Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

Prof. Somashekhar Nimbalkar

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On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Saraswati Dental College
On Sep 2018

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On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : July | Volume : 16 | Issue : 7 | Page : VC16 - VC20 Full Version

COVID-19 Related Mental Health Issues among Patients with Cancer: A Pilot Study

Published: July 1, 2022 | DOI:
Kumari Padma, Deepthi Saka, Sharol Fernandes, Sagar Nanaware, Ishwar Patil, Ramdas Ransing

1. Assistant Professor, Department of Psychiatry, B.K.L. Walawalkar Rural Medical College, Sawarde, Ratnagiri, Maharashtra, India. 2. Senior Resident, Department of Psychiatry, St John Multispeciality Hospital, Guwahati, Assam, India. 3. Assistant Professor, Department of Psychiatry, Father Muller Medical College and Research Centre, Manglore, Karnataka, India. 4. Assistant Professor, Department of Medicine, B.K.L. Walawalkar Rural Medical College, Sawarde, Ratnagiri, Maharashtra, India. 5. Assistant Professor, Department of Psychiatry, B.K.L. Walawalkar Rural Medical College, Sawarde, Ratnagiri, Maharashtra, India. 6. Assistant Professor, Department of Psychiatry, B.K.L. Walawalkar Rural Medical College, Sawarde, Ratnagiri, Maharashtra, India.

Correspondence Address :
Dr. Ramdas Ransing,
B.K.L.Walawalkar Rural Medical College, Sawarde, Ratnagiri-415606, Maharashtra, India.


Introduction: Coronavirus Disease-2019 (COVID-19) pandemic is associated with more psychological distress than its rampant spread, mortality, and morbidity. Cancer patients are at increased risk of mortality and morbidity than the general population. Due to this, there is a possibility that cancer patients may be suffering from a higher level of COVID-19 related anxiety, fear, and obsession.

Aim: To explore COVID-19 related mental health issues (anxiety, fear, and obsession) and its correlates in patients with cancer.

Materials and Methods: The present study was a cross-sectional pilot study which was conducted in a tertiary care teaching hospital located in Ratnagiri, Maharashtra, India. Patients receiving treatment for cancer (n=55) consequently at tertiary care teaching hospital of India were recruited. The Corona Anxiety Scale (CAS), Obsession with COVID-19 Scale (OCS), Fear of COVID-19 Scale (FCV-19S), Patient Health Questionnaire-9 (PHQ-9), and Generalised Anxiety Disorder-7 Scale (GAD-7) were used to assess all eligible patients. Fisher’s-exact test, spearman’s rank correlation, and logistic regression were used to analyse the data.

Results: Among the 55 patients (mean age was 49.64±13.08 years) with cancer, 11 (20%) had Coronavirus related anxiety and 2 (3.6%) had obsession related COVID-19, 22 (40%) had depression and 18 (32.7%) has GAD. CAS score positively correlated with FCV-19S score [ρ=0.50 (p<0.001)], PHQ-9 score [ρ=0.90 (p<0.001)] and GAD-7 score [ρ=0.74 (p<0.001)].

Conclusion: COVID-19 related mental health issues (fear, anxiety), depression, and GAD were prevalent among patients with cancer. Further, COVID-19 specific issues may not be addressed in routine screening and evaluation in current practice. Therefore, there is an urgent need to develop systematic strategies to screen and develop specific mental health interventions for patients with cancer.


Anxiety, Consultation liaison psychiatry depression, Coronavirus Disease-19

The COVID-19 pandemic has influenced every aspect of individual life and sabotaged diverse dimensions of health, economy, social life, etc. within a few months (1). People with or without medical or mental illness is at the increased risk of developing mental health distress due to pandemic, public health measures, and the spread of virus (1). The vulnerable population (i.e., people with medical co-morbidities like cancer, mental illness, personality traits) are at increased risk for developing the COVID-19 related distress along with the increased prevalence of the common mental disorder. Avoidance of these common mental health issues related to COVID-19 infection and public health measures can lead to serious consequences including suicides (2).

Besides, these issues can lead to non compliance to medical management of cancer including chemotherapy and radiotherapy, and increased risk of mortality and morbidity during this pandemic (3). Published literature suggests that patients with cancer are more commonly associated with depression and GADs (3),(4). However, most of these studies have used traditional self-reported scales such as PHQ-9, GAD-7, and Beck Anxiety Inventory (BAI) (3),(5).

These scales have limited utility to screen these populations for COVID-19 related mental health issues (e.g. anxiety, fear, or obsession) due to lack of face and construct validity (6). Also, patients suffering from COVID-19 related anxiety should not be treated for GAD as measured on GAD-7 or BAI. Moreover, Position statement of the Indian association of palliative care recommends that patients receiving palliative care should be evaluated for mental health issues using validated measures and should be managed by appropriate interventions (7),(8).

To address these critical limitations of previously published studies and estimate the COVID-19 specific mental health issues, authors attempted to evaluate the COVID-19 common mental health issues (fear, anxiety, and obsession) and their relation with depression and anxiety using newly developed scales and traditional scales.

Material and Methods

In this cross-sectional study, patients attending the oncology Out Patient Department (OPD) were invited to participate in the study during the period of May 2020 to June 2020. This was a pilot study conducted in a tertiary teaching hospital of Maharashtra, India in the initial stages of the pandemic and was approved by the Institutional Ethics Committee (IEC) (BKLW/RMC/LEC/42/2020).

Inclusion criteria: Patients with a diagnosis of cancer who were aged more than 18 years, treated for atleast six months and willing to give consent were included in the study.

Exclusion criteria: Patients with delirium, acute radiation syndrome and those diagnosed with COVID-19 were excluded from the study.

Seventy five patients who consented for the study were recruited. A semi-structured form was used to collect socio-demographic data. COVID-19 related anxiety, obsession, and fear were assessed by using the Marathi version of the CAS, OCS, and fear of COVID-19 Scale (6),(9),(10). In addition, Generalised anxiety and depression were measured by translated and validated GAD-7 and PHQ-9 scales.

Corona Anxiety scale (CAS): The CAS is a 5-item scale having robust reliability, validity, sensitivity, and specificity (9). A self-report screen for identifying people who might suffer from an unhealthy degree of anxiety due to the COVID-19 pandemic, which mainly entails behavioural and physiological reactions of elevated fear and excessive worry about coronavirus and its related stimuli. It discriminates those with dysfunctional anxiety and non anxiety while using an optimised cut-off score of 9 (6),(9). The CAS captured information regarding how frequently respondents experienced COVID-19 anxiety in the past two weeks regarding behavioural and physiological symptoms. They are scored using the 5-point Likert scale (0 = not applicable to me, 1 = hardly ever applicable to me, 2 = sometimes applicable to me, and 3= Most of the times 4 = very applicable to me daily). The level of anxiety is determined by taking the average of the scores (ranging from 0 to 4). A higher score indicates that an individual has more COVID-19 related anxiety. CAS is translated and available in several languages including Marathi (10).

The Obsession with COVID-19 Scale (OCS): The OCS is a self-reported, 5-item scale with robust reliability, validity, sensitivity, and specificity (6),(11). OCS was developed to detect maladaptive thinking about COVID-19 over the period of two-week time-frame. It is scored using a 5-point Likert scale, ranging from 0=not at all to 4=nearly every day. The scoring format is consistent with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) cross-cutting symptom measure. The OCS discriminates the non functional COVID-19 thinking patterns from those without such a pattern using an optimised cut-off score ≥7 and so that the higher the average, the greater the obsession of the individual regarding COVID-19. Elevated scores on a particular item or a high total score (≥7) may indicate problematic symptoms for the individual that might warrant further assessment and or treatment (12). OCS is available in several languages including Marathi (10).

Fear of COVID-19 Scale (FCV-19S): The FCV-19S scale is a self-reported, Likert-scale, consists of seven items and has possible scores range from 7 to 35 (13). Responding to items on a five-point Likert scale (1=strongly disagree; 5=strongly agree), the FCV-19S has been found to be psychometrically sound in assessing fear of COVID-19 in different populations, including different ethnic groups (14). An example item in the FCV-19S is “I cannot sleep because I’m worrying about getting coronavirus-19”. A higher level of fear toward COVID-19 is indicated by the higher FCV-19S score. Moreover, different language versions of the FCV-19S used in the present study have been validated (15). The higher scores are indicative of greater coronavirus fear. The scale has excellent validity, reliability, and availability in various languages (6).

Patient Health Questionnaire-9 (PHQ-9): PHQ-9 is a self-reported, Likert type scales used for screening for the depression. The questionnaire has nine items which are scored as “0” (not at all) to “3” (nearly every day). The PHQ is part of Pfizer’s larger suite of trademarked products, called the Primary Care Evaluation of Mental Disorders (PRIME-MD). The PHQ-9 takes less than three minutes to complete and simply scores each of the 9 DSM-IV criteria for depression based on the mood module from the original PRIME-MD (16). Primary care providers frequently use the PHQ-9 to screen for depression in patients.

The PHQ-9 questions are based on DSM-IV diagnostic criteria for depression. The patient’s experience over the previous two weeks in terms of level of interest, mood, sleep, energy, and eating habits is elicited. The questionnaires have excellent validity, reliability, sensitivity, and specificity to screen for depression. Cut-off points of 5, 10, 15, and 20 are interpreted as representing mild, moderate, moderately severe, and severe levels of depression on PHQ-9 (17),(18).

Generalized Anxiety Disorder-7 Scale (GAD-7): GAD-7 scale has good reliability as well as validity. The GAD-7-is a useful tool with strong criterion validity for identifying probable cases of GAD. The scale is an excellent severity measuring tool and is strongly correlated with multiple domains of functional impairment and days with disability. The scores of 0,1,2, and 3 are assigned to response categories of ‘not at all’, ‘several days’, ‘more than half the days’, and ‘nearly every day’. The total GAD-7 score is calculated by adding the scores of seven questions. Cut-off points for mild, moderate, and severe anxiety are 5,10, and 15, respectively. Furthermore, the GAD-7 is a moderately good screening tool for other common anxiety disorders such as panic disorder (sensitivity 74%, specificity 81%), social anxiety disorder (sensitivity 72%, specificity 80%), and post-traumatic stress disorder (sensitivity 66%, specificity 81%) (19),(20).

The administration of these scales along with socio-demographic proforma was done online (for those patients who have appointments with oncologists and have internet access) and by administration of printed forms [for those who didn’t have phone or internet access under all standard precaution led by Indian Council of Medical Research (ICMR)]. The presence of any COVID-19-related symptoms, high-risk contact, and travel history was asked to all patients and advice was offered as per Indian Government guidelines (21).

Statistical Analysis

Descriptive analysis of socio-demographic, clinical variables and scores on scales was carried out using Statistical Package for the Social Sciences (SPSS) 20.0. SPSS Inc., Chicago, Ill., USA). Fisher’s-exact test was used to assess the association between two categorical variables. A Kolmogorov-Smirnov test was used to assess the normality of data. The spearman’s correlation coefficient correlation was used to seeing the correlation between scores of different scales and other variables. Logistic regression was carried out to predict the presence/absence of Corona Anxiety (CAS) with Age, FCV-19S, PHQ-9 (total score), GAD-7 (total), and OCS. All the statistical analysis was carried out while keeping statistical significance at 0.05.


Out of 75 patients approached for the study, 55 (mean age=49.64±13.08 years) completed the survey. Most of the patients were female (n=30, 54.5%), married (n=48, 87.3%), Hindu (n=53, 96.4%), and hailing from rural region (n=52, 94.5%) (Table/Fig 1).

Among the studied patients, the mean score on studied clinical scales were FCV-19S=17.02±4.42; CAS=5.16±4.52; PHQ-9=4.10±3.74; GAD-7=3.54±3.72 and OCS=1.83±2.20.

About 11 (20%) of the respondent patients were positive on CAS while only 2 (3.6%) were positive for OCS (Table/Fig 1). About 22 (40%) of the respondent reported presence of depressive symptoms on PHQ-9, where 18 (32.7%) had mild symptoms, 3 (5.5%) moderate symptoms and 1 (1.8%) had severe symptoms. Also on GAD-7, 18 (32.7%) of the patient were screened positive, amongst them 12 (21.8%) has mild symptoms, 6 (11%) moderate symptoms of GAD.

The difference among patients screened positive for OCS and those of PHQ-9 or GAD-7 was insignificant (p=0.28, p=0.48) respectively. Further, there was a significant difference between patients screened CAS positive and PHQ-9 or GAD-7 screened positive (p=0.004, p=0.0003). Among the patients with cancer, 14 (25.45%) of them resulted positive on both PHQ-9 and GAD-7, and 21.81% (n=21) population were screened positive for either depressive symptoms or anxiety (p=0.0001) (Table/Fig 2).

The relationship of scores on COVID-19 related scales (CAS, OCS, FCV-19S) and traditional scales (PHQ-9, GAD-7) with age, duration of illness and treatment, education (except PHQ-9, ρ= 0.27, p=0.04), was statistically insignificant (p>0.05) (Table/Fig 3). Scores on COVID-19 related scales positively and significantly correlated with each other and with scores of traditional scales (PHQ and GAD-7) (Table/Fig 3). Further, the logistic regression results showed that higher score on FCV-19S was a significant predictor of coronavirus anxiety (OR=1.41, p=0.025) than screened positive on PHQ-9, GAD-7, and OCS-7 (Table/Fig 4).


The COVID-19 outbreak is leading to an epidemic of mental health issues such as stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear among patients with cancer (1). In this study, authors found increased the Coronavirus related anxiety (20%) and fear about COVID-19 (17.02±4.42) among patients with cancer. These COVID-19 related mental health issues are known to affect the healthcare utilisations, decision making for treatment choice, quality of life, and compliance with treatment (3),(22),(23). Though the previous studies attempted to highlight the significance of these issues, no study attempted to estimate or measure the COVID-19 related mental health issues using standardised scales (3),(4),(18),(24),(25).

As expected, a higher prevalence of depression (40%) and anxiety (32.7%) was found among the patients with cancer receiving the treatment in the form of chemotherapy or radiotherapy than the previous study findings among general population (26). However, these findings of the survey ran contrary to previous studies. Jaunjuan L et al., have found that the prevalence of anxiety (56%) and depression (43%) was among the patients with breast cancer (n=658) in China (5), whereas Wang Y et al., reported the prevalence of depression (23.4%) and anxiety (17.7%) along with COVID-19 related distress among the cancer patients (n=6213) from the same country which was lower than Indian population (4). This could be due to the psychological impact of different stages of the pandemic as mentioned in the emotional epidemic curve (1). Juanjuan L et al., had conducted a study in February 2020 while Wang Y et al., in April 2020. An early phase of the epidemic is often characterised by increased prevalence of fear, anxiety, and depression due to uncertainty, and lack of information which often decreases after some time (27),(28).

Also, the study conducted among the patients with lymphoma had a higher prevalence of GAD (36 %) and a lower prevalence of depression (36%) during this pandemic (29). This could be due to the use of Hospital Anxiety and Depression Scale-A (HADS-A) which has higher specificity and screening accuracy than PHQ-9 (30). The recently conducted online survey from India (n=1685) reports that about two-fifth (38.2%) had anxiety and 10.5% of the participants recruited from the general population had depression during a period lockdown and COVID-19 pandemic. Both (Present and Grover S et al., study) has used reliable and validated tools i.e., PHQ-9 and GAD-7 (26). However, this study findings suggest that patients with cancer receiving treatment were more depressed and were less anxious than general population. This could be due to the chronic nature of the illness, adverse effects of radiotherapy and chemotherapy, effects of lockdown on services, uncertainty, fear, and coping among patients with cancer. Besides, study by Grover S et al., had several limitations of being an online survey such as snowball sampling, data collection, the unpredictable response rate from participants. Thus, may not representable as the general population (26).

Among the patients with cancer, 14 patients (25.45%) were screened positive on both PHQ-9 and GAD-7, and 12 patients (21.81%) population screened positive for either depressive symptoms or anxiety. However, it is important to note that an increased score on GAD-7 in patients with depressive symptoms is strongly associated with multiple domains of functional impairment. Though, symptoms of depression and GAD has often had co-occurrence these symptoms have differing but independent effects on functional impairment and disability (31),(32).

During interviews with some screened positive patients, most of the patients reported that they are worried more about their stay in the hospital, delaying treatment or appointment due to lockdown and other public health measures, and infecting their relatives. Most of the patients denied COVID-19 related anxiety instead they reported they are more worried about the prognosis of cancer and the adverse effect of on-going treatment. This could be an underlying reason for a low score of CAS, OCS while a higher score of PHQ-9 and GAD-7 in present study patients.

Despite having significant correlations among all scales, only scores on FCV-19 was able to predict the coronavirus anxiety among the patients with cancer. It can be due to possible under-reporting of CAS due to the use of a high cut-off score of 9 instead of 5 considering the population at risk of developing coronavirus related anxiety (33). However, lowering the cut-off score of 9 may be required to reduce the under-diagnosis of Coronavirus related anxiety. Therefore, future studies are needed to reconsider the cut-off score without compromising the robust sensitivity and specificity of CAS.

In most of the previous epidemiological studies, the online platform was used to collect data (4),(5),(22),(23),(24). Further, COVID-19 related scales are also developed by using online platform (6). The online survey has several limitations (34). These limitations include the restriction on internet access leading digital divide of people, motivation to respond, and comfort with self-reporting emotional and behavioural symptoms which often influence the participation rates, and the responses. In this study, authors have surveyed OPD providing these questionnaires due to the non availability of internet, poor, or low internet connection in the rural part of India. However, this method might have provided us more robust data than previously reported studies.

Only two patients (3.6%) were found to have positive scores from the OCS scale. Though the finding may not be significant in this study, it warrants the need to look out for the recent onset of obsessive-compulsive disorder, given the fact that safe hygienic practices like hand washing play a vital role in preventing infection; which has been fiercely propagated by World Health Organisation (WHO) and several medical organisations.

To the best of our knowledge, this is the first study that attempted to COVID-19 related mental health issues (anxiety, fear, and obsession) and its relationship with GAD and depression using standardised instruments. In addition, there was only one study that has attempted to evaluate the psychological impact of COVID-19 among patients with cancer (35). Present study findings emphasise the need of assessing the common mental disorders along with COVID-19 related mental health issues in this pandemic which could otherwise be easily overlooked. Only those praticipants who attended OPD were included in this survey which adds on to methodological limitations of web-based or internet surveys (such as snowball sampling).

Future direction: Both palliative care services and mental health services are poorly developed in India due to human resource deficits, stigma, and financial constraints (36). In many instances, psychological need for patients suffering from cancer is often overlooked even during the pre-pandemic era. Based on present study findings with the use of recently prepared scales, we would like to propose a patient care model for the mental health needs of patients with cancer during the COVID-19 pandemic. However, this stepped care model along with triage needs further evaluation in subsequent studies (Table/Fig 5). Though this model was prepared based on cross-tabulation of results, before implementation in practice the clinician or researchers should consider the dynamic nature of COVID-19 pandemic, COVID-19 related stigmatising experiences, and screening or diagnostic properties these tools for underlying mental healthcare (37). In this scenario, digital technology including artificial intelligence can help to predict and interpret the emerging and existing mental health issues (38).


First, this was a single-centre study, having a small sample size, and cross-sectional study design which has a recall bias especially for biological symptoms of chronic medical disorder and response bias. Second, authors used self-reported scales (PHQ-9, GAD-7, and CAS) which are proxy of underlying conditions and their diagnosis was not confirmed in a structured interview (e.g. Mini International Neuropsychiatric Interview-MINI) or clinician’s interview. Third, the adverse effects of medications or medical conditions such as anaemia may have over-diagnosed depressive or anxiety symptoms. Fourth, present study have not used the scales related to other common mental disorders such as insomnia. Fifth, the various public mitigation efforts (e.g. restricted movement, lockdown) may have exaggerated the effects of depression or anxiety. Screening accuracy is dependent on prevalence and anxiety, as identified by the GAD-7, was relatively low in this population. Therefore, the CAS or OCS may require a lower threshold score to maximise sensitivity and specificity in this specific population. The scales CAS and OCS are yet to be validated in the local language (Marathi)


COVID-19 related anxiety and fear are highly prevalent among patients with cancer which may be an exaggeration of pre-existing, untreated common mental disorders or new ones due to public mitigations measures, infodemic, and fear. This study found co-existence of COVID-19 related anxiety and fear along with common mental disorders among the patients with cancer and these conditions may have a prognostic or predictive significance that needs immediate attention in terms of implementation of COVID-19 related mental health issues in routine clinical screening.


Authors would like to thank Prof. Mark D. Griffiths and Prof. Sherman Lee for their kind permission to allow translation and use of FCV-19S, CAS, and OCS in Marathi for this study. The authors would also like to express the gratitude to COVID-19 and Mental Health -India Group members for being supportive.


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DOI and Others

DOI: 10.7860/JCDR/2022/52123.16571

Date of Submission: Aug 28, 2021
Date of Peer Review: Dec 10, 2021
Date of Acceptance: Apr 26, 2022
Date of Publishing: Jul 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: Aug 31, 2021
• Manual Googling: Apr 16, 2022
• iThenticate Software: Apr 22, 2022 (9%)

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