A CROSS SECTIONAL STUDY ON THE PREVALENCE OF PSYCHIATRIC COMORBIDITIES IN PATIENTS ADMITTED FOR COVID-19 IN A TERTIARY CARE HOSPITAL IN NEW DELHI

Context: The COVID-19 pandemic caused by the novel Corona virus has impacted more than 200 countries. COVID-19 patients are frequently isolated and quarantined due to high infectivity thus adding to further mental stress, uncertainty, anger, confusion, stress and insecurity. It has given rise to various psychological problems such as anxiety, depression, fear of isolation, fear of dying, feeling of helplessness, insomnia and many more. The aim of this study is to investigate stress, anxiety, and depression in COVID-19 positive patients during Conclusions: COVID-19 patients score higher on comorbid anxiety and depression. Mild to Moderate level of depression is commonly seen among female, married, less educated, middle age and above group and low oxygen saturation. Anxiety is more amongst male, married, less educated and elderly group and stress is more common in male, widow, tobacco smokers and patients with less oxygen saturation in COVID-19 patients. Our study represents exploration and understanding of psychiatric complications of COVID-19 infection. One of the limitations of our study was lack of data of severe psychiatric complications such as psychosis and persistent agitated delirium of COVID-19.(30–32)Further studies are required for addressing this issue. We suggest the need for systematic psychiatric screening for individuals diagnosed with COVID-19 infection. Despite many limitations in conducting research on infected with COVID-19, we were able to maintain progress in our data collection. Small sample size and inclusion of only admitted patients were some other limitations of our study.

The deadly SARS-CoV-2 virus continues to disrupt public life across the world even more than one year since COVID-19 was declared a pandemic on March 11, 2020 by World Health Organization (WHO). India is currently reeling under the effect of the 2 nd wave. COVID-19 infection has impacts on both, physical well-being of the patients as well as on their mental health.(1) A variety of psychological symptoms have been observed in patients, like, emotional distress, depression, mood swings, fear of being left alone or being away from family, fear of dying, feeling of helplessness, sleep disturbances, and anxious preoccupation. (2) Studies which have been conducted during this pandemic have recorded a high prevalence of moderate-to-severe depressive and anxiety symptoms among the general population as well as among the infected or suspected COVID-19 patients. (3) Research studies conducted earlier have focused on COVID-19-related mental health issues in the general population and health-care workers. (4)Research data are still limited on mental health effects of COVID-19 in infected patients. Therefore, our study was planned to assess the prevalence of psychological distress in COVID-19 patients in the form of anxiety, depression and stress to raise the understanding and awareness on importance of addressing mental health issues in these patients.

Aim: -
To study the prevalence of psychiatric comorbidities in patients admitted for COVID-19 in a tertiary care hospital in New Delhi Objectives: - 1. To estimate the socio demographic profile of patients diagnosed with COVID-19, admitted in HAHC hospital. 2. To estimate the prevalence of psychiatric comorbidities in patients diagnosed with COVID-19, admitted in HAHC hospital.

Materials & Methods: -
The study will be conducted in Department of Psychiatry, HAHC Hospital, and New Delhi.

Study Design
It will be a cross sectional single assessment study conducted in the hospital.

Sample
The sample will be obtained from the patients admitted in COVID wards of HAHC Hospital, New Delhi.

Procedure
All patients who fulfil the inclusion criteria will be explained about the purpose of the study and a written informed consent will be obtained. Patients' demographic data will be collected through a semi structured proforma. Patients will be assessed for depression, anxiety and stress using DASS 21 scale.

Statistical Analysis
The data will be analysed by using descriptive statistics. Frequency counts will be obtained for all discrete variables such as age, gender, occupation etc. Mean and standard deviation will be computed for all continuous variables e.g. age, etc.

Ethical Consideration
1. Written informed consent of participants will be obtained prior to induction. 2. No invasive procedure will be carried out as a part of the current study. 3. Patient treatment will not be modified as part of the study. 4. No additional benefits will be given to the participants. 5. Confidentiality of the information obtained will be maintained. 6. Participants have the right to withdraw consent at any stage of the study. This would not affect their treatment in any way.
Depression was more in females (9%) than male (6%) patients. (P=0.039) Anxiety was found in male patients (12%) than female patients (9%) (P=0.014) and stress was also found in male patients (6%) and none of the female patients scored on stress grade. (P=0.148) Depression and anxiety were more in married patients. (P=0.981) and (P=0.000) respectively. Stress grade was more in widow. (P=0.000) The higher rate of depression was found in patients with more than one medical comorbidity which was not statistically significant (p>0.05) Anxiety and stress was more common in patients with less than 95% SPO2 levels than those with more than 95% Spo2 levels (20%vs 8% and 20%vs 0% respectively). Moreover, total anxiety score was lesser in patients with low SPO2 levels which was statistically significant (P=0.012) Depression was more in patients with more than 95% SPO2 levels than those with more than 95% SPO2 levels (8%vs 0%) Substance abuse particularly tobacco smoking was seen more in patients without depression as compared to those with depression. ( Depression, anxiety and stress were more in those who had family members affected with COVID-19 infection (21% vs 5%, 42%vs 4 % and 21% vs 4% respectively) and was statistically significant(P<0.001).

Discussion: -
Our primary goal in this study was to examine the levels of depression, anxiety, and stress in the COVID-19 patients who were admitted in hospital during the pandemic. (6)(7)(8) During the initial stage of the pandemic many studies reported a high prevalence of moderate to severe depressive and anxiety symptoms among the general population. Some of the frequently observed factors in various studies are being married or divorced, fear of contacting infection or death, disturbed sleep, lack of support, loneliness, and lower oxygen saturation in COVID-19 patients with anxiety and depression. (6,7) The mean age of the hospitalized patients with COVID-19 in our study was 52.21± 12.23 years. In some other studies, most of the hospitalized patients were in the age range of 31-70 years (75.97%) (6)(7)(8) Statistically significant depression was more found in females (P=0.039) and anxiety more in males (P=0.014) with admitted COVID-19 infection. In addition to this stress was found more in male. (P=0.148). Mild depression was seen commonly in females (9%) than male patients (0%) whereas moderate depression was more in males (6%) as compared to females (0%) Mild anxiety was seen commonly in males (12%) than female patients (0%) whereas moderate to severe level of anxiety was more in females (9%) as compared to males (0%) In contrast one Indian study found (60%) females patients had mild anxiety levels (28.75%) in male patients whereas (71.25%) of male patients had moderate to severe level of anxiety as compared to females (40%).(1) In Indian context, it is usually seen that a female is more concerned and apprehensive as she has fear of passing infection to her kids or other vulnerable family members. (1) 856 As we know that men is main bread earner and women are usually the key caretaker at home in Indian setup. So if women in the house contract infection and are isolated the whole care and emotional support gets disturbed. Similarly if male is affected financial situation of the house is mostly affected. (1,9).Many researchers have supported the statement that severity level of anxiety and depressive symptoms are more in admitted patients. (1,10) Travel restrictions, home isolation, financial constraints and consequent social stigma can make patients vulnerable for the development of depressive and anxiety symptoms. Due to lockdown and decline of the economic growth in the countries, workers receive less salary and some even lose their job. Once they get infected due to physical morbidity financial situation further worsen. Similar findings have been found in other studies (3,9,(11)(12)(13)(14)(15) Low socioeconomic status (SES) generally leads to poorer access to health care and thus more psychiatric morbidity. (9) Our study found an inverse relationship between depression and socioeconomic status, mostly belonged to upper lower or lower class and was statistically significant (P< 0.001). Anxiety was increased in unskilled worker, semiprofessional group, less than primary school educated and lower socioeconomic group and was statistically significant. (P< 0.001) This is supported by other studies which confirmed inverse relationship between socioeconomic levels and education, with depression. (6)(7)(8) In contrast many studies have shown a controversial association SES and depression. (8,9) This is also consistent with other researchers studies as we found higher rate of depression in unskilled workers, less then primary school educated groups, and housewives which was statistically significant (p<0.001).
The COVID-19 pandemic has raised concerns about mental health issues and economic stability worldwide. This economic turbulence has led to various mental health disorders, including depression and anxiety(16,17) Thus, it is essential to effectively manage existing resources and social capital so as to lighten the burden of economic crisis in the country. (18,19) The social crisis created by the COVID-19 pandemic might increase inequality, social exclusion, discrimination, and unemployment in the patients. (1) Many studies have suggested a protective role for marriage in depression and anxiety (20), which are in contrary to our finding with higher rate of depression and anxiety in married COVID-19 patients. Our data is also consistent with psychiatric manifestations of other severe corona virus infections including Middle East respiratory syndrome and severe acute respiratory syndrome-1 (SARS).
We found a positive correlation between stress, anxiety and depression with patients with COVID-19 positive family members which was statistically significant. Also married patients were more depressed while anxiety was more in married and widow group which was statistically significant. (P<0.001) Stress was more in widow group and was statistically significant. (P<0.001) COVID-9 infection in family members especially spouse could have been the reason for stress, anxiety and depression. Stress was found in only a few tobacco smokers (23%vs77%) and was found to be statistically significant. (P<0.001) Mild anxiety was also found in few tobacco smokers (23%vs77%) but not statistically significant. Stress, depression and anxiety were not seen in tobacco chewer, alcohol and other substance abusers.
There is paucity of studies on epidemiology of the COVID-19 (8). To explore the effectiveness of common protective factors in this field requires extensive research. The role of environmental and social factors in this regard seems important. Given the complexity of the conditions associated with COVID-19, relationship between anxiety, depression and stress; and marriage among these patients requires further evaluation.
We investigated various underlying diseases or conditions in people infected with SARS-CoV-2 in hospitalized patients. Interestingly we found less stress, anxiety and depression in patients with underlying physical comorbidities as compared to those who did not have. While various underlying diseases such as hypertension, diabetes mellitus, hyperlipidemia, ischemic heart disease, asthma and many more were seen in other studies with higher prevalence. (21,22)we found both increased anxiety and stress levels in only a few diabetic patients (20%vs80%) out of all patients with comorbid medical illness. While more than 1 comorbid medical illness was seen in only a few depressed patients (18% vs 82%) However vast difference in sample size makes it difficult to compare the prevalence. Physical illnesses can weaken the immune system and thus can further exacerbate COVID-19 disease and give rise to various complications. (21,22)Hence it is essential to pay attention to this issue however could be challenging at the same time. (23) Further studies with preferably larger sample sizes are necessary to explore their impact.

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It is seen that various factors during the pandemic contributed to stress and long term negative psychological implications among COVID-19 patients. This included isolation, quarantine conditions, insufficient or negative reports from media and stigmatization. (24) A prospective study following hospitalization showed lover prevalence of depression and anxiety in the post illness phase (12.3% and 10.5%, respectively) while another study Discharge to home did not lead to any significant improvement in psychiatric symptoms. A significant minority of patients experienced acute stress disorder symptoms as well although these were mainly mild to moderate. (7) This is in contrast to existing data, such as that presented by Mazza et al., (25) which focused on patients in the post hospitalization period. (7) We found no correlation between SPO2 levels and depression while anxiety was positively correlated with lower oxygen saturation i.e., SPO2 less than 95%. [(20% vs. 8 %); (P=0.087)]. 20% who had less than 95%SPO2 patients also had high stress score which was statistically significant. (P<0.001) A systematic review and meta-analysis conducted by Rogers et al reported 32.6% depression rate and 35.7% anxiety rates in covid19 patients and was also positively associated with lower oxygen saturation. (26) One of the main clinical indexes for assessing the severity of patients with COVID-19 is oxygen saturation levels. Our study represents exploration and understanding of psychiatric complications of COVID-19 infection. One of the limitations of our study was lack of data of severe psychiatric complications such as psychosis and persistent agitated delirium of COVID-19. (30)(31)(32)Further studies are required for addressing this issue. We suggest the need for systematic psychiatric screening for individuals diagnosed with COVID-19 infection. Despite many limitations in conducting research on infected with COVID-19, we were able to maintain progress in our data collection. Small sample size and inclusion of only admitted patients were some other limitations of our study.

Disclosure:
The authors have no conflicts of interest to disclose.

Conclusions: -
COVID-19 infection has adversely affected the mental health of the patient as well as physical, social, and occupational domain of life. Stress, Anxiety and depression have been seen frequently among the infected. Further research is necessary to understand the epidemiology of psychiatric symptoms among patients with COVID-19 infection. Isolation, loneliness, loss of income and fear of re-infection or spread of worsen the stress, anxiety and. The understanding and realization of association of anxiety and depressive symptoms in COVID-19 infected patients is essential for early screening and timely psychiatric intervention for a better functional outcome of the patient.
Early recognition and intervention in form of psychiatric medications and psychological interventions can be helpful in decreasing burden of psychiatric morbidity. Medication, supportive psychotherapy, and crisis management for short term management and Behavioral management such as Cognitive Behavior Therapy and family therapy can be planned for long run.