key: cord-0987286-qdnp03c7
authors: Sahoo, Swapnajeet; Mehra, Aseem; Dua, Devakshi; Suri, Vikas; Malhotra, Pankaj; Yaddanapudi, Lakshmi Narayana; Puri, G D; Grover, Sandeep
title: Psychological Experience of patients admitted with SARS-CoV-2 infection
date: 2020-08-18
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2020.102355
sha: bd0db3a86d98c22a16ad7e8df1370a6ce933ca03
doc_id: 987286
cord_uid: qdnp03c7

nan

SARS-CoV-2 or COVID-19 pandemic outbreak has been creating havoc and has imposed a sense of severe insecurity and panic like situation (Tandon, 2020a (Tandon, , 2020b . The mass media/telecommunications /newspaper/blogs have been updating the information about the rapid rise in cases leading to admission to the hospital, being kept in the isolation ward, requiring oxygen support, being admitted in intensive care units (ICUs), associated mortality and the fate of the dead bodies (packaging/filled up graveyards/crematorium). All this news has led to a significant fear, anxiety, uncertainty, and restlessness in the general public. In this background, when one is diagnosed with COVID-19 infection, the diagnosis brings, in a feeling of shock and disbelief, and a feeling of being on the death bed. Many a time, the diagnosis not only leads to admission into the hospital but also leads to a diagnosis of COVID-19 infection in other family members, family members being sent to quarantine and other contacts being traced to the person (Sahoo et al., 2020a) .

Given the high infectivity and reported consequences of infections, including mortality, COVID-19 is known to have significant negative mental health outcomes, not only in those who are diagnosed with the infection and their family members but also in the general public Zhao and Huang, 2020) and the front line health care workers (HCWs) Lai et al., 2020; Rossi et al., 2020; Tan et al., 2020) . Currently, there are viewpoints and perspectives of mental health professionals regarding the different emotional reactions/issues and possible psychiatric problems which may arise in people diagnosed with COVID infection (Grover et al., 2020; Yao et al., 2020) . Due to the negative mental health consequences, it is suggested that a mental health professional should be part of the core team managing patients with COVID-19 infection (Grover et al., 2020) .

Available literature from the previous epidemics of infectious diseases suggests the occurrence of post-traumatic stress disorder, depression, and anxiety disorders in patients admitted with SARS (2002) and Middle East Respiratory Syndrome (MERS, 2012) during the postillness/recovery stage (Rogers et al., 2020) . Further, emerging evidence also suggests the occurrence of delirium (confusion, agitation, altered consciousness) in patients admitted to ICUs J o u r n a l P r e -p r o o f with severe COVID-19 infection Helms et al., 2020) and neuropsychological deficits (dysexecutive syndrome) at discharge (Helms et al., 2020) .

However, there is very limited literature on the psychological experience of patients with COVID-19 during their hospital stay. One study (n=144) reported significant anxiety (34%) and depression (28%) at admission to isolation wards (Kong et al., 2020) , the other (n=26) study reported higher anxiety and depressive scores on HAM-A and HAM-D respectively after one week of hospitalization, which decreased after comprehensive psychological interventions . Another study (n=57) found prevalence of depression to be around 30% in newly recovered COVID-19 patients . Further, a study with large sample (n=714) of hospitalised but stable patients with COVID-19 reported post-traumatic stress symptoms in 96.2% patients (Bo et al., 2020) . However, these studies had not explored in detail the emotional reactions which the patients went during the entire period of hospital stay till discharge.

We reported the narrative experiences of our patients during their hospital stay, who had significant distress when diagnosed with COVID-19 infection (Sahoo et al., 2020a (Sahoo et al., , 2020b .

These experiences of few patients prompted us to evaluate the experience of all the patients, admitted to the COVID-19 ward. In this background, the current study aimed to evaluate the emotional reactions/experiences which the patients go through, while admitted to the COVID-19 ward, at the time of discharge. Those who provided verbal consent to participate in the study were sent the study questionnaire through an online survey link (Survey Monkey® platform) on Whatsapp/ SMS, for completion.

The survey questionnaire consisted of patient health questionnaire-4 (PHQ-4) (Kroenke et al., 2009) , and a self-designed questionnaire to rate their overall experience during the hospital stay, about the emotions/feelings they went through during the entire stay and how they coped up during their hospital stay. PHQ-4 is a self-administered, ultra-brief screening instrument to screen for both depression and anxiety; it has 2 items each from PHQ-9 and Generalized Anxiety Questionnaire-7]. Additional clinical data were retrieved from case notes of individual patients.

The data were analyzed using SPSS software, version 20.0. Descriptive statistics were applied.

Pearson's correlation coefficient, Chi-square test, and independent t-test were used to finding the association between different variables.

As no specific questionnaire is available to assess the various dimensions of the experience of people admitted with COVID-19 infection, based on our initial experience with working with patients with COVID-19 and those in quarantine, we designed a questionnaire. The questionnaire covered the assessment of emotional reaction to the diagnosis, emotional experience during the stay in the hospital stay, fear of death at the time of diagnosis, reaction to the medical professionals, reaction to the environment of the ward, emotional experiences during the different stages of treatment, coping with the negative emotions, the value of interaction with others, change in perspective after surviving the COVID-19 infection, and anticipatory stigma.

Rating for different aspects was kept flexible. Coping and Anticipatory stigma were rated on a 4 point numerical rating scales with a range of 0 to 4. The questionnaire has not been validated.

During the study period (23 rd March to 5 th May 2020), a total of 131 patients were admitted in our COVID designated center, 30 of patients were less than 18 years and 4 patients expired. A J o u r n a l P r e -p r o o f total of 97 patients were approached for the study and were sent the survey link, of which 50 patients completed the survey and comprised of the current study sample.

The study sample comprised of 50 patients with a mean age of 36.94 (SD-12.33; range-21 to 67;

Median: 32.5) years. Majority of the participants were male (n=33; 66%) and married (n=37;74%). The mean duration of hospital stay was 18.26 (SD-4.96; range-14 to 38; median: 16) days. About one fourth (n=13; 26%) had at least one chronic physical illness. About twofifth (n=30; 40%) had to stay alone in isolation rooms, and a half (50%) of the participants stayed with another infected family member in the same room. One-tenth (10%) required oxygen support through oxygen prongs and required ICU stay, of which 3 had brief ICU stay for the initial few days, and 2 had prolonged ICU stay ( Table-1) .

When asked about their initial emotional reaction to the information about their COVID positive status, a majority reported going through multiple negative emotional states, with the most common emotional states being that of shock (n=36;72%), along with feelings of sadness (n=30;60%), panic/anxiety (n=34;68%) and disbelief (n=27; 54.0%). When asked to rate the thoughts of "going to die", on hearing the news about the diagnosis of COVID-19, about onesixth (n=8; 16%) rated it as 100%, and about two-fifth (n=20; 40%) rated it as more than 50%, with a mean score of 40.5 (SD: 36.3; median: 26). When asked about their reaction to seeing the health care professionals (HCWs) in personal protective equipment (PPEs), about half of them reported it to be like usual interaction with HCWs. In contrast, the other half reported that it felt like they were interacting with Aliens (24%), astronauts/space scientists (14%), or robots (22%).

However, the majority of the participants rated the behavior of HCWs to be better than usual times (Table-2) .

When the participants were asked to rate their overall experience of staying in the COVID ward environment, taking the entire hospital stay into account, one third reported the experience as if staying in a prison/jail (34%), as a bad dream (30%), and a small proportion of them reported it as torture (16%) and worse than jail (6%). However, others reported the hospital environment to be relaxing (40%), pleasant (38%), soothing (28%), and homely (16%). Those who stayed in ICU (n=5), described the experience as painful. Overall, the majority of the patients described the experience as one of the bad phases of life (58%) and the most horrible time of their life (20%) ( Table-2 ).

When enquired about the emotions/feelings during the major part of the hospital stay (having options of 'not at all', 'occasionally', 'for few days during the stay', 'for most days during the stay' and 'for almost all days during the stay'), ≥90% of the patients reported of having anxiety (92%), remaining worried (96%) and feeling isolated (90%) for most days during the stay or for almost all the days during the hospital stay. Other common negative emotional states experienced for most days during the hospital stay were anger (66%), irritability (76%), fear of death (64%), feeling disconnected (86%), and hopeless (70%) ( Table-3) .

When asked about experience of different events and time frames during the hospital stay and close to discharge, things which were mostly evaluated negatively were disclosure of diagnosis and first 3 days of stay in the COVID ward. The things which were valued the most were going out of the COVID-19 ward, travelling back to home and reaching home ( Table-4) .

When asked about the coping methods used during the hospital stay to adapt to the situation and negative emotions, about two-thirds of the participants reported remembering God (66%), talking to friends and family members over the phone (64%) and praying to God (62%) helped them to a large extent. Listening to music (34%) or to religious discourses (34%) and watching movies (30%) were also reported by one-third of the patients to be quite helpful during their stay to overcome negative emotional states. Coping strategies, such as sleeping, eating, shouting, were less frequently used and when used, helped minimally (Table-5) .

Further, when asked to rate the experience, in terms of interaction with various people, interaction with various people, including HCWs, family members (in person or telephonically), mental health professionals, were valued by all the participants (Table-6 ).

When asked about change in perspective in life, after surviving the COVID-19 infection, almost all of the participants reported an increase in 'faith in God', 'faith in human relationships', 'respect for doctors and health professionals' and 'respect for police and security personnel'.

About one-fourth reported a decrease in faith in 'power of money' (Table-7) .

When enquired about anticipated stigma, overall, the level of anticipated stigma related to self and family was lower, compared to that anticipated in the form of reaction of neighbors and society ( Table-8 ).

The Additionally, those mental health professionals, who are involved in the training of other staff, should focus on improving the communication skills of the staff, so that the patients could feel at ease, as has feel suggested by some of the authors (Grover et al., 2020) . In terms of coping, the present study suggests that the majority of the patients reported following religious techniques (remembering God, praying God, listening to religious songs/discourses, etc.) to deal with the stress and found it to be useful. This finding can be understood from various perspectives. First, people in India usually follow one or the other religion (Ministry of Home Affairs, and Government of India, 2020), turn to God at the time of crisis ("Power of prayer," 2020) , and possibly externalizing the responsibility to a higher power leads to a reduction in the anxiety and distress (Weber and Pargament, 2014) . Accordingly, clinicians involved in managing people

with COVID-19 infection should carefully evaluate the religious beliefs and practices of the persons, and if they find that the person has been successfully using positive religious coping in the past, they should be encouraged to use the same.

Another interesting finding of the present study is the change in the perspectives towards life after surviving COVID-19 infection. The increase in faith in God increased, which can be explained by religious beliefs. However, an important aspect of change of perspective increased in the faith in human relationships. This finding possibly reflects that prior to COVID-19, people did not value the importance of relationships, and they were fighting with each other from various materialistic things. However, when the humans have been faced with an enemy, which cannot be defeated by any currently available means, except for being able to support each other and cooperate with each other, people start valuing the importance of relationships (Editorial, 2020) . These findings suggest that there is a need to evaluate this aspect in more detail in the future to understand the impact of the pandemic on the human psyche per se. However, there was not much impact with respect to the power of money, with only one-fourth of the participants reporting a reduction in the faith of the power of money. This could be due to the fact that a significant proportion of our study sample came from low or low middle-income strata, who were already struggling with financial issues, prior to being diagnosed with COVID-19 infection.

Another aspect which this study tried to evaluate was the anticipatory stigma among the patients prior to discharge. Stigma has emerged as an important outcome of COVID-19 infection, WHO has issued an advisory to people to break the social stigma and discriminatory behavior toward people from a certain ethnic background and those who have recovered from COVID-19

infection. The current study was first of its kind to explore the anticipatory stigma close to the discharge from the hospital and revealed that people have a high level of public/societal stigma in different aspects (people feeling uncomfortable, being unkind, avoiding to touch, avoiding and people being afraid of recovered patients), compared to self-stigma and apprehension of being stigmatized by their family members. This finding suggests that it is important to create awareness in the public about COVID-19 infection and how they should react to people who have recovered from COVID-19 infection.

Our finding suggests that, despite being provided psychological support, about two-fifth (38%) of the people diagnosed with COVID-19 infection screen positive for anxiety disorder and/or depression close to their discharge. This suggests that overall, going through the experience of COVID-19 infection is very stressful, and despite providing psychological support, many patients go on to develop psychological morbidity. This finding suggests that there is a need to follow-up the patients with COVID-19 infection, even after discharge to evaluate them for ongoing psychiatric morbidity and manage the same adequately.

The present study has certain limitations, which must be kept in mind while interpreting the results. These include a small sample size, and the majority of the study participants being asymptomatic or minimally symptomatic for COVID-19 infection. We evaluated the experience of the patients, close to the discharge. In the real sense, this could be considered as retrospective evaluation. Further, these patients were provided psychological support during the hospital stay, which could have influenced the experience of the patients. Further, the experience could have also been evaluated by the treatment setting, per se. We did not evaluate for symptoms of posttraumatic stress disorder. Two-fifth of the participants screened positive for depression and anxiety, but this could be an underestimate, considering the fact that they were provided psychological support during the hospital stay.

To conclude, the present study suggests that going through the whole experience of infection, in the form of staying in isolation wards could be very stressful, even for patients who are minimally symptomatic or asymptomatic. Use of adaptive copings, such as remembering and praying to God, talking to family and friends, and interaction with mental health professionals, could help reduce the distress. Despite being provided psychological support, about two-fifths of the patients develop psychological morbidity.

Financial disclosure : We have no financial disclosure to make .

The authors declare that they have no conflict of interest. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

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We sincerely thank all the healthcare workers involved in the care of patients with

Research, Chandigarh.

J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f (Table-9 ). 10 (20.0%) % of patients reporting only anxiety but no depression 9 (18.0%) % of patients reporting only depression but no anxiety 3 (6.0%) % of patients reporting both anxiety and depression 7 (14.0%) % of patients reporting anxiety either/or depression or both 19 (37.3%) Age, gender, marital status, presence/absence of physical illness, a total duration of hospital stay were not found to have any significant association with anxiety, depression, or on total PHQ-4 score.