psychological health of the general public (18).
According to the results of this study, the highest proportion (23.1%) of the respondents were between the ages of 46 and 55 years. This is because the risk of COVID-19-related illness and mortality increases with age (8). In some studies, individuals under the age of 45 had more adverse psychological symptoms during the pandemic (23,24). This is consistent  with our findings that about 54% of the participants were below 45 years of age. This finding could be explained in part by their role as family caregivers, who provide financial and emotional support to children and the elderly. Among the respondents, 61.5% were male, although females have been linked to mental health issues, but there were no significant sex differences (P = 0.379) in regard to depression in the current investigation (18,25). Because of the COVID-19 condition, sex disparities in this study may be negated. COVID-19 is highly contagious and can be passed from person to person (26). Therefore, individuals fear either having COVID-19 themselves or becoming asymptomatic carriers who spread the disease unknowingly to family and friends, contributing to psychiatric symptoms (21,26). In line with previous studies, the present study also showed that fear of infection is significantly associated with depression (P = 0.001) (23,27). That the death of a loved one leads to psychological problems, such as depression, is supported by the findings of the present study (26).
The present study showed that daily exposure to COVID-19-related news was significantly associated with overall mental health problems. Previous studies showed that people who were exposed to COVID-19-related news were more likely to develop psychiatric symptoms (23,28). Moreover, symptoms of depression and anxiety among COVID-19 inpatients could increase due to uncertainty about the prognosis of the disease and the experience of adverse outcomes (16). Furthermore, side effects of COVID-19 medication and physical discomfort may also promote psychiatric problems among COVID-19 inpatients (28). This high prevalence of anxiety and depressive symptoms among Bangladeshi COVID-19 inpatients could be because of an inadequate health care system (8), shortage of beds, ICUs, and ventilators (16), treatment-related negligence in health care facilities (29), and less social interaction along with rampant circulation of misinformation on social and conventional media (30).
In this study, the result showed that 78.2% of respondents had physical symptoms after recovery from COVID-19 and weakness (56.6%) was the most prevalent feature. However, a prospective cohort study among the Bangladeshi population reported that the incidence of post-COVID-19 syndrome was 46%, and other features included persistent cough (8.5%), postexertional dyspnea (7%), headache (3.4%), vertigo (2.3%), and sleep-related disorders (5.9%), rates which were lower than those in the present study (31). COVID-19 can cause acute respiratory syndrome with consequent release of proinflammatory cytokines, including interleukin-1b (IL-1b) and IL-6, from the respiratory tract. These cytokines were commonly found to be increased in major depressive disorder (32).
Due to the COVID-19 epidemic, we have had to make some adjustments to our regular schedule. Because of the substantial changes in everyday lives, in this study, 25.2% had suffered from interruption of regular personal life, which has led to concerns in other studies on mental health (3,16,23).
The Pearson chi-square test was used in this study to evaluate the association between depression and sociodemographic characteristics with factors related to COVID-19-recovered patients. According to the results, education qualification (P = 0.001), diabetes mellitus comorbidity (P = 0.001), receiving an antidepressant drug (P = 0.006), having fear of further contamination (P = 0.003), feeling of being harmful to family members (P = 0.001), fear of losing one's job (P = 0.013), being affected by social media posts about COVID-19 (P = 0.001), mental distress due to social distancing (P = 0.001), and duration of hospitalization (P = 0.007) were statistically significantly related to depression (P = 0.001), a finding which is consistent with other researches (12,13,16). The current study highlights the necessity for reducing this psychological suffering in Bangladesh. Appropriate supportive programs and interventional approaches should be implemented in Bangladesh during the COVID-19 pandemic.
Limitations. This study has a few limitations. First, for convenience data were collected from the patient during the COVID-19 recovery period, which could result in recall and selection bias. Second, the risk factors for depression were not able to be analyzed in association with the level of depression. Third, all the respondents in this study were sampled from two selected post-COVID units in Dhaka city, so the generalizability of this study was indeterminate and might not present the whole country's situation during the COVID-19 pandemic.
Conclusion. That the state of depression impacts COVID-19-recovered patients is undeniable. The study found that a significant portion of respondents reported mental health problems, with different levels of severity of depression. Most of the respondents were concerned about the presence of COVID-19-related symptoms, and fear of losing jobs, fear of reinfection, distress due to social distancing, etc., provoked depression in individuals. The findings of the study suggest the need for more targeted measures like health education intervention for people infected with COVID-19 in Bangladesh to accelerate progress in reducing the incidence of depression.

MATERIALS AND METHODS
Study design. This cross-sectional study was conducted among COVID-19-recovered patients, who came for follow-up from 14 days up to 3 months after infection at the post-COVID unit of Dhaka Medical College Hospital (DMCH) and Dhaka North City Corporation Hospital (DNCCH), Dhaka, Bangladesh, from 1 January to 31 December 2021. Patients with known cases of depressive illness and other psychiatric disorders were excluded from this study.
Sampling and sample size. A nonprobability convenience sampling method was used, and to estimate the required sample size, the prevalence for depression was set as 47.2% (16). So, the calculated sample size was 382, but because of the unfavorable COVID-19 scenario, it was possible to conduct interviews with only 325 respondents during the designated data collection period.
Ethical considerations. Ethical approval for the study was granted by the Institutional Review Board (IRB) of National Institute of Preventive and Social Medicine (NIPSOM) with memo no. NIPSOM/IRB/2021/ 18 dated 13 December 2021. Written informed consent for participation was required for this study in accordance with national legislation and institutional requirements.
Data collection. According to the specific objectives and after the pretest observation, a semistructured questionnaire was developed in English and then translated into Bengali using the selected variables. The respondents were advised of the title and purpose of the study, their anonymity, and voluntary participation in the study by ensuring privacy and confidentiality.
Data collection instrument. After informed written consent, the respondents were interviewed face to face with the questionnaire examining sociodemographic variables and the factors causing depression among them. The questionnaire was developed by using the patient health questionnaire (PHQ-9).
Level of depression. PHQ-9 has nine different questions that assess the depressive symptoms of the respondents. The total score ranges from 0 to 27 points, where each question is scored from 0 to 3 depending on the answer: 0 (not at all), 1 (several days), 2 (half of the days), and 3 (nearly every day). To determine the state of depression, the total score was divided into four categories: cumulative scores of ,10 indicate no depression, 10 to 15 indicate mild depression, 16 to 21 indicate moderate depression, and 22 to 27 indicate severe depression (17).
Statistical analysis. Data processing and analysis were done using Statistical Package for Social Sciences (SPSS) version 23 according to objectives and variables. Frequency, percentage, mean, and standard deviation (SD) were used for descriptive statistics, chi-square (x 2 ) tests were carried out to assess the association of qualitative data with 95% confidence interval (CI), and a P value of ,0.05 was considered statistically significant. Data are presented through tables and figures.
Data availability. The original contributions presented in the study are included in the article; further inquiries can be directed to the corresponding author.