key: cord-0731193-mya4ftpa
authors: Gonzalez-Diaz, Sandra Nora; Martin, Bryan; Villarreal-Gonzalez, Rosalaura Virginia; Lira-Quezada, Cindy Elizabeth de; Macouzet-Sanchez, Carlos; Macias-Weinmann, Alejandra; Guzman Avilan, Rosa Ivett; Garcia-Campa, Mariano; Noyola-Perez, Andres; Garcia-Gonzalez, David Uriel
title: Psychological Impact of the COVID-19 Pandemic in Patients with Allergic Diseases
date: 2021-01-22
journal: World Allergy Organ J
DOI: 10.1016/j.waojou.2021.100510
sha: 83325c823173a87a468413c35a417d4c5f82d567
doc_id: 731193
cord_uid: mya4ftpa

Background On March 2020, WHO declared COVID-19 as a pandemic disease. Interactions between allergy-related inflammatory and psychiatric disorders including depression, anxiety and posttraumatic stress disorder (PTSD) have been documented. Therefore, those who have pre-existing allergic conditions may have an increased psychiatric reaction to the stresses of the COVID-19 pandemic. Objective Identify the psychological impact of COVID-19 in patients with allergic diseases and determine if these individuals have a greater risk of presenting with post-traumatic stress disorder (PTSD). Methods It is a cross-sectional, survey-based study designed to assess the degree of symptoms of depression and the risk of PTSD using the Patient Health Questionnaire (PHQ-9) and the Impact of Event Scale–Revised (IES-R), respectively in allergic patients. Results A total of 4,106 surveys were evaluated; 1,656 (40.3%) were patients with allergic disease, and 2,450 (59.7%) were non-allergic (control) individuals. Of those with allergies, 76.6% had respiratory allergic disease including asthma and allergic rhinitis. Individuals with allergic disease reported higher scores regarding symptoms of PTSD on the IES-R scale (p = 0.052, OR 1.24 CI .99 - 1.55) as well as a higher depression risk score in the PHQ-9 questionnaire (mean 6.82 vs. 5.28) p = 0.000 z = -8.76. The allergy group presented a higher score in the IES-R questionnaire (mean 25.42 vs. 20.59), being more susceptible to presenting PTSD (p = 0.000, z = -7.774). The individuals with allergic conditions were further divided into subgroups of those with respiratory allergies such as allergic rhinitis and asthma vs those with non-respiratory allergies such as drug and food allergy, urticaria and atopic dermatitis. This subgroup analysis compares respiratory versus non-respiratory allergic patients, with similar results on the IES-R (mean 25.87 vs 23.9) p = 0.0124, z = -1.539. There was no significant difference on intrusion (p=0.061, z=-1.873) and avoidance (p=0.767, z=-0.297), but in the hyperarousal subscale, patients with respiratory allergy had higher scores (mean 1.15 vs. 0.99) p = 0.013 z = -2.486. Conclusions Psychological consequences such as depression and reported PTSD are present during the COVID-19 pandemic causing an impact particularly in individuals with allergic diseases. If we acknowledge the impact and how it is affecting our patients, we are able to implement interventions, follow up and contribute to the overall well-being.

1

Background: On March 2020, WHO declared COVID-19 as a pandemic disease. 2

Interactions between allergy-related inflammatory and psychiatric disorders including 3 depression, anxiety and posttraumatic stress disorder (PTSD) have been documented. 4

Therefore, those who have pre-existing allergic conditions may have an increased 5 psychiatric reaction to the stresses of the COVID-19 pandemic. 6

Objective: Identify the psychological impact of COVID-19 in patients with allergic 7 diseases and determine if these individuals have a greater risk of presenting with post-8 traumatic stress disorder (PTSD). 9

Methods: It is a cross-sectional, survey-based study designed to assess the degree of 10 symptoms of depression and the risk of PTSD using the Patient Health Questionnaire 11 (PHQ-9) and the Impact of Event Scale-Revised (IES-R), respectively in allergic patients. 12

Results: A total of 4,106 surveys were evaluated; 1,656 (40.3%) were patients with allergic 13 disease, and 2,450 (59.7%) were non-allergic (control) individuals. Of those with allergies, 14 76.6% had respiratory allergic disease including asthma and allergic rhinitis. Individuals 15 with allergic disease reported higher scores regarding symptoms of PTSD on the IES-R 16 scale (p = 0.052, OR 1.24 CI .99 -1.55) as well as a higher depression risk score in the 17 PHQ-9 questionnaire (mean 6.82 vs. 5.28) p = 0.000 z = -8.76. 18

The allergy group presented a higher score in the IES-R questionnaire (mean 25.42 vs. 19 20 .59), being more susceptible to presenting PTSD (p = 0.000, z = -7.774). 20

The individuals with allergic conditions were further divided into subgroups of those with 21 respiratory allergies such as allergic rhinitis and asthma vs those with non-respiratory 22 allergies such as drug and food allergy, urticaria and atopic dermatitis. This subgroup 23 analysis compares respiratory versus non-respiratory allergic patients, with similar results 24 on the IES-R (mean 25.87 vs 23.9) p = 0.0124, z = -1.539. There was no significant 25 difference on intrusion (p=0.061, z=-1.873) and avoidance (p=0.767, z=-0. 297 allergic diseases it is recommended to monitor their allergy and asthma symptoms, as there 61 may be overlapping symptoms and these overlapping symptoms may lead to a misdiagnosis 62 of COVID-19. The relationship between viral infections, immune response and allergic 63 diseases has been widely discussed and it has been established that allergy can increase the 64 risk of exacerbation of virus-induced symptoms [4, 5] . Respiratory allergies such as asthma 65 and allergic rhinitis have not been shown to be risk factors for severe SARS-CoV-2 66 infection [6] ; however, the data is not yet conclusive and allergic patients may experience a 67 misperception of their allergic disease against COVID-19 leading to additional 68 psychological changes [7] . 69

Asthma and other chronic respiratory diseases appear to be underrepresented in the 70 comorbidities reported for patients with COVID-19, observing a similar pattern as that 71 reported in patients with SARS (2.4%), with this in mind, changes in the treatment of 72 chronic respiratory diseases should not be considered, including chronic obstructive 73 pulmonary disease (COPD) and asthma [8] . With a great part of the world in quarantine, 74 levels of anxiety have begun to surge, leading patients to identify, and in some cases seek 75 medical attention for symptoms that might otherwise have not caused concern [9] . 76

Other psychological reactions that appear in pandemics include emotional distress, 77 maladaptive behaviors, and defensive responses. People who have greater susceptibility to 78 psychological problems are particularly vulnerable [10] . 79

Interactions between allergy-related inflammatory and psychiatric disorders, such as 80 depression [11] , anxiety, bipolar disorder, and schizophrenia have been previously 81 documented [12] . More specifically, asthma, rhinitis or atopic dermatitis and the 82 combination of all these three allergic diseases, have been associated with a higher risk of 83 psychiatric disorders [13] . A higher incidence of allergic diseases has been seen in patients 84 with post-traumatic stress disorder (PTSD), and it has been suggested that immune 85 activation is contributor to clinical status [14] . The prevalence of PTSD among direct 86 victims of disasters such as natural, technological or human-made (terrorism) ranges 87 between 30 % and 40 %, while the range of PTSD rates in the general population is the 88 lowest and expected to be between 5 % and 10 % [15] . Immunologic morbidity has been 89 J o u r n a l P r e -p r o o f reported in patients with history of PTSD including lower number of lymphocytes, T cells, 90 NK cell activity, and total amounts of IFN-g and IL-4 [16] . Other immune alterations such 91 as increased levels of inflammatory cytokines including IL-1, IL-6, and TNF-α have also 92 been studied [14] . This time of pandemic crisis is generating stress throughout the 93 population therefore the aim of this study was to identify the psychological impact of 94 COVID-19 in patients with allergic diseases and determine if these individuals have a 95 greater risk of presenting with PTSD. 96

Surveys were sent out by allergists, to adults over 18 years old, via a Google Forms link 98 and shared through different social media platforms as well as by telephone in the case of 99 patients who attended the allergy and immunology clinic. There were no other limitations 100 regarding the population surveyed. Digital informed consent was provided by all survey 101 participants prior to their enrollment. A copy of the survey will be available as an online 102 supplement. Participants were allowed to deny the survey if they did not accept digital 103 informed consent. The survey was anonymous, and confidentiality of the information was 104 assured. 105

The study is a cross-sectional, survey-based, stratified study with demographic data and 106 mental health measurements from 4,106 participants collected from April 1st to 15th, 2020 107 a period in which our country, Mexico, was entering the uncertainty of phase 3 of the 108 pandemic response due to COVID-19 and most of America was under quarantine. 109

The survey contained two questionnaires that assessed the degree of symptoms of item IES-S test has a range of 0 to 88 and tests the severity of symptoms of distress. Scores 119 are interpreted as follows: significant clinical concern (24-32), probable diagnosis of 120 PTSD, and reflecting long-term suppression of immune system functioning (39 and above). 121 [16, 19] 122

With the introduction of the DSM-IV, the IES was updated to include three subscales: 123 intrusion, avoidance and hyperarousal [19] . These categories were based on values 124 established in the literature. The cutoff score for detecting symptoms of major depression 125 and distress were 10 and 24, respectively. In the DSM-5, PTSD is included in a new 126 category, Trauma-and Stressor-Related Disorders. The scales were used based on the 127 DSM-IV. Participants who had scores greater than the cutoff threshold were characterized 128 as having severe symptoms [17] [18] [19] Of these patients, 64% (1,055 individuals) presented one allergic condition (AC) and 23% 160 (386 individuals) had two reported allergic conditions (Figure 1) . 161

In total, 1,656 patients declared to suffer from 2,535 allergic diseases, of which 57. This group also had a higher depression risk score in the PHQ-9 questionnaire (mean 6.82 170 vs. 5.28) p = 0.000 z = -8.76. Even so, both groups presented data suggesting mild 171 depression symptoms (Table 2) . 172

The group with respiratory allergy also had higher IES-R scores (mean 25 In addition, in the respiratory allergy group a higher score on the PHQ-9 depression scale 177 (mean 7.14 vs. 5.35) p = 0.000, z = -9.43 was evidenced (Table 3) . Regardless of exposure, people may present with fear and anxiety of becoming ill or dying, 228 triggering a mental breakdown [20] . Psychiatric morbidities have been found including 229 depression, anxiety and posttraumatic stress disorder symptoms [21, 22] . 230

Our study revealed that during this period of quarantine due to COVID-19, the 231 psychological impact in patients with allergic diseases was greater compared to individuals 232 without allergy. Allergic patients had a higher risk of depression symptoms measured with 233 the PHQ-9 scale and of reported PTSD evaluated with the IES-R scale which is measured 234 within 2 weeks of exposure to event, impacting specifically in the intrusion, avoidance and 235 hyperarousal section. Individuals with respiratory allergy such as asthma and rhinitis were 236 particularly vulnerable to a higher PHQ-9 and PTSD scale. Previous studies have 237 demonstrated an association between PTSD and an increased incidence of allergic and 238 autoimmune diseases [23] . Huang et al. showed a significant link between PTSD and 239 asthma [24] , where underlying alterations in psychophysiological, neuroendocrine and 240 neurobiological systems have been implicated [25] . Glenk associated with any psychiatric disorder [28] . 252 Similar to our results, depression as well as anxiety and reported PTSD have been found to 253 affect women more than men, peaking at the age of 20-40 years, possibly due to underlying 254 biological predispositions such as hormonal fluctuation related to the menstrual cycle [27] . 255

Also, depression was more prevalent in unmarried or widowed individuals as previously 256

reported [29] . 257 In our results, the level of patient´s allergic disease control did not influence the risk of 258 developing depression or affect the scores in the PHQ-9 questionnaire. Depression may 259 modify the degree of severity with which symptoms are perceived by patients and in 260 consequence modify the level of asthma control, while poorly controlled asthma could lead 261 to depression [30, 31] . According to Ferro et al, adolescents with asthma are associated with 262 an increased risk of clinically relevant symptoms of depression, on the other hand food 263 allergy is associated with an increased risk of clinically relevant symptoms of anxiety [32] . 264

Atopic dermatitis is associated with high levels of social withdrawal, stigmatization, 265 anxiety and depression among patients and their caregivers. Stress caused by atopic 266 dermatitis can make the symptoms of the disease worse. [33] Individuals with chronic 267 urticaria may develop PTSD symptoms which influence their psychological well-being 268 through using different levels of emotional suppression, especially suppressing depression. 269

The levels depend on the severity of PTSD symptoms and whether they experienced 270 interpersonal traumas [34] . allergic diseases showed mild symptoms [35] . Cultural differences, state of the pandemic as 280 well as public perception of the virus may be some of the causes for the differences. Based 281 on their results, they recommended prompt intervention measures that should be taken to 282 alleviate the psychological issues faced [35] . Vanaken et al., published after the execution 283 of this study, the use of IES-COVID19 which proved to be a reliable and valid measure that 284 can be used to investigate stress symptoms related to trauma regarding intrusion and 285 avoidance due to shorty and long term impact of the COVID-19 pandemic. The IES-286 COVID19 may be a resourceful instrument in assessing individual changes in traumatic 287 stress symptoms over time [36] . 288 J o u r n a l P r e -p r o o f

To the best of our knowledge this is one of the first studies that evaluates the psychologic 289 effect of COVID-19 in allergic patients. However a limitation to this study is that there are 290 no pre-measurements, therefore it may not be well defined if the reactivity to the 291 environmental stressor is causal. As specialists in the allergy field, it is imperative that we 292 recognize the psychological burden that the pandemic has on our patients which may be a 293 limiting factor in overcoming the crisis. We conclude that psychological consequences such 294 as depression, anxiety and PTSD are present during the COVID-19 pandemic causing an 295 impact in individuals with allergic diseases that may persist even after the pandemic has 296 ended. If we acknowledge this impact and how it affects people during the pandemic, we 297 are better able to implement interventions, follow up and contribute to the entire well-being 298 of our patients. Due to a worldwide increase in allergic diseases, the mechanisms involved 299 in stress experiences as well as best practice management strategies should be studied in- J o u r n a l P r e -p r o o f 

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