key: cord-0749158-hucdq1e6 authors: Lim, Shiau Li; Tay, Voon Yaa; Bhullar, Avreena; Baharuddin, Hazlyna; Ch’ng, Shereen Suyin; Yusoof, Habibah Mohd; Zain, Mollyza Mohd; Rosman, Azmillah title: A Questionnaire-based Survey on Depression and Anxiety among Rheumatology Patients during the COVID-19 Pandemic: Patient’s Perspective date: 2021-09-30 journal: Oman Med J DOI: 10.5001/omj.2022.34 sha: 958e4bb52415631a7beb97f22f718b9af98283a6 doc_id: 749158 cord_uid: hucdq1e6 OBJECTIVES: The Coronavirus Disease 2019 (COVID-19) outbreak is a global pandemic and has caught the attention of the rheumatology fraternity, where patients are thought to be at higher risk of infection. We aimed to study the incidence of COVID-19 infection and depression and anxiety symptoms among patients with rheumatic disease (RD) in Hospital Selayang, Malaysia, during the COVID-19 pandemic. METHODS: A cross-sectional study was conducted via phone interview using a structured questionnaire in patients with RD aged > 18 years old scheduled for clinic appointments from 4 to 28 May 2020, which coincided with the second wave of COVID-19 cases in Malaysia. The questionnaire included demographics, COVID-19 screening questions, depression and anxiety symptoms screening using questions derived from the Patient Health Questionnaire-2 (PHQ-2) and Generalized Anxiety Disorder-2 (GAD-2). RESULTS: Among the 361 patients enrolled, the majority were females (83.1%), and over half (54.3%) were ethnic Malays, 41.6% had rheumatoid arthritis, 34.6% had systemic lupus erythematosus, 12.2% had spondyloarthropathy, and only one (0.3%) patient had COVID-19 infection. The mean age of patients was 48.2 years (range: 16–80 years). The frequency of patients with depression and anxiety symptoms was 8.6% and 6.9%, respectively. Married patients reported feeling more anxious (p =0.013), while patients with tertiary education levels reported feeling more depressed (p =0.012). CONCLUSIONS: The incidence of COVID-19 infection is low, probably due to the low rate of testing. Depression and anxiety symptoms reported by patients in our cohort were modest. Our findings suggest that the COVID-19 pandemic has a greater impact on married patients with RD and those with a higher education level. Many pieces of research have demonstrated negative psychological impact among the general population and health care workers. [7] [8] [9] Higher psychological distress related to the COVID-19 pandemic were reported among patients with autoimmune arthritis in Italy. 10 However, studies examining psychological impact in patients with rheumatic diseases are limited globally and none in Malaysia. The purpose of this research was to study the incidence of COVID-19 infection and depression and anxiety symptoms among patients with rheumatic disease (RD) in Hospital Selayang, Malaysia, during the COVID-19 pandemic. A phone interview was conducted in a cross-sectional design using a structured questionnaire. eligible participants were all patients with RD aged > 18 years old on immunosuppressive therapy, including corticosteroids, conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs), biological DMARDs (bDMARDs), and targeted synthetic DMARDs (tsDMARDs) who were scheduled for a rheumatology clinic appointment from 4 to 28 May 2020 in the Rheumatology Unit, Hospital Selayang. The study duration coincided with the middle of the second wave of COVID-19 cases in Malaysia. Patients with severe cognitive, language, or hearing deficits were excluded from the study. Demographic data such as age, gender, ethnicity, marital status, education level, and occupation were collected. In addition, comorbidities, rheumatological diagnosis, and treatment history were recorded. Supplementary information was also obtained from the hospital electronic medical record system (CeRNeR Power Chart). the structured questionnaire was designed with closed-ended questions -yes/no questions and multi-choice questions. The questionnaire was composed of: Descriptive data was expressed as mean±standard deviation (SD) for normally distributed continuous data and relative frequency and percentages for categorical data. the association of categorical data was analyzed using the chi-squared test or Fisher's exact test. A p-value < 0.050 was considered statistically significant. ethical approval from the Medical Research and ethics Committee (MReC) was obtained before the initiation of the study (ID approval: NMRR-20-839-54731 (IIR)). The protocol was reviewed and approved by institutional review boards according to local requirements. Verbal consent was obtained from patients before data collection. A total of 361 patients were enrolled in the study and were phone interviewed within the study period. The mean age of patients was 48.2 years (range: 16-80 years) with female preponderance (83.1% vs. 16.9%). the ethnic distribution in descending order was Malay (54.3%), Chinese (25.5%), Indian (18.3%), and others (2.0%). the majority were married (76.2%) and had a secondary level education (49.3%). the employment rate was 52.1%, and among the unemployed, the majority were housewives (66.5%). Almost half (49.3%) of patients had at least one comorbidity, of which 3.8% had chronic lung disease while 0.8% had bronchial asthma. The demographic characteristics are shown in table 1. The highest proportion of patients in our study was diagnosed with rheumatoid arthritis (41.6%), followed by systemic lupus erythematosus (34.6%), and spondyloarthropathy (12.2%). Consumption of prednisolone was 43.8%, with the mean dose of 7.9 mg daily (range: 1-40 mg ). Usage of hydroxychloroquine (44.0%) was highest followed by methotrexate (37.4%), leflunomide (13.0%), and sulfasalazine (11.1%). twenty-two (6.1%, 22/361) patients were taking bDMARD, while three (0.8%, 3/361) patients took tsDMARD. the overview of rheumatic disease and its treatment in our studied patients is shown in The incidence of confirmed COVID-19 infection among patients with RD is low. In addition, the patients in our cohort reported a low rate of depression and anxiety symptoms. We found that married patients were statistically significantly more anxious while patients with tertiary level education felt more depressed. Patients with RD are more susceptible to infections due to immunological alterations, diseasesrelated, and drugs-related factors. the lungs were reported to be the most frequent site of infection. 13 Since the emergence of the COVID-19 pandemic, the question of whether patients with RD, especially those receiving DMARDs are at increased risk of COVID-19 infection, remains unclear. However, the prevalence of COVID-19 infection in patients with RD is limited. According to the systemic review on 6095 patients from eight observational cohort studies, only 2% of patients were found to be COVID-19 positive or highly suspicious for infection based on clinical features. 14 based on COVID-19 Global Rheumatology Alliance's data on 29 December 2020, 847/13 363 (6.3%) patients were reported to be infected with COVID-19. 15 Another observational study in Northern Italy reported 65 (4.3%) patients were diagnosed with COVID-19 infection among 1525 patients with rheumatic and musculoskeletal diseases. 16 the majority of patients in our cohort with COVID-19-like symptoms were not tested for COVID-19 as they did not seek medical consultation. Hence, this result might not truly reflect the incidence of COVID-19 in our patients. the COVID-19 pandemic has led to significant psychological and social effects on our global population. Different strata of society were affected psychologically and socially by this pandemic, including COVID-19 positive patients and quarantined individuals, health care workers, children, the elderly, marginalized communities, and psychiatric patients. 17 Few published studies reported the psychological impact in patients with RD. In turkey, there were changes in the psychological state and routines of patients with RD during the COVID-19 outbreak. 18 Patients with rheumatoid arthritis and lupus in the Philippines showed moderate to severe anxiety (38.7%), moderate to severe depression (27.7%), and stress (12.3%) during the pandemic. 19 A small number of our patients perceived themselves to have depression and anxiety symptoms. We would expect patients with RD to have a higher psychological impact; however, this was not shown in our study. A possible explanation for this could be the rapid response from the Malaysian government and Ministry of Health to protect citizens from infection by implementing a lockdown on 18 March 2020 at the first peak of COVID-19 cases in Malaysia. transparent up-todate information about relevant news on COVID-19 infection was delivered to the public through daily press briefings. Additionally, awareness programs on basic protective measures (mask wearing, frequent hand washing, and social distancing) were easily available via local television and social media. Continuity of care in our patients was maintained via virtual clinics and any concerns were addressed via teleconsultation. Factors affecting psychological impact during the COVID-19 pandemic varied from study to study. A study from China in the general population reported more depression, anxiety, and stress in uneducated individuals. 20 However, this was contradictory to our analysis where patients with tertiary education had more depression symptoms. Married patients were more anxious in our analysis and this was in agreement with a study done in Pakistan. 21 We would anticipate that married couples had better support in reducing anxiety, yet it was shown differently in our study, probably due to the quality of the marital relationship. This was reported in a study in Austria where good relationship quality was a protective factor, whereas poor relationship quality was a risk factor for anxiety. 22 A study from India reported that males in the general population were more likely to be anxious. 23 However, gender did not show any significant association in our sample. this study has some limitations. First, the incidence of COVID-19 infection in this study might not be well represented as a number of patients with symptoms were not subjected to testing. Second, psychological impact assessment pertaining to depression and anxiety was not measured via validated tools and merely based on the patient's perception, which was a subjective assessment tool. The incidence of COVID-19 infection in our cohort was low, probably due to the low rate of testing. Depression and anxiety symptoms reported by patients with RD in our cohort was modest. Our findings suggest that the COVID-19 pandemic has a greater impact in patients who are married and had a higher education level. Future studies are necessary to explore and validate the conclusions that can be drawn from this study. The authors declared no conflict of interest. No funding was received for this study. WHO Director-General's Opening remarks at the media briefing on Covid-19 COVID-19 Map -Johns Hopkins Coronavirus Resource Center turning the tide on Malaysia's third Covid-19 wave. TheStar Covid-19 (latest updates) A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: implications and policy recommendations Rheumatic Disease-Related Symptoms During the Height of the COVID-19 Pandemic Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and metaanalysis Psychological impact of COVID-19 on medical care workers in China Psychological Distress in Patients with Autoimmune Arthritis during the COVID-19 Induced lockdown in Italy The Patient Health Questionnaire-2: validity of a two-item depression screener Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection lung Infections in Systemic Rheumatic Disease: Focus on Opportunistic Infections COVID-19 Infection Among Patients with Rheumatic Disease on biologic & targeted Therapies: A Systematic Review COVID-19 Global Rheumatology Alliance. The Global Rheumatology Community's Response to the Worldwide COVID-19 Pandemic COVID-19 in patients with rheumatic diseases in northern Italy: a single-centre observational and case-control study Psychosocial impact of COVID-19 the psychological state and changes in the routine of the patients with rheumatic diseases during the coronavirus disease (COVID-19) outbreak in turkey: a web-based cross-sectional survey Psychological State and Associated Factors During the 2019 Coronavirus Disease (COVID-19) Pandemic Among Filipinos with Rheumatoid Arthritis or Systemic lupus erythematosus Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) epidemic among the General Population in China Psychological Responses and Associated Correlates of Depression, Anxiety and Stress in a Global Population, During the Coronavirus Disease (COVID-19) Pandemic Relationship quality and mental health during COVID-19 lockdown Depression, anxiety, and stress and socio-demographic correlates among general Indian public during COVID-19 We would like to thank our patients for their willingness to participate in the study.