|Year : 2022 | Volume
| Issue : 1 | Page : 82-85
Depression anxiety and stress in patients visiting medicine outpatient department of tertiary care hospital during COVID pandemic
Zain, Manjiri Chaitanya Datar, Jyoti Vittaldas Shetty
Department of Psychiatry, Bharati Hospital and Research Centre, Bharati Vidyapeeth University, Pune, Maharashtra, India
|Date of Submission||14-Jan-2021|
|Date of Decision||29-Jul-2021|
|Date of Acceptance||29-Aug-2021|
|Date of Web Publication||29-Apr-2022|
Department of Psychiatry, Bharati Hospital and Research Centre, Bharati Vidyapeeth University, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Coronavirus disease 2019 is a unique pandemic that has struck all the nations. Extraordinary crisis warrants extraordinary response like severe lockdown. The study aims to assess the prevalence of depression, anxiety, and stress, in general, and around corona, in particular, in people with medical comorbidity. Setting and Design: This is a cross-sectional study that was carried out in outpatient department setting of a tertiary care hospital from July 2020 to September 2020. Aims and Objectives: The study aimed to assess the prevalence of depression, anxiety, and stress, in general, and anxiety around corona, in particular, and the correlation with sociodemographic profile and comorbid medical illness. Materials and Methods: Fifty patients with various medical comorbidities were assessed using depression anxiety and stress scale and corona anxiety scale (CAS) and a specially designed pro forma. Statistical Analysis: The collected data were coded and entered in Microsoft Excel sheet. The data were analyzed using Statistical Packages for the Social Sciences version 20.0 software. The results are presented in a tabular and graphical format. For quantitative data, mean, standard deviation, median, etc., were calculated. For qualitative data, various frequency, rates, ratio, and percentage were calculated. Results: A statistically significant relationship was found between education and anxiety (P = 0.027) and between medical comorbidity and depression. Conclusion: In our study, medical comorbidities are associated with depressive cognition. Surprisingly, no significant anxiety on CAS could be found.
Keywords: Corona anxiety scale, coronavirus disease 2019, depression anxiety and stress scale
|How to cite this article:|
Zain, Datar MC, Shetty JV. Depression anxiety and stress in patients visiting medicine outpatient department of tertiary care hospital during COVID pandemic. Ann Indian Psychiatry 2022;6:82-5
|How to cite this URL:|
Zain, Datar MC, Shetty JV. Depression anxiety and stress in patients visiting medicine outpatient department of tertiary care hospital during COVID pandemic. Ann Indian Psychiatry [serial online] 2022 [cited 2023 Apr 1];6:82-5. Available from: https://www.anip.co.in/text.asp?2022/6/1/82/344425
| Introduction|| |
There have been several pandemics in human history, with plague and influenza being etched on memory. Coronavirus disease 2019 (COVID-19) is the latest pandemic. It has shaken the entire world, and depending on its stage, it has variable psychological impacts. The COVID-19 outbreak was declared a public health emergency of international concern by the World Health Organization on January 30, 2020. It is thought to have stemmed from a seafood wholesale market in the city of Wuhan of Hubei Province in late December 2019, and then unfortunately spreading through the world.
In India, it is observed that COVID-19 presents with a wide range of symptoms such as fever, dry cough, breathlessness, and gastrointestinal symptoms with most commonly diarrhea. However, there is woeful ignorance among people regarding the symptoms, its mode of transmission, and protective measures. This ignorance is amplified by the “infodemic” crisis due to blatant misinformation on social media. As COVID-19 is a new disease and is having the most devastating effects globally, its emergence and spread cause confusion, anxiety, and fear among the general public.
The governments across the world have resorted to social distancing or physical distancing to contain the menace of coronavirus infection. While the primary intervention of isolation may well achieve its goals, it can lead to worsening anxiety and depressive symptoms. There was documented moderate-to-severe psychological impact during the initial phase of the COVID-19 outbreak in China. The severe lockdown from the month of March affected jobs across the education spectrum from the well-documented migrant crisis to massive-scale job losses that has contributed to the misery of people.
The above measures of social distancing along with the lockdown have brought untold misery and stress to people with chronic diseases.
Patients with chronic diseases find themselves in an unenviable spot, an immune system that is compromised in chronic diseases and make them more vulnerable to this infection.
There is also mobilization of health personnel to the frontline of management of COVID-19. The paucity of healthcare professionals compromises healthcare.
The negative effects of stress on disease outcomes and medication adherence have been documented.
Elderly individuals suffering from chronic diseases such as hypertension, cardiovascular diseases, or diabetes that warrant regular monitoring have been understandably putting off their visit to hospital. This has, unfortunately, led to exacerbation of complications., Medical services reported the highest-ever number of cardiac arrests in the field – 45% more than the previous month, suggesting that patients were waiting too long to seek cardiac care. Of note, all of these heart patients tested negative for COVID-19. The possible reasons for decline of presentation of myocardial infarction are not certain but could also reflect true decline in the incidence of myocardial infraction during lockdown due to reduced risks such as excess physical activity and air pollution.
One multicenter survey involving 1563 individuals visiting Nanfang Hospital, China, found the prevalence of depression to be 50.7% (PHQ-9) and generalized anxiety disorder to be 44.7% (GAD-7).
With this in mind, we wished to get some perspective of prevalence of anxiety, depression, and stress, in general, in people with medical comorbidities and also wished to assess their worries around being impacted with COVID-19 during a particular period of lockdown. We also wished to see if there is any association between their sociodemographic profile and scores on the above scales.
| Materials and Methods|| |
The study was conducted in the outpatient department (OPD) of medicine in a tertiary hospital in India. Ethical clearance was obtained from the institutional ethics committee before conducting the study. The reference number of ethical clearance is BVDUMC/IEC/38 and was obtained on June 30, 2020. This was a cross-sectional study. The sample consisted of 50 patients of both sexes between 18 and 70 years and having medical diagnoses such as obesity, hypertension, diabetes, chronic kidney disease, hypothyroidism, and coronary artery disease. Written informed consent was obtained from all the participants. Patients with preexisting psychiatric conditions were excluded from the study.
The study was conducted from July 2020 to September 2020.
Sociodemographic and clinical data were gathered using a pro forma, specially designed for the study. They included age, sex, years of education, marital status, religion, and family structure and the medical comorbidity. Depression, anxiety, and stress, in general, were assessed using:
- Depression anxiety stress scale (DASS) is a 42-point scale with subsections for assessing symptoms of depression, anxiety, and stress in the past 1 week. Each question has responses ranging from not at all to apply to me very much. The individual does not have to spend too much time on each question
- Coronavirus anxiety scale (CAS) is used to assess the degree of anxiety in the patients visiting the hospital. This five-item scale is used to identify dysfunctional anxiety associated with COVID-19 crisis. An optimized cutoff score of ≥9 has a 90% sensitivity and 85% specificity. The scale has five questions each rated on a 5-point Likert scale with 0 = not at all and 4 = nearly every day in the last 2 weeks. Each question assesses the physiological response of a person (sleep, nausea, autonomic symptoms) on hearing or listening to corona news.,
The collected data were coded and entered in Microsoft Excel sheet. The data were analyzed using Statistical Packages for the Social Sciences Version 20.0 Software (IBM Statistical Packages of Social Science Version 20.0 with the Company in Newyork, USA). The results are presented in a tabular and graphical format.
For quantitative data, mean, standard deviation, median, etc., were calculated.
For qualitative data, various frequency, rates, ratio, and percentage were calculated.
| Results|| |
Out of 50 people, 20 (40%) had mild depression on DASS and 2 (4%) had moderate depression. 22 (44%) had mild anxiety and none had significant score on stress levels [Figure 3]. Out of 50 people, 37 (74%) had a score of 2 on CAS and 13 (26%) had a score of 3. None of the above is significant, as a score of 9 is considered.
In the sociodemographic profile, the only statistically significant relation is found between education and mild anxiety score (P = 0.027). 13 out of 38 (33.33%) of the graduates had mild anxiety. 3 out of 3 (100%) of the postgraduates had mild anxiety. 1 out of 3 (33%) had mild anxiety among higher secondary and 5 out of 6 (85%) with secondary education had mild anxiety [Table 1].
|Table 1: Relationship between demographics and depression anxiety and stress score|
Click here to view
Statistically significant relation is found between some medical comorbidities namely diabetes, hypertension, coronary artery disease, and chronic kidney disease and depression [Table 2]. Only people with coronary artery disease and chronic kidney disease have some individuals in moderately depressed category, viz., 1 out of 5 (20%) in coronary artery disease and 2 out of 11 (about 20%) in chronic kidney disease.
No statistically significant relationship is found between sociodemographic profile and score on CAS or medical comorbidity and score on CAS.
| Discussion|| |
In our study, we found a significant relation between medical illness and depression score. This is replicated in earlier studies. Our study failed to find any significant relation between medical illness and anxiety scores (DASS and CAS). A study conducted in Spain found that factors that contributed to the prevalence of anxiety in chronically ill are difficulty in transportation, mobilization of healthcare workers to COVID-19–affected area and shortage of medications. Our study was conducted in the late July, August, through September 2020 and lockdown had eased by then. The patients who came to medicine OPD with chronic illnesses did not report any significant anxiety around corona as measured by CAS. This could be because of multiple reasons:
- The easing of lockdown and improvement in mobility of people
- People coming to the OPD for their primary medical illness to OPD were aware of primary symptoms of COVID-19 and ways to prevent the spread through social distancing and personal hygiene/mask. Hence, they could be reasonably confident that following the above measures could prevent them from getting corona and this could reflect a low score on CAS.
- Shift in priorities from health concerns to economic concerns could also explain the decrease in health-related anxiety.
This was a cross-sectional study carried out on a small sample size of people coming to a tertiary care COVID-designated hospital during the easing of the lockdown. A study with a larger sample size would make for more robust data.
| Conclusion|| |
There is correlation between education of the people and prevalence of anxiety (on DASS). This could be a reflection on more awareness of their medical illness, treatment, and threat of corona and also to healthcare access. There is an expected relationship between chronic illness and depression score but not on anxiety score. Since the study was done when healthcare access for non-COVID treatment was rising, it necessitates further study to detect undetected/subclinical/clinical depression in chronically medically ill.
No relation could be found between chronic illness and score on corona anxiety during that period of the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tandon PN. COVID-19: Impact on health of people & wealth of nations. Indian J Med Res 2020;151:121.
] [Full text]
Ho CS, Chee CY, Ho RC. Mental health strategies to combat the psychological impact of coronavirus disease 2019 (COVID-19) beyond paranoia and panic. Ann Acad Med Singap 2020;49:1-3.
Kretchy IA, Asiedu-Danso M, Kretchy JP. Medication management and adherence during the COVID-19 pandemic: perspectives and experiences from low-and middle-income countries. Research in social and administrative pharmacy. 2021 Jan 1;17(1):2023-6.
Wong LE, Hawkins JE, Langness S, Murrell KL, Iris P, Sammann A. Where are all the patients? Addressing COVID-19 fear to encourage sick patients to seek emergency care. NEJM Catalyst Innovation in Care delivery Delivery 2020 May 14.
Mauro V, Lorenzo M, Paolo C, Sergio H. Treat all COVID 19-positive patients, but do not forget those negative with chronic diseases. Intern Emerg Med 2020;15:1.
Sebrié EM, Sandoya E, Hyland A, Bianco E, Glantz SA, Cummings KM. Hospital admissions for acute myocardial infarction before and after implementation of a comprehensive smoke-free policy in Uruguay. Tob Control 2013;22:e16-20.
Available from: https://
. [Last accessed on 2020 Jul 02].
Lee SA. Replication analysis of the coronavirus anxiety scale. Dusunen Adam 2020;33:203-5.
Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry 2003;54:216-26.
Spinelli A, Pellino G. COVID-19 pandemic: Perspectives on an unfolding crisis. Br J Surg 2020;107:785-7.
Narayana G, Pradeepkumar B, Ramaiah JD, Jayasree T, Yadav DL, Kumar BK. Knowledge, perception, and practices towards COVID-19 pandemic among general public of India: A cross-sectional online survey. Curr Med Res Pract 2020;10:153-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]