key: cord-0272805-qt1w64lc authors: Okogbenin, E. O.; Seb-Akahomen, O. J.; Edeawe, O. I.; Ehimigbai, M.; Eboreime, H.; Odike, A.; Obagaye, M. O.; Aweh, B. E.; Erohubie, P.; Eriyo, W.; Inogbo, C. F.; Akhideno, P.; Eifediyi, G.; Eifediyi, R.; Asogun, D.; Okogbenin, S. A. title: Psychiatric Manifestations and Associated Risk Factors among Hospitalized Patients with COVID-19 in Edo State, Nigeria. date: 2021-10-16 journal: nan DOI: 10.1101/2021.10.12.21264913 sha: f001b7164060f4fb959d4e4dba952d82510d2d3b doc_id: 272805 cord_uid: qt1w64lc Objective The Coronavirus Disease 2019 (COVID-19) has had devastating effects globally. These effects are likely to result in mental health problems at different levels. Although studies have reported the mental health burden of the pandemic on the general population and frontline health workers, the impact of the disease on the mental health of patients in COVID-19 treatment and isolation centres have been understudied in Africa. We estimated the prevalence of depression and anxiety and associated risk factors in hospitalized persons with COVID-19. Methods A cross-sectional survey was conducted among 489 patients with COVID-19 at the three government-designated treatment and isolation centres in Edo State, Nigeria. The 9-item Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) tool were used to assess depression and anxiety respectively. Binary logistic regression was applied to determine risk factors of depression and anxiety. Results Of the 489 participants, 49.1% and 38.0% had depressive and anxiety symptoms respectively. The prevalence of depression, anxiety, and combination of both were 16.2%, 12.9% and 9.0% respectively. Moderate-severe symptoms of COVID-19, [≥]14 days in isolation, worrying about the outcome of infection and stigma increased the risk of having depression and anxiety. Additionally, being separated/divorced increased the risk of having depression and having comorbidity increased the risk of having anxiety. Conclusion A substantial proportion of our participants experienced depression, anxiety and a combination of both especially in those who had the risk factors we identified. The findings underscore the need to address these risk factors early in the course of the disease and integrate mental health interventions into COVID-19 management guidelines. In recent times, the world has been challenged with a new coronavirus disease, which has demonstrated startling levels of spread, severity, and fatality all over the globe. [5-7] These mental health consequences are predictable in both the short and long term. [8] The SARS outbreak, for instance, was accompanied by significant mental health morbidity in both patients and healthcare providers. [9] . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021. 10.12.21264913 doi: medRxiv preprint Precisely, persons who test positive for COVID-19 or are suspected to have COVID-19 are especially vulnerable to psychological distress and mental illnesses. [8, 10] Such persons may experience fear of the possible outcomes considering the potentially fatal nature of the infection. Also, staying in an isolation ward may trigger a wide range of emotions, which may include feelings of frustration, despair, hopelessness, stigma/humiliation, fear, anger and so on. Furthermore, research has demonstrated that the presence of high concentrations of inflammatory mediators above the physiologically relevant range may trigger mental disorders. [11] The literature establishes a fundamental link between mental health and physical health. Poor physical health can lead to an increased risk of having mental health problems, conversely, poor mental health can negatively impact physical health, leading to an increased risk of some medical conditions. [12, 13] Consequently, the co-existence of psychological and other medical conditions can result in increased distress, longer illness duration, poorer health outcomes and an increased cost/burden on the already scarce health resources and health care system. [8, 12, 13] There is a dearth of literature on the mental health effects of COVID-19 among infected persons in Africa including Nigeria the most populous nation in Africa. [14] To the best of our knowledge, there is only one study in Nigeria that has reported the psychosocial health effects of COVID-19 infection on patients in treatment centres since the onset of the pandemic. [6] More studies are needed to understand the mental health sequelae of COVID-19 infection. Therefore, this study aimed to determine the prevalence of depression and anxiety, as well as associated risk factors in persons with COVID-19 hospitalized at the Edo state-designated treatment and isolation centres over 30 weeks. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021.10.12.21264913 doi: medRxiv preprint A descriptive cross-sectional study was conducted from 15 th April to 11 th November 2020. The participants were COVID-19 Real Time-Reverse Transcriptase -Polymerase Chain Reaction (rRT-PCR) positive persons who were hospitalized at the three governmentdesignated treatment and isolation centres in Edo State. These were the Irrua Specialist Teaching Hospital, Irrua, Stella Obasanjo Treatment and Isolation Centre and the University of Benin Teaching Hospital, Benin-City, Edo State, Nigeria. All three centres were government-funded. All eligible and consenting persons who were COVID-19 rRT-PCR positive and hospitalized at any of the study institutions within the period of the survey were recruited. The inclusion criteria comprised of persons with confirmed COVID-19, hospitalized at any of the study institutions who consented to participate in the study and were eleven years and above. Exclusion criteria comprised of hospitalized persons who tested positive for COVID-19 but declined or were unable to give consent to participate in the study and persons below 11 years due to the inappropriateness of the assessment tools for anxiety and depression in this age group. A total of 796 patients with COVID-19 were hospitalized at the three government designated treatment and isolation centres in Edo State over the study period. Nineteen of them were below 11 years and were excluded, and 265 patients did not give consent to participate in the study. A total of 512 were recruited for the study as shown in the flowchart in Figure 1 . Semi-structured and structured questionnaires incorporating sociodemographics, basic clinical history/information and an assessment of anxiety and depression . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021. 10.12.21264913 doi: medRxiv preprint were administered to recruited participants on the fifth day of admission into treatment and isolation centres. This was designed to provide information about the participant's age, gender, marital status, employment status and the highest level of formal education. Clinical variables such as COVID-19 rRT-PCR status, previous/family history of mental illness, the severity of COVID-19 infection, the number of days in isolation, comorbidity were ascertained as well. To ascertain the worry factor, the question "what is your greatest worry about being COVID-19 positive" was asked. This consists of nine items, each of which is scored 0 to 3, providing a 0 to 27 severity score. [15] PHQ-9 severity is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of: Not at all, several days, more than half the days, and nearly every day, respectively. It consists of the nine criteria for depression from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). The PHQ-9 is comparable or superior in operating characteristics, and valid as both a diagnostic and severity measure. [16] Scores of 5, 10, 15, and 20 represent cut-off points for mild, moderate, moderately severe, and severe depression respectively. A PHQ-9 score of 10 or greater is recommended if a single screening cut-off is to be used, this cut-off point has a sensitivity for major depression of 88% and a specificity of 88%. The modified version for adolescents PHQ-A was used for participants within the ages of 11 and 17 years. A cut-off score of ≥ 10 was used to represent cases of depression. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021. 10.12.21264913 doi: medRxiv preprint This is a 7-item self-report questionnaire that allows for the rapid detection of GAD. [21] Participants are asked if they were bothered by anxiety-related problems over the past two weeks by answering seven items on a 4-point scale. The total scores range from 0 to 21. At a cut-off score of 10, the GAD-7 had a sensitivity of 89 % and a specificity of 82 % for detecting GAD compared with a structured psychiatric interview. [17] Notably, among clinical and general population samples, the GAD-7 has demonstrated good reliability and cross-cultural validity as a measure of GAD (16) . Its use has been validated in adolescents. [18] A cut-off score of ≥ 10 was used to represent cases of anxiety. Ethical clearance was obtained from our institutional ethical committee. Informed written consent was obtained from each participant and from the parents or guardians of participants who were less than 18 years. Participants who were less than 18 years also assented to the study. Confidentiality and anonymity were ensured by not indicating the names of the participants on the questionnaires. The collected data were analysed using the Statistical Package for Social Sciences (SPSS) version 21. Dependent variables were depression and anxiety. Independent variables were sociodemographic and clinical characteristics. Descriptive statistics were used to summarise socio-demographic and clinical related data and mean with standard deviation for continuous variables. Chi-square (χ2) tests were used to test the association of independent variables with dependent variables. Fisher's exact test was used for cells with expected frequencies < 5. The student's t-test was used to compare means. Binary logistic regression was applied to identify predictors of depression and anxiety that were significant at bivariate analysis. All tests were 2-tailed, and the level of significance was set at a P-value of <0.05. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021.10.12.21264913 doi: medRxiv preprint A total of 512 patients participated in the study over the survey period. Twenty-three questionnaires were excluded from analysis due to inconsistencies and incomplete responses giving a total sample of 489 participants and a response rate of 95.5%. The mean age of participants was 43.39 (SD=16.94). Most of the participants were Christians (80.8%), married (59.3%) and slightly more than half had tertiary education (50.7%), and were employed (51.5% . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021. About half of the patients 240 (49.1%) had mild to severe depressive symptoms, 161 (32.9%) had mild symptoms, 62 (12.7) had moderate symptoms, 12 (2.5%) had moderately severe and 5 (1.0%) had severe symptoms of depression. More than a third of the patients 186 (38.0%) had mild to severe anxiety symptoms, 124 (25.4%) had mild symptoms, 47 (9.6) had moderate symptoms, and 15 (3.1%) had severe symptoms of anxiety. Seventy-nine (16.2%) patients were classified as cases of depression while 63 (12.9%) patients were classified as cases of anxiety and 44 (9.0%) as cases of anxiety comorbid with depression. Prevalence of depression and anxiety are reported in Table 2 . . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021. Worry factors are reported in Figure 2 . Using bivariate analysis, being separated/widowed (χ2 = 10.943, P =0.012), having moderate to severe COVID-19 symptoms (χ2 = 5.302, P = 0.021), staying in isolation for 14 days or more (χ2 = 11.368, P = 0.001) and having outcome of illness as worry factor (18.056, P = 0.002) were found to be significantly associated with cases of depression. Having moderate to severe COVID-19 symptoms (χ2 = 5.302, P = 0.021), staying in isolation for 14 days or more (χ2 = 11.368, P = 0.001), having outcome of illness as worry factor (18.056, P = 0.002) and having a comorbidity were found to be significantly associated with cases of anxiety. Analysis of factors associated with depression and anxiety are shown in Table 3 . We conducted a binary logistic regression analysis to measure the correlations between dependent and independent variables that were significant at bivariate analysis. The unadjusted odds ratios are displayed in Table 4 . Analysis for adjusted odds ratios was conducted to control for confounders. The model We present the estimates of depression and anxiety and associated risk factors from a crosssectional cohort of hospitalised patients with confirmed COVID-19 in the three treatment and . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. [5] Although in this study, apparent lower prevalence rates were recorded for patients classified as cases of depression (16.2%), anxiety (12.7%) and a combination of both (9.0%) when compared to the proportion having symptoms, these rates are higher than the prevalence rates of depression (5.5%), anxiety (3.5%) and anxiety . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021.10.12.21264913 doi: medRxiv preprint health services as a useful alternative to face-to-face intervention, a model they reported helped ameliorate the mental health effects of COVID-19 infection in patients at the Irrua Specialist Teaching Hospital's treatment and isolation centre in Nigeria. [26] It is becoming apparent that deliberate efforts are needed to address the mental health and psychosocial effects of COVID-19 in persons with the disease. Being separated/divorced was a strong predictor of depression compared to being married in our study. This is in tandem with previous studies that reported a significant association between being separated/divorced and experiencing depression. [29] In the analysis of the severity of COVID-19, we found that having moderate to severe symptoms significantly increased the risk of having depression and anxiety. This may occur for two reasons. Firstly, they may have a more intense immuneinflammatory dysregulation. [30] and secondly, the awareness of the relationship between the severity of COVID-19 and its outcomes in these patients may precipitate depression and anxiety. This may also explain why patients with comorbidity had an increased risk for anxiety. Staying 14 days or longer in isolation was significantly associated with increased risk of depression and anxiety. This compares with other studies that have linked social isolation during the pandemics with depression, anxiety, and other mental health disorders. [29, 30] Loss of functionality and social interaction, limited physical activities, suffering without the support of loved ones, and watching others suffer or even die are possible contributory . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. As far as we know, this is the second study exploring psychiatric manifestations in hospitalized patients with COVID-19 in Nigeria, the most populous country in Africa. The study identified important risk factors. Also, we conducted a multi-centre study that collected samples over 30 weeks in the ongoing pandemic, this increased our sample size compared to the previous study, giving more room for generalization of findings. Our study had some limitations. Firstly, it had a cross-sectional design and so could not permit causal inferences. Secondly, we did not have a control group, this minimised our ability to estimate the true impact of COVID-19 on the mental health of our participants and thirdly, a structured diagnostic interview was not used to confirm our cases of depression and anxiety. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021. 10.12.21264913 doi: medRxiv preprint In conclusion, we report that a considerable proportion of hospitalized patients with COVID- Data are available from the corresponding author on reasonable request. Not required The study was approved by the Irrua Specialist Teaching Hospital Research Ethics Committee -Protocol No: ISTH/HREC/20202004/065. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021. ; https://doi.org/10.1101/2021.10.12.21264913 doi: medRxiv preprint . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021 is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted October 16, 2021 . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 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