Introduction
COVID-19 caused by SARS-CoV-2 virus has profoundly affected thousands of lives around the world.1 Various strict public health measures such as imposing lockdown, travel restrictions, social distancing and home quarantine were carried out to contain and slow down the spread of the virus. As a result, there were significant changes in the daily lives of people.2 Furthermore, globally people experienced economic loss or financial crises throughout this pandemic which also affected their mental health status.3 Thus, COVID-19 has become the seed of a major mental health crisis.2
In Nepal, the first case was confirmed on 23 January 2020.4 With the identification of the second case, a nationwide lockdown was declared starting from 24 March.5 The government imposed protective measures against COVID-19 such as lockdown, self-isolation, social distancing and quarantine which created fear, anxiety and uncertainty among the Nepalese.3 And a year later, the government imposed a lockdown again from 29 April 2021 with the outbreak of the second wave. The second wave of COVID-19 caused a serious and devastating result compared to the first wave. The majority of hospitals faced a shortage of intensive care unit (ICU) beds and oxygen supplies. There were a higher number of morbidities.6
The COVID-19 survivors, as the direct victims of this infectious disease, were the most affected. In the initial days, the disease was new and unknown to everyone. So, COVID-19 created social stigma and discriminatory behaviour towards the people who tested positive.7 People had the tendency to distance and isolate themselves from COVID-19 positive cases.8 Along with the fear of unknown disease, the discriminatory behaviour and the stigma associated with it, negatively affected the mental health of COVID-19 infected patients.9 Furthermore, adverse mental health outcomes were evident among COVID-19 patients who were discharged after hospitalisation.10 11 Confronted with this novel deadly infectious disease, their experience of witnessing adverse events during hospitalisation, uncertainty regarding one’s prognosis and the need for ICU care all constituted a terrifying experience for the patients.12 Several studies reported that COVID-19 survivors have depression, anxiety disorders, psychological distress and suicidal behaviour.11 13–15 A study in China showed that COVID-19 patients were more affected by the pandemic than psychiatric patients and healthy individuals.16 They exhibited elevated levels of neuropsychiatric symptoms, such as impulsivity and insomnia, alongside a range of emotions and concerns, including shock, fear, boredom, discrimination, medical costs, healthcare provider support and self-care strategies. A retrospective cohort study conducted among the COVID-19 cases in the USA showed that the COVID-19 survivors were at increased risk of anxiety disorders in the 3 months after infection.17 However, a prospective observational cohort study in the USA conducted among patients with severe COVID-19 disease reported their worse mental health status even within 1 month after hospital discharge.18 A systematic review revealed that individuals having pre-existing mood disorders are more likely to be hospitalised or die from COVID-19, so they should be seen as at higher risk due to their existing conditions.19
COVID-19 can lead to long-term mental health impacts among the infected patients.20 21 One reason for the potential long-term impact of COVID-19 is existing insights from previous pandemics such as severe acute respiratory syndrome (SARS), and middle east respiratory syndrome (MERS).22 There were long-term psychiatric morbidities in survivors of SARS and MERS. The prevalence of depression and anxiety among the survivors of months beyond hospital discharge was 33% and 30%, respectively.22 Similarly, there were psychiatric complications among SARS survivors treated in hospitals 30 months after the outbreak.23 Post-traumatic stress disorder (33.3%) was the most prevalent long-term psychiatric condition, followed by depression disorders (15.6%).
COVID-19 survivors are at risk of psychiatric sequelae with symptoms often improving over time.24 A significant prevalence of psychiatric sequelae, such as depression,25 persistent fatigue and cognitive impairment26 was reported among people following recovery from COVID-19. A study in Japan found an increased risk of psychiatric sequelae within 3 months of infection but a decreased risk 4–6 months later.27 In a systematic review, approximately 11%–28% of individuals continued to experience depressive symptoms after 12 weeks post-infection, with 3%–12% reporting clinically significant depression or severe depressive symptoms, helping to understand the long term impact of depression.25 Moreover, a systematic review and meta-analysis found that there were a significant proportion of individuals experiencing persistent fatigue and cognitive impairment beyond 12 weeks after diagnosis, emphasising the need to understand and treat these symptoms effectively.26
In Nepal, a study using the data from the COVID-19 social media survey showed a higher prevalence of psychological distress among the Nepalese population residing within and outside the country following COVID-19 outbreak.28 However, there is a dearth of research on the mental illness due to COVID-19 among COVID-19 positive patients. Moreover, the data on hospitalised COVID-19 patients and their follow-ups are scarce. The evidence on the long-term mental health implications among the post-discharged COVID-19 patients remains unknown in Nepal. Therefore, this present study has been carried out to assess the mental health status and the associated factors among patients who recovered from COVID-19 infection. This study will help determine the burden of the mental health problems and may be instrumental in designing effective interventions to address these issues. Moreover, this study will ultimately contribute to understanding the epidemiology of mental health and drawing the attention of the government, concerned stakeholders, policy makers and researchers in designing and implementing programmes and policies. This will prepare Nepal for potential pandemic and the various mental health outcomes associated with them in the future.