Psychiatric manifestations and associated risk factors among hospitalized patients with COVID-19 in Edo State, Nigeria: A Cross-sectional Study

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. 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. 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 modifiable risk factors for psychiatric manifestations early in the course of the disease and integrate mental health interventions and psychosocial support into COVID-19 management guidelines. --Funding provided by: PANDORA-ID-NET funded by the European and Developing Countries Clinical Trials Partnership (EDCTP2) programme*Crossref Funder Registry ID: Award Number: EDCTP Reg/Grant RIA2016E-1609Setting and study design A descriptive cross-sectional study was conducted from 15th April to 11th November 2020. The participants were COVID-19 Real Time-Reverse Transcriptase -Polymerase Chain Reaction (rRT-PCR) positive persons who were hospitalized at the three government- designated treatment and isolation centres in Edo State, Nigeria. Participants and data collection procedure 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. Medical records/registers at the treatment and isolation centres were reviewed daily in order to identify new admissions and discharges in the centres and ineligible patients due to age (less than 11 years). A total of 796 persons with confirmed COVID-19 were hospitalized at the three government designated treatment and isolation centres in Edo State over the study period. All patients were informed and acknowledged a detailed description of the study, eligibility requirements and voluntariness to participate in the study. Nineteen of them were below 11 years and were excluded, and 265 patients either refused to give consent or were too ill (critically ill) to consent and participate in the study. A total of 512 were therefore recruited for the study. Semi-structured and structured questionnaires incorporating socio-demographics, basic clinical history/information and an assessment of anxiety and depression were administered to recruited participants on the fifth day of admission into the treatment and isolation centres. The questionnaires were self - administered except for those who opted for interviewer-administered questionnaires (mainly those with severe COVID-19 infection). Questionnaires were administered in the English language as all participants had some levels of formal education and were literate enough to understand the language. Those who were critically ill with COVID-19 infection were unable to consent and participate in the study. Online survey and hard copies of the questionnaires were made available for completion. All the participants preferred hard copies of the questionnaires and a copy of the signed consent form was retained by each participant and one by the researchers. Clinical information on severity of COVID-19 infection and presence and type of comorbidity were obtained from their medical records (case files). Length of stay in treatment and isolation centres was obtained from their case files after discharge from the centres as the questionnaires were coded for ease of identification. Measurements The socio-demographic/clinical history questionnaire This was designed to provide information about the participant's age, gender, religion, 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. The 9-item Patient Health Questionnaire (PHQ‑9) 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. The PHQ-9 can be self-administered or clinician administered. The Generalized Anxiety Disorder-7 (GAD-7) This is a 7-item self-report questionnaire that allows for the rapid detection of GAD, the validity is not compromised if the clinician reads the questions to the client.[17] 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. Ethics Ethical clearance was obtained from our Research Ethics Committee of the Irrua Specialist Teaching Hospital, Irrua. 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. Statistical analysis 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