Original Research

Prevalence and factors associated with depression and anxiety among patients recovered from COVID-19: a cross-sectional study in a tertiary care hospital in Nepal

Abstract

Introduction COVID-19 has immensely affected the mental health of all people with prominent effects among the COVID-19 survivors who underwent hospitalisation. The evidence of the long-term mental health implications among the recovered COVID-19 patients remains unknown in Nepal. The study aimed to determine the prevalence of depression and anxiety and the associated factors among COVID-19 recovered patients.

Methods An analytical cross-sectional study was conducted from May to August 2021 among 269 COVID-19 recovered patients admitted to Dhulikhel Hospital during the first wave (July 2020 to January 2021), and second wave (April 2021 to July 2021) of the COVID-19 pandemic. Anxiety and depression of the participants were assessed using the Hospital Anxiety and Depression Scale. Multivariate logistic regression analysis was performed to determine the factors associated with anxiety and depression.

Results The prevalence of anxiety and depression were 38.66% (95% CI 32.99 to 44.65), and 30.48% (95% CI 25.24 to 36.28), respectively. Participants who received COVID-19 related information from the radio reported higher levels of anxiety and depression symptoms. Similarly, stigma, and being a health worker were significantly associated with a higher level of anxiety and depression symptoms, respectively. However, social support and long recovery duration were protective factors against anxiety and depression symptoms. Participants receiving a higher level of social support and having a recovery duration of 3–6 months, 7 months and more reported lower odds of anxiety and depression symptoms, respectively.

Conclusions The greater prevalence of anxiety and depression symptoms among recovered COVID-19 patients highlights the need to design and implement appropriate mental health interventions. This could be done through psychosocial support and counselling services in health facilities, mental health service in emergency situation and post-discharge rehabilitation programmes.

What is already known on this topic

  • Prior research has shown that anxiety and depression were prevalent among individuals who had recovered from COVID-19 and were discharged from the hospital.

What this study adds

  • This study is novel in its focus on assessing the mental health status and associated factors among a sample of COVID-recovered adults who were hospitalised with COVID-19 during the early waves of the pandemic in Nepal, providing valuable insights into a previously understudied population. The comprehensive assessment of a range of sociodemographic and health-related variables has added depth to the understanding of factors influencing mental health outcomes in this population.

How this study might affect research, practice or policy

  • The study can have practical implications for policy makers in the development of policies, as well as tailored interventions and support systems to meet the needs of the groups. The findings have significant implications and inform healthcare policymakers, emphasising the need to prioritise mental health support and develop targeted interventions. Further, the findings prompt further research into the long-term mental health effects of COVID-19. Longitudinal studies could be conducted to see the changes in mental health outcomes over time.

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.

Methods

Study design and setting

An analytical cross-sectional study was conducted from May to August 2021 among the COVID-19 recovered patients of Dhulikhel Hospital, Nepal. Dhulikhel Hospital affiliated with Kathmandu University is a government-designated COVID-19 testing and treatment centre. The hospital has a catchment area that includes approximately 2.1 million people from Kavrepalanchowk and its neighbouring districts that is, Sindhupalchowk, Dolakha, Sindhuli, Ramechhap, Bhaktapur and other surrounding districts.29

Participants

The study population was COVID-19 recovered patients, who were admitted to Dhulikhel Hospital during the first wave of COVID-19 pandemic (July 2020 to January 2021), and second wave (April 2021 to July 2021) and were later discharged from the hospital. The study included Nepalese citizens aged between 18 and 65 years, who were hospitalised with the diagnosis of COVID-19. Participants who could easily understand the Nepali language and provided informed voluntary consent were included in the study. We excluded critically ill patients, those with a prior history of mental illnesses, and individuals with hearing impairment.

Participants recruitment procedure

The hospital provided a database that contained the sample frame for COVID-19 patients. The list included the data of 769 COVID-19 patients with their names and contact numbers who were admitted to the hospital during the first and second waves of COVID-19. Out of the total 769 COVID-19 patients, 649 patients were approached for interviews because 120 of them could not be reached due to the wrong and/or incomplete phone number. A total of 394 COVID-19 patients met the study’s eligibility criteria and were included in the interviews.

We recruited a total of 269 participants in the study. The refusal rate for the interviews was 23.3%. These 269 participants were the recovered patients getting service in the Dhulikhel Hospital during the first and second wave of COVID-19 pandemic. The common reasons for refusal were being uncomfortable in sharing the information, and being contacted frequently by other similar research studies. Figure 1 presents the number of participants approached for interviews and the selection of participants in the study.

Figure 1
Figure 1

Flow diagram of participant enrolment in the study.

The data were collected from 25 May to 10 August 2021 in an electronic database using KoBo Toolbox by the trained enumerators having previous intensive experience in data collection and the software. We contacted the participants by telephone to participate in the study and provided them with more detailed information about the study. A structured questionnaire was used to interview the participants at their convenience (online supplemental file 1).

Outcome variable

Anxiety and depression of the participants were assessed using the validated 14-item Nepali version of ‘Hospital Anxiety and Depression Scale (HADS)’ with satisfactory psychometric properties.30 The study demonstrated a Cronbach’s alpha of 0.76 for anxiety and 0.70 for depression, respectively.

It consists of 14 items in two subscales: HADS-anxiety and HADS-depression, each of seven items for the measurement of anxiety and depression where participants reported their subjective experience during the past week, which was rated as 0–3 (3 indicating maximum symptom severity) with total score ranging from 0 to 21. The total scores of these tools were interpreted as normal (0–7), borderline abnormal (8–10) and abnormal (11–21). For analysis, we considered the score of more than 7 as the presence of anxiety and depression symptoms.

Independent variables

The sociodemographic variables consisted of sex (male/female), age (18–25/26–35/36–45/46–55/56–65 years), marital status (unmarried/married including widowed and divorced), religion (hindu/buddhism/others), education (no formal education/primary/secondary/higher), occupation (employed: non-health workers/unemployed/employed: health workers), residence (rural/urban) and family type (nuclear/joint along extended).

COVID-19 related and health related variables consisted of experience of initial symptoms of COVID-19 (no/yes), presence of medical conditions (no/yes), treatment setting (no ICU admission/ICU admission), length of hospitalisation (days) recovery duration (< 3/3–6/≥7 months), source of information for COVID-19 related news/information (radio, TV, print newspaper/magazine, social media, online newspaper, others), previous contact with COVID-19 positive (no/yes), experience of COVID-19 related health complications (no/yes), experience of COVID-19 related economic difficulties (no/yes), COVID-19 related death in family (no/yes), stigma and social support. The stigma scale, comprising 15 items that measured the overall level of stigma, was adapted from the previous studies.31 The responses were rated on a 4-point Likert scale from 0: strongly disagree to 3: strongly agree. All the scores were summed with total score ranging from 0 to 45. The higher score indicated a greater experience of stigma. The Cronbach’s alpha for the scale was 0.71.

The social support was measured using the validated Nepali version of Multidimensional Scale of Perceived Social Support. It is 12 items measuring a subjective assessment of social support received from three sources: family, friends and significant others.32 Each item can be scored using a 7-point Likert scale from 1=very strongly disagree to 7=very strongly agree with total score ranging from 12 to 84. The higher scores indicated a higher level of social support the participant feels. The study demonstrated a Cronbach’s alpha of 0.96.

Data analysis

The statistical analysis was done in STATA V.13 (StataCorp). Descriptive statistics were done by calculating frequencies and percentages and mean and SD for continuous variables. The χ2 test was used to determine the association between categorical variables. To determine the potential factors associated with the outcome variable, a multivariable analysis using logistic regression was performed with adjusted OR (AOR) and 95% CI. For adjusted regression analysis, those variables associated with the outcome variable with a p value <0.1 in bivariate analysis were included in the multivariate logistic regression analysis.33

Results

Prevalence of anxiety and depression symptoms among the study participants

Out of 269 participants, 38.66% had symptoms of anxiety that is, borderline: 27.88% and abnormal: 10.78%. Similarly, 30.48% of the participants had depression symptoms, that is, borderline: 21.93% and abnormal: 8.55%. The prevalence of depression was lower than anxiety (table 1).

Table 1
|
Prevalence of anxiety and depression among the study participants (n=269)

Sociodemographic characteristics of the study participants

Table 2 shows the study participants’ sociodemographic characteristics and their association with anxiety and depression symptoms. Of the 269 study participants, 51.30% were male, and 30.48% belonged to the age group 26–35 years with age ranging from 18 to 65 years. The majority of the participants were married (83.27%) and had joint family (52.79%). About 44.98% of the participants had a higher level of education, and 56.88% of them were employed.

Table 2
|
Sociodemographic characteristics of the study participants (n=269)

Descriptive analyses showed significant associations between depression symptoms and age (χ2 test, p=0.015), marital status (χ2 test, p=0.042), education (χ2 test, p<0.001), occupation (χ2 test, p=0.007) and residence (χ2 test, p=0.032). These findings indicated that these factors significantly contribute to developing depression symptoms (all p<0.05) (table 2).

COVID-19 related and health related characteristics of the study participants

Table 3 shows the association between COVID-19 related as well as health related characteristics of the study participants with anxiety and depression symptoms. Stigma was associated with the presence of both anxiety and depression symptoms (p<0.05).

Table 3
|
COVID-19 related and health related characteristics of the study participants (n=269)

Experiencing initial symptoms of COVID-19, presence of medical conditions, recovery duration, receiving COVID-19 related information from the radio, TV, online newspapers and having previous contact with COVID-19 positive were significantly associated with depression symptoms (p<0.05). Recent recovery was associated with greater risk of developing depression symptoms.

Factors associated with anxiety and depression symptoms among the study participants (n=269)

Receiving COVID-19 related information from the radio was significantly associated with higher odds of experiencing the symptoms of both anxiety (1.88; 95% CI 1.08 to 3.27) and depression (AOR: 2.88; 95% CI 1.37 to 6.08) after controlling the confounders. Similarly, stigma was significantly associated with higher odds of anxiety symptoms (1.07; 95% CI 1.01 to 1.14). On the other hand, receiving higher level of social support (0.97; 95% CI 0.95 to 0.99) was associated with a reduced risk of anxiety symptoms as compared with those with lower level of support.

The risk of having depression symptoms was greater for health workers (4.79; 95% CI 1.41 to 16.22) compared with other occupations. However, participants with a recovery duration of 3–6 months (0.13; 95% CI 0.02 to 0.66) and 7 months or more (0.32; 95% CI 0.15 to 0.68) had lower risk of having depression symptoms compared with those with less than 3 months of recovery duration (table 4).

Table 4
|
Factors associated with anxiety and depression among the study participants

Discussion

This study assessed the prevalence and the factors associated with anxiety and depression symptoms among COVID-19 recovered patients in Nepal. The prevalence of anxiety (38.66%) and depression symptoms (30.48%) among COVID-19 recovered patients in Nepal were relatively consistent, compared with the general population; 34% and 31% of anxiety and depression, respectively34 but lower than home isolated COVID-19 patients; 74.2% and 79% of anxiety and depression, respectively.35 The difference may be due to the fear of COVID-19 related complications, lack of healthcare support and loneliness. The prevalence rate in this study is similar to the study conducted among COVID-19 recovered patients at 1-month follow-up after hospital treatment in Italy, which showed the prevalence of anxiety and depression to be 42% and 31%, respectively.13 Compared with other studies conducted among COVID-19 hospitalised patients in different countries, the prevalence of anxiety and depression in this study was higher than the study conducted in China (22.2% with anxiety and 38.1% with depression),15 Italy (28% and 16% of anxiety and depression, respectively)11 and Thailand (19.1% and 11.1% of anxiety and depression, respectively).36 The difference in the prevalence may be due to differences in health system responses, differences in the study sample size, use of different measurement tools for anxiety and depression and different follow-up times. Nepal has a fragile health system and poor COVID-19 response. ICU and wards were overcrowded. The greater prevalence of anxiety and depression in Nepalese population could be due to increased stress and worries about seeking quality healthcare and recovery. Additionally, the economic shutdown in Nepal was quite severe and it could have led to an increase in anxiety and depression. The study findings suggest that the mental health should be considered in COVID-19 response plan.

Our study findings indicated that being a health worker had higher odds of having depression symptoms compared with other occupations. These findings are relatively consistent with the result of previous studies conducted in Nepal,37 38 Iran,39 Trinidad and Tobago40 which have found a high prevalence of depression among the health workers. Direct dealing with COVID-19 cases with greater risk of contracting the disease, overburdening workload, stigma and discrimination faced by health workers from the general community, lack of personal protective equipment, frequent accusation and physical assault against health workers which could contribute to poor mental health outcomes among them.

Another important finding from this study was lower level of depression among the recovered COVID-19 patients with a recovery duration of 3 months and more. Contrary to our finding, a study conducted in Morocco41 found that the COVID-19 survivors reported having higher levels of depression at 3 months after hospital discharge. A study from Bangladesh42 also reported a different level of severity of depression in COVID-19 patients 3 months after recovery. The lower prevalence of depression in our study could be because the majority of the participants did not require ICU admission, did not experience COVID-19 related health complications and had shorter hospital stays. It is possible that they developed effective coping strategies for their mental health. Furthermore, the quality of care received at home, along with the love, care and support from their loved ones might have played a role in lower rate of depression.

Similarly, stigma has been found as a significant factor for increased levels of anxiety among the participants. This finding was consistent with the previous studies conducted in India,31 China43 and Saudi Arabia44 which have found that stigma score was significantly associated with higher levels of anxiety. The participants who perceived a higher level of stigma had more symptoms of anxiety. Isolation and increased discriminatory behaviour could have contributed to an increase in the prevalence of anxiety. Thus public awareness and psychosocial support programmes should be implemented to promote the mental health and well-being of patients during such pandemics.

Our study identified that a higher level of social support was associated with lower level of anxiety. This finding was in line with the result of previous study conducted in Turkey45 where perceived social support from friends and family played a protective role against anxiety. Similar studies conducted in Israel,46and Turkey47 also demonstrated that those who perceived social support exhibited lesser symptoms of anxiety. It provides some protection against the adverse effects of anxiety. Social isolation often leads to social disconnection making people lonely during difficult times. Social support from friends is one of the greatest social resources in coping with such stressful situations. It helps to minimise loneliness and reduce the prevalence of anxiety.

Our study found an association between sources of information, such as radio, and a higher level of anxiety and depression among the participants. First, frequent news updates on the radio may focus on topics like increasing COVID-19 cases, economic decline, and thereby increasing fear among them. Second, the constant stream of negative news content can have a negative influence on their mental health. Finally, prolonged exposure to news consumption, coupled with misinformation related to COVID-19, may have contributed to a higher prevalence of anxiety and depression. Besides these, radio remains one of the fastest and cheapest means of communication, often perceived as a reliable source of news and information.

The COVID-19 pandemic has provided an opportunity to enhance access to psychological interventions such as cognitive behavioural therapy (CBT).48 Internet-based cognitive behavioural therapy (I-CBT) emerges as a potential solution in this regard.49 It has been shown to effectively treat mild to moderate depression symptoms.50 Individuals whose mental health has been impacted by the COVID-19 pandemic have shown improvement in clinical symptoms of anxiety and depression.51 Besides, it has been found an effective therapeutic option in treating insomnia.52 Given that CBT is one of the most evidence-based treatments for mental health problems, there is an urgent need to optimise its potential, particularly in times of a COVID-19 pandemic. By integrating I-CBT into COVID-19 response approaches, we can address the psychological impact of the pandemic and provide comprehensive support for those dealing with mental health issues.

Strengths and limitations

To our knowledge, this is the first study to determine the mental health status and associated risk factors among the COVID-19 recovered patients who had been discharged after hospitalisation in Nepal. This study provides important insights into mental health research and important public health issues. Second, the study used the standard tools which have been validated in Nepal allowing the comparability of the findings with other studies. Third, the study provides a scope of collaboration among experts from several disciplines, including clinical medicine, psychology and epidemiology resulting in a more comprehensive and insightful study.

This study has few limitations. First, depression and anxiety were assessed using HADS. Primarily used as a screening instrument, HADS might not be sufficient for making specific diagnoses of anxiety and depressive disorders. Second, the study was a cross-sectional study design which limited the causal inference. Further in-depth study, that is, longitudinal studies, in this area would be required so that causal inferences could be generated regarding COVID-19 and depression and anxiety outcomes. Third, the data on previous mental illness was not assessed so it remains unclear whether these symptoms are associated with the COVID-19 pandemic or pre-existed. Fourth, since the study was conducted in a single hospital, it limits the generalisability of the findings. Finally, there could be recall bias among the participants with a long recovery duration.

Conclusion

In conclusion, the present study helped in understanding the mental health status of recovered individuals who had been hospitalised for COVID-19. The study found a significant proportion of anxiety and depression among the participants which requires prompt action. The findings of the study highlight the need to conduct further research to explore the perspective of the participants with regard to their lived experience with COVID-19 and to develop the mental health interventions accordingly. Our study also contributes to understanding the long-term mental health outcomes and prioritising mental health preparedness for future pandemics. It also recommends policy makers prepare plans and programmes to integrate mental health and psychosocial support services within the primary healthcare level and hospitals for timely screening, detection and management of the mental health conditions Furthermore, it emphasises the importance of developing and implementing post-discharge rehabilitation programmes to meet the needs of this vulnerable population. If not addressed, it can be expected to contribute to an epidemic of mental illness in the future.