Abstracts

Assessment Of Change in Severity of Stress, Anxiety and

Depression in Covid-19 Patients During Hospital Stay –
A Cross-sectional Study
Riya Gupta, Anuradha V. Patil1, Manik C. Bhise,
Deepanjali Deshmukh, Arun V. Marwale, Siddhant Mathur
Departments of Psychiatry, 1Pathology, MGM Medical College and Hospital,
Aurangabad, Maharashtra, India

Corresponding Author: Dr. Deepanjali Deshmukh,

Assistant Prof., Department of Psychiatry, Mahatma Gandhi Mission Medical
College and Hospital, Aurangabad, Maharashtra, India.
E-mail: Deepanjali.deshmukh@hotmail.com

Background – COVID 19 illness is associated with psychological

impairments. Whether this impairment is due to illness itself or inpatient
stay also contributes to it needs to be ascertained. Present study was
done to assess the change in severity of stress, depression and anxiety in

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COVID-19 patients on the day of hospital admission and on the day of
discharge and its association with clinical variables.
Methods – A cross sectional study design with sample of 104 patients
admitted in the COVID wards. Socio-demographic and COVID related
clinical variables and laboratory parameters were recorded. The severity
of stress (PSS scale), anxiety (HAM-A scale) and depression (HAM-D
scale) was assessed on the day of hospital admission & on the day of
discharge. Association between change in severity of these and other
variables was assessed.
Results - Significant increase in severity of stress, anxiety and
depression was found during indoor stay of Covid-19 patients. Severity
increased despite improvement in physical status of subjects. There
was no significant association of increased severity of stress, anxiety,
depression with demographic variables and laboratory parameters.
Conclusion – There was a significant increase in level of stress, anxiety
and depression during the inpatient stay despite improvement in clinical
symptoms, with minimal association with demographic and clinical
variables.
Keywords – COVID 19, stress, anxiety, depression, in patient care,
Covid-19 ward
INTRODUCTION
Since the beginning of COVID 19 pandemic, issues related to
mental health has been highlighted repeatedly. Apparently fear of the
consequences of this deadly disease has led to increase in stress, anxiety
and depression in COVID hospitalized patients.[1]The psychosocial
stressors are not only limited to those who were infected but are also
exacerbated in the un-infected individuals.[2] Various factors that may
be responsible for this include the direct effect of virus in central
nervous system, the neuropsychiatric effects of inflammatory markers,
the psychological impact of contact isolation and the stigma of getting
infected, and disrupted social functions associated with serious illness.
[4]
Few studies from other countries have shown that most of the
hospitalized COVID 19 patients report increased symptoms of anxiety
and depression during their inpatient stay. This was significantly
associated with occupation status, level of education and severity of
Covid-19 illness. [2, 3] However, most of published research available on
psychological impact of COVID 19 had focussed more on healthcare
workers [11, 12, 25] and general public or outpatient setting. [13]To our
knowledge, there is no literature from India that had assessed change in
severity of stress, anxiety and depression in COVID 19 and its associated
variables during their hospital stay as indoor patients in Covid-19 Ward.
The primary objective of present study was to assess the change in
severity of stress, anxiety and depression in COVID-19 patients on the
day of admission and on the day of discharge. Secondary objective was to
find any association between the change in severity of stress, anxiety and
depression with socio-demographic and Covid 19 related clinical variables.
METHODS
Study Setting –COVID inpatient ward in a tertiary care medical college.
Study Design –A cross-sectional study design with assessment of
subjects at two points- 1st on the day of admission and 2nd on the day of
discharge.
Sample size –All the subjects admitted to COVID wards over two
months period between 25th May 2021 and 24th July 2021 were
approached for their willingness to participate in the study. We could
recruit total 104 subjects who met eligibility criteria and gave informed
consent.
Eligibility Criteria -
Inclusion criteria –
1. Patients above 18 years of age with positive COVID RT-PCR report.
2. Patients admitted to Covid-19 ward in the tertiary care hospital.
Exclusion criteria – the following patients were excluded:
1. Only Rapid Antigen Test positive
2. Only HRCT suggestive of atypical pneumonia
3. Pre-existing psychiatric illness and substance abuse except nicotine
4. Non-invasive ventilation support or medically unstable
5. Persons with impaired capacity
Indian J Psychiatry Volume 64, Supplement 3, March 2022
Abstracts
Ethical aspects – As per institution’s policy for research on human
subjects approval from the Scientific Advisory Committee (SAC) and
then from Ethics Committee for Research on Human Subjects (ECRHS)
of the institute was obtained. Written informed consent was obtained
from all the participants and they were explained about their right to
leave the study at any point of time without any impact on their ongoing
treatment for Covid-19 illness. No additional financial burden was put
on the subjects by participation in study.
Assessments – Subject’s socio-demographic and clinical information
was recorded anonymously in a pre-designed and pilot tested format.
Information included sex, age, marital status, employment status,
education, income of head of family and details of primary care giver. The
socio-economic status was classified using Kuppuswamy scale. We also
recorded clinical variables related to COVID-19 illness like Heart Rate,
temperature, Blood pressure, respiratory rate, Oxygen saturation (SPO2)
on the day of admission and on the day of discharge to assess clinical
improvement in Covid-19 illness. Severity of stress, Depression and
anxiety were also assessed at same two time points. Level of stress was
assessed using perceived stress scale (PSS) which classifies stress level
into Mild stress (0-13), Moderate stress (14-26), Severe stress (27-40). [4,5]
The severity of anxiety was assessed using Hamilton Anxiety rating scale
(HAM-A). Total score obtained can be classified into No anxiety (0-7),
mild anxiety (8-14), moderate anxiety (15-23), severe anxiety (>24). [6]
Severity of depression was assessed using Hamilton Depression rating
scale (HAM-D). Total score obtained classifies severity of depression as
no depression (0-7) mild depression (8-16), moderate depression (17-
23), severe depression (>24). [7] Both these scales are already validated
to estimate the change in severity of anxiety and depression over a
period in time.[8] Laboratory investigations like d-dimer, ferritin, Lactate
Dehydrogenase, Erythrocyte Sedimentation Rate, C-Reactive Protein
were recorded only once during the inpatient stay.
Statistical analysis - The collected data was analysed using SPSS
(Statistical Software for social Sciences) software version 25. Initially
descriptive statistics was carried out for the variables using appropriate
measures of central tendency. Association between the severity of stress,
anxiety and depression with socio-demographic and clinical variables
was done using the Wilcoxon Signed Ranks Test and spearman’s
correlation. Significance was set with 95% confidence level and p value
< 0.05 was taken as significant.
RESULTS
Majority of the patients were male (63.4%) with male to female ratio of
1.7. Maximum patients were in the age group of 31-40 years (35.5%)
followed by 51 - 60 years (27.8%) and 41-50 years (24.2%). Most were
from the rural area (79%), belonging to Hindu religion (95.2%) and
had education up to middle school (34.6%). The participants were at
clerk level (41.3%), married (85.6%), had full time job (79%). As per
Kuppuswamy scale, the subjects could be classified as upper middle
(10%), lower middle (67%), upper lower (23%) and none belonged to
upper and lower class.Spouse (67%) were the most common caregivers.
Average IPD stay in covid-19 ward was 8.23 (2.9).
Table-1 shows change in severity of stress, anxiety, depression and
clinical variables measured at two cross sections. It is evident that more
number of patients experienced higher levels of stress, anxiety and
depression at the time of discharge despite being sent to their homes to
stay with their family members.
Change in stress level, anxiety and depression and the Covid -19 related
clinical variables from day of admission to on day of discharge is stated in
Table-2. Compared to the assessment on the day of admission, there was
significant increase in the level of stress, anxiety and depression on the
day of discharge, despite favourable improvement in physical condition
as indicated by covid-19 related clinical variables (temperature, pulse
rate, blood pressure and oxygen saturation) as listed in the table. This
indicates that it’s not the clinical severity of Covid-19 illness itself that
causes psychological distress, but inpatient stay and factors associated
with it, may also lead to psychological distress in patients admitted to
Covid-19 wards.
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Table-1: Severity of Stress, anxiety and depression as measured on day of admission and day of discharge from
COVID-19

Variable Severity On day of Admission N (%) On day of discharge N (%) Significance

(p value)
Stress (PSS) Mild 66 (63.46) 46 (44.23) 0.0054
Moderate 33 (31.73) 41 (39.42) 0.2479
Severe 05 (4.80) 17 (16.35) 0.0069
Anxiety (HAM-A) No Anxiety 63 (60.57) 53 (50.9) 0.1614
Mild 16 (15.38) 21 (20.19) 0.3684
Moderate 14 (13.46) 22 (21.15) 0.1436
Severe 01 (0.96) 08 (7.69) 0.0173
Depression(HAM-D) No Depression 88 (84.61) 77 (74.03) 0.0602
Mild 12 (11.53) 19 (18.26) 0.1739
Moderate 02 (1.9) 5 (4.8) 0.2463
Severe 02 (1.9) 3 (2.8) 0.6691

Table 2: Change in stress level, anxiety and depression and the Covid -19 related clinical variables from day of
admission to on day of discharge
Variables PSS HAM-A HAM-D Temperature Pulse Rate Respiratory BP Systolic BP Diastolic Oxygen
rate Saturation

Mean value (SD) 10.30 (9.10) 6.05 (6.54) 3.78 (4.57) 99.01 (1.54) 90 (9.79) 32 (32.8) 123.96 (9.75) 82.82 (6.14) 94.28 (10.2)
on Admission
Mean value (SD) 15.08 (9.88) 8.57 (8.65) 4.91 (5.83) 98.17 (0.60) 84 (6.28) 26 (9.73) 120.55 (5.56) 80.56 (5.56) 96.98 (9.88)
on Discharge
Difference -4.78 -2.52 -1.13 0.84 6 6 3.41 2.26 -2.7
Z -4.93b -4.18b -3.20b -5.94a -5.72a -3.11a -3.38a -3.74a -7.49b
P value 0.000 0.000 0.001 0.000 0.000 0.002 0.001 0.000 0.000
Wilcoxon Signed Ranks Test. p<0.01 is highly significant, a=based on positive ranks, b=based on negative rank

Table 3: Association of the demographic and pathologicalvariables with the change the level of stress, Anxiety and
Depression during the hospital stay
Variables PSS HAMA HAMD
Total Stay in Covid Ward -0.147/NS -0.271(r)/0.005** -0.285/0.003**
Urban / rural Locality 0.021/NS -0.008/NS 0.050/NS
Education -0.196/0.046* -0.246/0.012* -0.052/NS
Income of family 0.131/NS 0.279/0.004** 0.004/NS
Occupation 0.165/NS 0.126/NS 0.020/NS
Employment status of subjects -0.111/NS 0.025/NS 0.037/NS
Interaction with caregiver 0.085/NS 0.128/NS -0.054/NS
Socio-economic Status 0.085/NS 0.128/NS -0.057/NS
Haemoglobin -0.050/NS -0.079/NS 0.128/NS
Lymphocyte percentage 0.040/NS -0.065/NS -0.051/NS
Neutrophil percentage 0.046/NS 0.105/NS 0.116/NS
SGOT -0.156/NS -0.126/NS -0.2370.017*
Lactate Dehydrogenase (LDH) -0.026/NS 0.070/NS 0.014/NS
D-DIMER 0.110/NS 0.214/0.035* 0.174/NS
Spearman’s correlation. *p<0.05 is statistically significant, **p<0.01 is statistically highly significant, NS = Not significant

Table-3 demonstrates association between demographic variables,
laboratory parameters with change in levels of stress, anxiety and
depression during hospital stay. Among the demographic variables, there
is a weak negative but significant association between perceived stress
and level of education. There is no significant association with other
demographic and pathological variables.When considering the increase
in the level of anxiety during hospital stay, there is a weak negative
but significant association with total stay and level of education. While,
there is weak positive but significant association between increased
level of anxiety and income, d-dimer levels. There is no significant
association with other demographic and pathological variables. For
change in level of depression there is a weak negative but significant
association between total stay and SGOT levels. There is no significant
association with other demographic and pathological variables.
DISCUSSION
Findings of present study reveal that as compared to day of admission,
many more subjects with covid-19 illness experienced significantly
higher level of stress, anxiety and depression at the time of discharge.
This is happening despite clinical improvement in these subjects. For
demographic variables, in line with previously published studies, a
higher proportion of patients in our study were in the age group of 31
– 60 years, more than half were male, belonged to rural region, had

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some education,and majority were doing clerical jobs or any part time
jobs,and belonged to lower middle class.[1,2] A recent study conducted to
assess the level of stress anxiety and depressions during hospitalization
reported similar demographic profile with majority participants being
male, married and had good level of education and were employed.[1]
Few studies which were of cross sectional nature suggested high levels
of anxiety as a form of psychological stress, especially following the
isolation to seek treatment of COVID 19 infection. [2, 9] Our study had
assessed these at two points and the level of stress, anxiety and depression
was found to be more on the day of the discharge from hospital than on day
of admission. In contrast to this, a study from Israel found that the level of
anxiety and depression decreased one month following hospitalization. [15]
Some studies included the past psychiatric illness and substance use as a
variable, but we excluded the subjects with pre-existing or past psychiatric
illness from our study to avoid confounding effect. [1,2] Authors in an Italian
study evaluated COVID 19 patients in the emergency department and
then screened for psychopathology approximately 1 month after initial
emergency department evaluation. It was found that 56% of patients
screened positive in at least one psychiatric domain. Approximately 31%
screened positive for depression, 42% for anxiety, and 28% for obsessive-
compulsive symptoms. [10] In our study there was no association between
interaction with care giver and severity of stress, anxiety and depression,
however few studies also found that isolation and lack of support from
care givers and relatives was the key factor for anxiety and depression
where less social supports led to more anxiety and depressive symptoms
and more depression was found in caregivers. [3,15,21] A study conducted in
Wuhan China, the prevalence rate of depression and anxiety was found
to be 21% and 16.4% respectively. [14] Few other studies also reported
psychological distress after hospital discharge. [17, 18, 23]
In our study severity of stress, anxiety and depression is not strongly
associated with demographic and social variables, may be due to strong
social support and intact family bonding in Indian settings. Depression
was also found in quarantined patients. The family support & social
interaction was alleviating factor. [24] This differs from findings of studies
from other countries which reported that lack of social support for patients
with COVID-19 being associated with depression and socioeconomic
status bearing major impact on severity of depression. [18,19,20]
Present study was unique from our country to assess the change in the
severity level of stress, anxiety and depression during hospital stay in
indoor patients of Covid-19 illness. Findings of our study highlight need
for inclusion of psychological screening and appropriate management of
all patients admitted to Covid-19 ward. Similar recommendations had
been made by other authors. Cognitive Behavioural Therapy was found
to be effective in reducing psychological distress in patients. [22] Among
our subjects, all those with significant levels of anxiety and depression
were provided treatment at the time of discharge itself. They were
informed to be on regular follow in psychiatry OPD after discharge from
the ward. After completion of study and preliminary analysis of data, to
reduce the stress of admitted patients, we conducted stress management
sessions in COVID wards itself as an initiative of our department.
STRENGTHS AND LIMITATIONS
The major strength is this is the first study in India which has assessed
the change in levels of stress, anxiety and depression during the
inpatient [IPD] stay of COVID 19 patients and initiated appropriate
management for same. The results of the study should be interpreted
with the limitations of it being a single centre study with assessment of
only inpatients and cross-sectional design of the study.
CONCLUSIONS
There was a significant increase in level of stress, anxiety and depression
during the inpatient stay of COVID 19 patients despite improvement
in fever and respiratory distress. This change was associated with
level of their income and some lab parameters. However, majority of
the demographic and clinical variables had no significant impact on
increased level of stress, anxiety and depression. Findings highlight the
need for appropriate intervention for their psychological health as an
essential part of care in COVID wards.
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CONFLICTS OF INTEREST: None
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