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

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Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
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Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
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."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




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.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
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,
Bengaluru.
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
Consultant
(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)
E-mail: drrajendrak1@rediffmail.com
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.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

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
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : VC01 - VC07 Full Version

Prevalence of Psychiatric Morbidity and their Clinical Correlates in Patients Post COVID-19: A Cross-sectional Study from Rural Northern India


Published: January 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/59074.17230
Abhishek Pathak, Rohit Pathak, Nitin Ranjan Gupta, Piyush Chopra

1. Associate Professor, Department of Psychiatry, Hind Institute of Medical Sciences, Sitapur, Uttar Pradesh, India. 2. Assistant Professor, Department of Respiratory Medicine, Hind Institute of Medical Sciences, Sitapur, Uttar Pradesh, India. 3. Professor, Department of Medicine, Hind Institute of Medical Sciences, Sitapur, Uttar Pradesh, India. 4. Junior Resident, Department of Medicine, Hind Institute of Medical Sciences, Sitapur, Uttar Pradesh, India.

Correspondence Address :
Dr. Piyush Chopra,
Junior Resident, Department of Medicine, Hind Institute of Medical Sciences, Sitapur, Uttar Pradesh, India.
E-mail: piyushchoprahims@gmail.com

Abstract

Introduction: Myriad of complications were observed in post Coronavirus Disease (COVID-19) survivors, psychiatric morbidities among one of them. Recent body of research has shown that significant number of patients developed psychological symptoms following COVID-19. Most of the Indian studies have assessed psychological morbidity among COVID-19 patients during admission. However, very few Indian studies have assessed the psychological impact of COVID-19 during the follow-up period, especially in rural India.

Aim: The study aimed to determine the prevalence of depression and anxiety and evaluate related socio-demographic (age, gender, education, occupation and marital status) and clinical factors (severity of COVID-19, presence of medical co-morbidity, Oxygen requirement, Intensive Care Unit (ICU) referral, duration of admission) in patients post-COVID-19.

Materials and Methods: This was a cross-sectional study conducted at Hind Institute of Medical Sciences, Sitapur, Uttar Pradesh, India. among 96 patients post-COVID -19 after their discharge from the hospital. Data collection was done between July 2021 to September 2021, using a semi-structured proforma and a psychiatric diagnosis was made (based on International Classification of Diseases- 10th Edition Diagnostic Criteria for Research criteria and clinically approved by two qualified psychiatrists). Rating scales such as Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Depression Rating Scale (HAM-D) were used for severity assessment. Data was analysed using Microsoft Statistical Package for Social Sciences (SPSS) version 20.0. A p-value of <0.05 was considered significant.

Results: In 96 patients, 70 (72.91%) were males. 38 patients (39.58%) were of the age group 45-60 years. 36 (37.50%) patients had Depression. Anxiety was seen in 40 (41.66%) participants. Among the clinical variables, the severity of the COVID-19 infection (p-value<0.01), presence of co-morbidity (p-value<0.01), and ICU referral (p-value<0.01), were found to be associated significantly with the presence of depression in the participants. Among 36 depressive patients, mild depression was present in 17 (47%), moderate depression in 12 (33%), severe depression in 5 (14%) and very severe in 2 (6%) of the participants. Anxiety was associated significantly with the gender (p-value=0.02), co-morbidity (p-value<0.01), severity of illness (p-value<0.01), oxygen requirement (p-value=0.04) and ICU admission (p-value<0.01). Mild anxiety was observed in 18 (45%), moderate anxiety in 16 (40%) and severe anxiety in 6 (15%).

Conclusion: The prevalence of depression and anxiety is high in patients post COVID-19. The severity of these disorders is significantly associated with presence of medical co-morbidity and severity of COVID-19. Hence, thorough evaluation and management of these disorders in post-COVID-19 patients can help in improving the overall outcome.

Keywords

Anxiety, Coronavirus disease 2019, Depression, Mental health

The Coronavirus Disease 2019 (COVID-19) was first reported in Wuhan, China in 2019 and then it spread like wildfire engulfing whole world (1). It is caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) (1). COVID-19 is generally characterized by symptoms such as fever, chills, cough, nausea, coryza, sore throat, myalgia and breathing difficulty of varying proportions (2). Various research studies in the past have suggested that Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) and MERS (Middle East respiratory syndrome) survivors are more likely to develop mental illnesses like depression, anxiety, and Post-Traumatic Stress Sisorder (PTSD), which can linger for months or years after being discharged from the hospital (3). Similarly, besides from physical symptoms and life-threatening medical complications, COVID-19 causes plethora of psychiatric morbidities ranging from depression, anxiety, panic attacks and delirium. Multiple causative factors have been attributed explaining psychiatric manifestation of coronavirus infection; like a direct neuronal invasion by coronavirus, dysregulated immunological response, abnormal activation of the hypothalamo-pituitary-adrenal axis, cerebrovascular hypoxia and metabolic derangements. Psychiatric symptoms can also be observed secondary to the side effects of drugs used to treat COVID-19 like oseltamivir, corticosteroids and interferons (4),(5). Additionally, patients suffering from COVID-19 can develop psychiatric morbidity because of the stigma associated with the disease, social isolation, concern and uncertainty about the outcome of this infection and limited information about the pandemic.The severity of psychiatric symptoms increases proportionally to the severity of COVID-19 infections (6),(7),(8). However, most of the times patient’s mental well-being is often neglected and compromised during the treatment of COVID-19 because of stigma, dearth of qualified psychiatrists and infrastructure. Psychological distress and depression may have an adverse effect on patient’s immune system response (9),(10),(11). Psychiatric morbidity negatively influences the long-term outcome of COVID-19 patients as it might lead to poor medication compliance. This warrants the urgent need to address the mental health issues accompanying viral pandemics like COVID-19. Therefore, strengthening consultation-liaison psychiatric services should be encouraged for the early detection and management of psychiatric disorders in patients post-COVID-19.

According to a survey conducted by the Indian Psychiatric Society, COVID-19 pandemic and resulting lockdown has led to a 20% rise in patients with mental illness (12). Different research studies in India have assessed the psychological impact of the COVID-19 pandemic in different clinical scenarios ranging from during quarantine/isolation, follow-up visits among the general public and high-risk populations such as frontline workers (11),(12),(13),(14). COVID-19 has drastically affected people’s quality of life by having long-term ramifications on their day-to-day lives, jobs and relationships (15),(16). Most of the Indian studies have studied the impact of COVID-19 on the mental health of the patients during admission, however very few Indian studies have documented the psychological impact of COVID-19 after discharge from the COVID hospital. In a cross-sectional study conducted by Gaur V et al., in clinically stable COVID-19 patients, the prevalence of depression and anxiety was found to be 44.44% and 34.72% respectively (17). In another study by Devi D et al., the prevalence of depression and anxiety among patients post-COVID-19 was 21.9% and 11.9%, respectively (18). Therefore, it is necessary to better understand the long-term psychological ramifications of COVID-19 to provide timely psychological interventions. This will not only ensure holistic management of the patients but will also help improve the long-term outcome of COVID-19.

It was hypothesised in the present study that the prevalence of depression and anxiety is high in patients post-COVID-19 and they have a significant association with various socio-demographic and clinical parameters, especially in rural areas because they had very little access to the knowledge and developments about COVID-19. Moreover, rural population has slightly different socio-cultural beliefs regarding diseases as compared to their urban counterparts. Socio-cultural beliefs and accessibility to medical services play a very important role in determining the long-term outcome of a disease. This study covered predominantly a rural population afflicted with COVID-19 and to the best knowledge of the authors none of the COVID-19 study in India has exclusively covered the rural population. Hence, the present study was planned to determine the prevalence of depression and anxiety and evaluate their socio-demographic (age, gender, education, occupation and marital status)and clinical correlates (severity of COVID-19, presence of medical co-morbidity, O2 requirement, ICU referral, duration of admission) in patients post-COVID-19, so that it will help in the holistic management and rehabilitation of such patients back into the community.

Material and Methods

This was a cross-sectional study conducted at Hind Institute of Medical Sciences, Sitapur, Uttar Pradesh, India. The study institute is located 50 km towards South from District headquarters Sitapur and 49 km from State capital Lucknow. HIMS, Ataria, Sitapur was one of the designated COVID-19 L2 (Level-2) hospitals during the pandemic. All the patients post-COVID-19, (diagnosed cases of COVID-19, atleast one month after their discharge from HIMS, Sitapur) attending follow-up COVID-19 Clinic at the Department of Respiratory Medicine and Department of Internal Medicine, between July 2021 to September 2021 were recruited into the study.

Total 207 COVID-19 positive patients were admitted during the second wave of pandemic at HIMS, Sitapur. Out of total, 96 patients were recruited into the study, as rest of the either patients did not meet the inclusion criteria or did not attend the follow-up clinics after their discharge (Table/Fig 1).

All the recovered COVID-19 positive patients attending the follow-up clinic in Department of Respiratory Medicine and Department of Internal Medicine postrecovery between July 2021 to September 2021 were approached and included in the study after informed consent. A recovered COVID-19 patient in the present study was defined as an adult (18 years and older) with a confirmed positive 2result on reverse transcription-polymerase chain reaction testing for the COVID-19 virus on oropharyngeal and nasopharyngeal fluid who was treated successfully and discharged with a COVID-19 discharge certificate. The study was approved by the Institute Ethics Committee under ethical approval number (IEC/IRB NO: HIMS/IRB/2020-21/43).

Inclusion criteria: Informed consent was taken from all the participants. All the patients post-COVID-19, (diagnosed cases of COVID-19, atleast one month after their discharge from the study institute attending follow-up COVID-19 Clinic at the Department of Respiratory Medicine and Department of Internal Medicine were included in the study.

Exclusion criteria: Patients who refused to provide consent to participate in the study and patients with a past history of psychiatric disorders like anxiety, depression, dementia, schizophrenia, substance abuse and/or a history of treatment with psychotropic drugs were excluded from the study.

Procedure

A semi-structured proforma was used for collecting socio-demographic and clinical details and it was filled by the investigator. History was collected from patient and reliable informants (First degree relatives). This semi-structured proforma was designed by the faculties of the Department of Psychiatry, Respiratory Medicine and Internal Medicine and it was approved by the scientific research committee of the Institute. It comprised of details of age, gender, education, occupation and marital status. Education was grouped under illiterate, upto upper primary (preprimary, primary and upper primary), upto senior secondary (secondary and senior secondary) and graduate/postgraduation education (19). Employment status was grouped as either employed or unemployed. Marital status was classified as married/unmarried/widowed. COVID-19 related variables explored included severity of COVID-19 infection, presence of medical co-morbidity, oxygen requirement, Intensive Care Unit (ICU) referral, duration of admission, history of psychiatric illness before being diagnosed with COVID-19, and knowledge of the death of close relative or friend who died with COVID-19. The severity of COVID-19 was assessed by doctors at the time of admission based on guidelines given by the Ministry of Health and Family Welfare (MOHFW) (20) and the same was documented in the case records of the patients.These case records were retrieved during the follow-up and patients were classified into mild, moderate, and severe categories of COVID-19 illness (20), depending upon the severity of symptoms during admission like those patients who had fever, dry cough, myalgia and other non specific symptoms were categorised as mild illness, while those patients who had above symptoms along with dyspnea on exertion or tachypnoea (respiratory rate >24/minute) and saturation of peripheral oxygen (SpO2) 90 to 94% on room air were categorised as moderate illness; patients having any of the above signs and symptoms with SpO2 less than 90% on room air or respiratory rate >30/minutes were categorised into “severe illness” category. Clinically, the diagnosis of depression and anxiety were established as per International Classification of Diseases-10th edition, diagnostic criteria for research (21) and was clinically approved by two qualified psychiatrists.

Hamilton Depression Rating Scale (HDRS): The HDRS was used to assess and rate the severity of depressive symptoms. It is a popular scale containing 21 items related to symptoms of depression. Score is calculated from first 17 items. Interpretation is;

0-7=Normal;
8-13=Mild Depression;
14-18=Moderate Depression;
19-22=Severe Depression and
>23=Very Severe Depression.

It has sensitivity of 86.4% and specificity of 92.2% and has good internal, inter-rater, and retest reliability (22).

Hamilton Anxiety Rating Scale (HARS): The HARS was used to assess and rate the symptoms of anxiety. It consists of 14 items which measures both psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety). Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where:

<17 indicates mild severity,
18-24 indicates mild to moderate and
25-30 indicates severe symptoms of anxiety.

It has sensitivity of 85.7% and specificity of 63.5% and has good reliability and validity (23).

STATISTICAL ANALYSIS

All the statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20.0. Descriptive analysis, using mean for variables such as clinical parameters and socio-demographic profile was assessed. Chi-square test was used to evaluate association between categorical variables (like the association of depression and anxiety with socio-demographic (age, gender, occupation, education and marital status) and clinical factors (severity of COVID-19, presence of medical co-morbidity, O2 requirement, ICU referral and duration of admission). A p-value of <0.05 was considered to be significant.

Results

The study sample comprised of 96 participants, consisting of 70 (72.91%) males and 26 (27.08%) females. 38 (39.58%) participants were 45 to 60 years of age group. Among participants only 10 (10.41%) were illiterates. Around 62 (64.58%) of the participants were employed and 56 (58.33%) were married. In this study, 36 (37.50%) participants were found to be suffering from depression. Among socio-demographic variables, an association of depression was found to be statistically significant with gender (p-value=0.02), marital status (p-value<0.01) and occupational status (p-value<0.01)of the participants (Table/Fig 2).

The majority of the participants had mild COVID-19 infection i.e. 64 (66.66%). Only 15 (15.62%) and 17 (17.70%) of them had moderate and severe infections respectively. 49 (51.04%) of the participants had co-morbid chronic medical illnesses. Among participants with co-morbidities, 20 (20.83%) had diabetes, 18 (18.75%) had hypertension, 6 (6.25%) had COPD and 5 (5.20%) had asthma. Around 17 (17.70%) patients needed ICU referral during their stay at the hospital. During the admission in hospital, 64 (66.66%) participants had stayed for more than 14 days while 32 (33.33%) stayed for less than 14 days. Only, 5 (5.20%) participants lost their relatives in that phase. Among the clinical variables, the severity of the COVID-19 infection (p-value<0.01), presence of co-morbidity (p-value<0.01), and ICU referral (p-value<0.01), were found to be associated significantly with the presence of depression in the participants (Table/Fig 3).

Among 36 depressive patients, mild depression was present in 17 (47%), moderate depression in 12 (33%), severe depression in 5 (14%) and very severe in 2 (6%) of the participants (Table/Fig 4).

Forty (41.66%) participants were found to be suffering from anxiety disorder. In patients suffering from anxiety, mild anxiety was observed in 18 (45%), moderate anxiety in 16 (40%) and severe anxiety in 6 (15%) (Table/Fig 5).
When socio-demographic variables of the participants were evaluated for statistical association with anxiety, only gender was found to be associated significantly (p-value=0.02) (Table/Fig 6).

While in the clinical variables of the participants, the presence of co-morbidity (p-value<0.01), severity of illness (p-value<0.01), oxygen requirement (p-value=0.04) and ICU admission (p-value<0.01) were found to be associated significantly with the presence of anxiety (Table/Fig 7).

Discussion

During the outbreak of viral pandemics, an increase prevalence of Depression and anxiety has been reported among postinfected patients across the globe. It was hypothesised in this study that the prevalence of depression and anxiety is high in patients post-COVID-19 and they have a significant association with various socio-demographic and clinical parameters. This hypothesis was found to be true as in the present study, 37% of the patients had a depressive disorder and 41% of them suffered from anxiety disorders. The prevalence of psychiatric morbidity has ranged from 10% to 48% in various international studies (24),(25),(26),(27),(28).

According to Wang C et al., about three fourth of the Chinese population showed significant psychological impact in the form of depressive symptoms during the initial stage of the 2019 coronavirus disease in China (24). Kong X et al., reported that 34.72% and 28.47% patients with COVID-19 had symptoms of anxiety or depression, respectively (25). Present study also depicted similar findings in terms of prevalence of depression and anxiety. The COVID-19 infection has been known to have far reaching ramifications on the brain and cause plethora of psychological symptoms in an individual. Viral infections triggers dysregulated inflammatory response and as a result number of proinflammatory mediators such as Tumor Necrosis Factor-alpha (TNF-alpha) , interleukin-6 (IL-6) and interleukin beta cytokines are released. Noradrenaline is also known to play important role in regulating depression like symptoms such as fatigue, aches, pains and loss of appetite. Additionally, the stigma of being diagnosed as COVID-19 positive further exacerbates the problem (29),(30). Certain Indian studies have also documented prevalence rates ranging from 10% to 40% (18),(31),(32). Prajapati NK et al., reported 73.3% psychiatric morbidity in COVID-19 inpatients (31). Major depressive disorder was present in 8.7% of the patients.

In a cross-sectional survey conducted using an electronic questionnaire, around 25%, 28% and 11.6% of the participants were moderate to extremely severely depressed, anxious and stressed, respectively (32). Major depressive disorder was present in 8.7% of the patients. In another study by Devi et al., the prevalence of depression and anxiety among patients post-COVID-19 was 21.9% and 11.9%, respectively (18). However, some Indian studies have reported the prevalence of psychiatric morbidity to be very high ranging from 50% to 70% (33),(34),(35),(36). In a study to determine the prevalence of psychiatric morbidities among COVID-19 survivors in Northern India, the prevalence of anxiety and depression, was found to be 44.54% and 61.34% respectively (33). Yadav R et al., in their cross-sectional study reported prevalence of Depression in 27 % and Anxiety in 67% of the participants (34). Kumar P et al., reported Depression in 48% of the admitted COVID-19 patients and anxiety was seen more commonly in females (60%) than in male patients (28.75%) (35). In another study, the prevalence of depression among hospitalised COVID-19 positive was nearly 40% (36). Bharti P et al., reported the prevalence of Depression and Anxiety to be 64% and 61% respectively among COVID-19 in patients (37). The higher prevalence of psychiatric morbidity in above mentioned studies can be attributed to the use of different sampling methods, diagnostic tools and rating scales. Another possible explanation for the above mentioned phenomenon can be because of the differences in the timing of the study. This study was conducted during the post-COVID-19 period (after the peak of the second wave in India). Some of the studies were conducted either at the beginning of the pandemic or at the peak of the pandemic.

Depression and anxiety in the participants were associated with the presence of male gender, marital status, employment status, medical co-morbidity, the severity of illness and ICU admission and this association was statistically significant (p-value <0.05).

unitIn present study majority of the patients were male (72%) and it can be explained by the fact that in rural north India, males are the sole earning member of their families and have to venture out in order to earn. Hence, they are more vulnerable to acquire COVID-19 infection and subsequent psychiatric morbidity (34). This is similar to the study conducted by Prajapati NK et al., Kumar P et al. and Iqbal Y et al., (31),(35),(38). However, in some studies higher psychiatric morbidity has been reported in females (39),(40). Sympathetic-adrenal and HPA responsiveness is attenuated by female sex hormones. This results in sluggish control feedback on the brain and less or delayed containment of the response among women (41). Moreover, the additional burden of household chores and care giving further compounds the problem for Indian females (18). Psychiatric morbidity was higher in single/divorced individuals and can be explained by the absence of a strong family support system in such individuals. The traditional family support system in India is known to act as buffer and absorb various kinds of stress during the time of crisis (42),(43). Depression was more prevalent in unemployed participants and it can be attributed to fear of financial insecurity, and overall economic ramifications of COVID-19. Secure financial system provides buffer against adversity. Sample size was predominantly agrarian based homogenised rural population. Most of the patients fall under middle lower and lower upper segment (according to modified Kuppuswamy classification). Hence, socio-economic status was not used in the results (44).

Around 51.04% of the participants had co-morbid chronic medical illnesses. Most common among them was Diabetes followed by Hypertension, COPD and Asthma. Medical comorbidities were significantly associated with depression and anxiety (p-value <0.05). This was in concurrence with the study by Arbelo N et al., in which severe somatic comorbidities were significantly associated with delirium, major and minor mental illnesses (45). Psychiatric morbidity was higher in patients suffering from severe COVID-19 infection and those who required ICU referrals. This can be explained by the fact that exacerbation of psychological symptoms is perpetuated by rapid deterioration of physical health and social isolation owing to COVID-19. These findings have been mirrored by various studies, which have found increased prevalence of psychiatric morbidity in admitted patients of COVID-19 having coexisting medical morbidity (46),(47). Moreover, apprehensions pertaining to long-term ramifications of infection, social stigma, and fear of re-infection might perpetuate the development of anxiety and depression in patients. (Table/Fig 8) shows the prevelence rate of psychiatric morbidity various studies in different countries (17),(18),(24),(25),(26),(27),(28),(31),(32),(33),(34),(35),(36),(37).

COVID-19 pandemic has taken a heavy toll on the mental health of the general public. The presence of psychiatric morbidity negatively influences the long-term outcome of COVID-19 patients. Hence, effective screening and robust consultation-liaison services are the need of the hour for the holistic management of such patients. This will not only help in the recovery of the patients but will also help in improving the overall quality of life of such patients.

More follow-up multicentric studies are needed to study long-term sequelae of COVID-19 infection and causality. Moreover, sample should include migrant workers, healthcare professionals and other emergency service providers, children in order to have a better understanding of the dynamics and various correlates of psychiatric morbidity and COVID-19.

Limitation(s)

It was a single-centre, cross-sectional study. Hence, only associations could be studied. Recall bias and response bias can be present in cross-sectional studies. No long term follow-up of the patient was done, so information about long-term sequelae of COVID-19 is lacking. This study was done at rural medical college, therefore, findings of the study cannot be generalised to the whole population. Other comorbid medical illnesses and persisting symptoms of COVID-19 can act as confounding factors.

Conclusion

Depression and anxiety were present in 37.50 % and 41.66 % respectively in patients post-COVID-19. Depression and anxiety were associated significantly with the presence of male gender, marital status, employment status, medical co-morbidity, the severity of illness and ICU admission. Hence, thorough evaluation and management of co-morbid psychiatric disorders in patients with COVID-19 is the need of the hour. Additionally, psychological symptoms are known to linger in patients of COVID-19, even after recovery. Therefore, it is necessary to have a better understanding about the long-term psychological ramifications with COVID-19 in order to provide timely psychological interventions and effective rehabilitation for such patients.

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DOI and Others

DOI: 10.7860/JCDR/2023/59074.17230

Date of Submission: Jul 15, 2022
Date of Peer Review: Aug 20, 2022
Date of Acceptance: Dec 02, 2022
Date of Publishing: Jan 01, 2023

AUTHOR DECLARATION:
• 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. Yes

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