Psychological trauma and depression in recovered COVID-19 patients: a telecommunication based observational study

Abstract Introduction Coronavirus disease 2019 (COVID-19) is adversely affecting the mental health of patients infected with the virus and the psychological impact on recovered COVID-19 patients is unclear. Objectives The study aimed to assess posttraumatic stress disorder (PTSD) and depression among COVID-19 patients after recovery from the disease. Methods This cross-sectional study was conducted from November 9, 2020, to December 23, 2020. The study used a telemedicine model to enroll recovered COVID-19 patients from a database of patients provided by the health authorities. The National Stressful Events Survey PTSD Short Scale (NSESSS) for adults was used to assess PTSD symptoms and the Patient Health Questionnaire (PHQ-9) was used to assess depression. Results The study enrolled 503 recovered COVID-19 patients with a mean age of 41.90 years. The majority were asymptomatic (64.6%), while 21.5% had had moderate to severe forms of the disease. Prevalence rates of PTSD symptoms and depression were 56.9 and 29% respectively. COVID-19 patients with severe forms of the disease were significantly more affected by PTSD symptoms (vs. mild, odds ratio [OR] = 18.7, 95%confidence interval [CI] 9.9-35.5) and depression (vs. mild, OR = 19.8, 95% CI 9.9-39.5). Similarly, patients who required oxygen or ventilator support reported significantly higher rates of PTSD symptoms (vs. managed at home, OR = 17.4, 95% CI 8.3-36.4) and depression (vs. managed at home, OR = 22.0, 95% CI 10.1-47.7). Conclusion This study reports that recovered COVID-19 patients suffered from a significant amount of depression and experienced significant PTSD symptoms. It will help with addressing a major psychological concern among the recovered subjects.


Introduction
Coronavirus disease 2019 (COVID- 19), caused by a newly discovered coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]), was declared a pandemic by the World Health Organization (WHO). 1 The COVID-19 pandemic reached unprecedented magnitude and India had recorded more than 10 million cases and 146,791 deaths as of late December 2020, when the present study was conducted. 2The pandemic had a significant effect on the psychological health of people in general and COVID-19 patients in particular, including fear, stress, anxiety, and depression that lead to social isolation and altered human relations. 3Studies of previous coronavirus (CoV) epidemics suggested that many patients with COVID-19 will manifest psychiatric symptoms and disorders. 4,5Fact-based and peoplecentric communication of pandemic-related information is indispensable to dispel fears and uncertainty among the population. 63][14] While most of these mental health problems will fade out with time, symptoms of PTSD, a common mental disorder caused by major psychological trauma, may last for a long time and result in serious distress and disability. 15aried prevalence of depression has been reported throughout the world in COVID-19 patients. 16,17A meta-analysis suggested evidence of depression, anxiety, and PTSD in the post-illness stage of a previous epidemics of SARS, but the current evidence regarding the prevalence of psychiatric disorders in CoV infected patients is scant and unclear. 18The COVID-19 pandemic has challenged the healthcare system to manage the crisis and provide the best possible healthcare facilities to patients. 19The present study aimed to assess the level of depression and PTSD in recovered COVID-19 patients.

Study design and setting
A cross-sectional study was conducted from This is a nine-item questionnaire used to evaluate depression that reflects the DSM-5 diagnostic criteria.
Each item assesses the individual's response over the previous 2 weeks with score options of 0 = not at all;, 1 = several days; 2 = more than half the days; and 3 = nearly every day.

Ethics approval
The study was approved by the institutional ethical committee at the authors' institute (reference no.

Participants
The study recruited 503 participants through telemedicine consultation with a mean (standard deviation [SD]) age of 41.90 (14.10) years.There was an almost equal participation by both genders with male participants accounting for 50.5% (n = 254) and female participants for 49.5% (n = 249).The majority of participants were married (n = 412; 81.9%) and lived in rural areas (n = 290; 57.7%).Furthermore, 39.8% (n = 200) had graduate qualifications and 30.2% (n = 152) were in a government or private job.
Of the total sample of recovered COVID-19 patients, 31 (6.2%) had been pregnant when they got infected and 110 (21.9%) were already suffering from noncommunicable disease (NCD) (Table S1, available as online-only supplementary material).

Characteristics of COVID-19 in the participants
The majority of COVID-19 patients had been asymptomatic when infected (n = 325; 64.6%) and only  S2, available as online-only supplementary material).
The median time taken to recover from the disease was 11 days.

PTSD and depression
The NSESSS score categorized the severity of PTSD symptoms in recovered COVID-19 patients as mild (n = 199, 39.6%), moderate (n = 65, 12.9%), and severe (n = 22, 4.4%), while none of the patients experienced an extreme form of PTSD (Table 1).Even after their recovery, some of the COVID-19 patients got emotionally upset on being reminded of the stressful experience (n = 129; 25.7%), and they had a very negative emotional state thereafter (n = 116; 23.1%).
The participants (n = 121; 24.1%) tried to avoid thoughts, feelings, or physical sensations that reminded them of the stressful experience (Table S3).The chisquare analysis (Table 2) showed that PTSD symptoms were significantly more prevalent in married participants The responses to the PHQ-9 questionnaire are given in Table S4, available as online-only supplementary material.The prevalence of depression (Table 2) was significantly higher among married participants (p < 0.001).There was a significant difference in presence

Discussion
With the spread of the pandemic, the psychiatric of PTSD as 6.3% among the general population in Manipur state. 22The findings of the present study revealed that 56.9% of the recovered COVID-19 patients suffered from some form of PTSD, among whom 17.3% experienced a moderate to severe form of PTSD.A study with SARS survivors found a 47.8% prevalence of PTSD, 23 while another study reported 66% PTSD prevalence among Ebola survivors. 15udies of diagnosed COVID-19 patients have reported PTSD prevalence as 25-31%, [24][25][26] and one systematic review found the prevalence of PTSD to be 32.2%. 18A very low prevalence of PTSD (3.8%) was reported in recovered COVID-19 subjects in a study from Iran. 27 significant difference in PTSD symptoms between female and male gender was found in the present study, similar to what was reported in a study from China, 28 while few studies and a systematic review reported that the female sex was more susceptible to developing symptoms of PTSD. 18,29,30The older age group was more prone to develop PTSD symptoms as suggested by the findings of other studies among COVID-19 survivors. 26,2729% prevalence of depression among COVID-19 survivors was found in this study, with 10.9% of subjects experiencing a moderate to severe form of depression.The NMHS 2015-16 reported a 9.1% overall prevalence of depression among the general population in Manipur state. 22A high prevalence of depression was also reported during the SARS outbreak. 23,31milarly, studies with COVID-19 survivors have reported prevalence of depression ranging from 23 to 38%. 26,32Most depression in this study was of mild severity, similar to the findings of another study. 33study from China reported a very high prevalence of depression (60.2%) among COVID-19 patients, 16 while, on the contrary, a study from Iran reported only 5% prevalence. 27The present study reported that patients in the older age group, particularly those over 60 years of age, were significantly more affected with depression, similar to another study, 32 while a third study reported depression to be significant in COVID-19 patients in the younger age group. 27Studies reported significantly higher levels of depression among females, 27,32 contrary to the present study, in which no significant difference in gender demographic groups was detected.The PTSD symptoms and depression in this study were significantly higher in patients who required oxygen or ventilator support compared to those managed at home.Similar findings were reported from Morocco, where depression was significantly related to the hospital stay. 32e number of asymptomatic COVID-19 patients is strikingly high (64.6%),which corroborates many other studies worldwide. 34,35Another finding that came to light in this study was about the use of prophylactic medicine from all streams of medical science taken by the participants.The majority of the participants (57.1%) took allopathic prophylactic medicine for COVID-19, while only 1.2% of the participants took AYUSH prophylactic medicine, as advised by the Ministry of AYUSH, Government of India (GOI). 36Claims have been made about the efficacy of AYUSH medicines as prophylactic against COVID-19 and as protecting the people from getting infected. 37,38

Disclosure
No conflicts of interest declared concerning the publication of this article.

November 9 , 3 =
2020, to December 23, 2020, in Manipur State, India.The inclusion criteria for the study were that the participants should have recovered from COVID-19 (tested negative or completed an isolation period or discharged from a health care center after treatment), should have no previous history of PTSD or depression, should be over 18 years of age, of either gender, and should agree to participate in the study via telemedicine.Subjects with a previous history of PTSD or depression and those who did not agree to participate were excluded from the study.Study procedure Participants were recruited for the study with a convenience sampling method.The investigators approached the district health authorities of Imphal and informed them about the study objectives and methods.The authorities were requested to provide the details of recovered COVID-19 patients in the city to enable selection of study subjects.The authorities shared the contact details of recovered patients, extracted from a database of COVID-19 patients in the city.A study representative contacted the recovered patients using telemedicine and apprised them of the objectives and purpose of the study.Subjects who were willing to give consent of their own free will were included in the study.Participants' demographic information and the characteristics of their COVID-19 infection, including its manifestations and management were collected by the study representative using a pre-designed format.Interviews were conducted with recovered COVID-19 patients around 4 weeks after their recovery from the disease and the median interval between recovery and interview was 27 days.Each telephone interview with a recovered patient lasted around 15-20 minutes.InstrumentsSeverity of posttraumatic stress symptoms -Adult (National Stressful Events Survey PTSD Short Scale [NSESSS])This is a validated nine-item measure that assesses the severity of PTSD symptoms in individuals following an extremely stressful event or experience.Each item asks the individual to rate the severity of his or her PTSD symptoms during the past 7 days on a five-point scale (0 = not at all; 1 = a little bit; 2 = moderately; quite a bit; and 4 = extremely).The total score can range from 0 to 36 with higher scores indicating greater severity of PTSD symptoms.If one or two items are left unanswered, a prorated score was calculated as per the scale instructions.The average total score reduces the overall score to a five-point scale, which categorizes the severity of PTSD symptoms as none (0); mild (1); moderate (2); severe (3); or extreme (4).Use of the average total score was found to be reliable, easy to use, and clinically useful to clinicians in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) field trials.20 Patient Health Questionnaire(PHQ-9)

2- 28 /
827).The study was conducted in accordance with the Declaration of Helsinki.The investigators from the institute requested data on recovered patients from the authorities and the request was approved by the competent state government authority.The contact details for recovered COVID-19 patients were thus duly transmitted to the research team and these data were only accessed by the research team and were maintained completely confidential.

35 .
4% (n = 178) had developed disease symptoms.A moderate form of the disease developed in 9.9% (n = 50) of the patients, while the disease progressed to a severe stage in 11.5% (58) of the patients and 7.8% (n = 39) of COVID-19 patients required oxygen or ventilator support at the hospital.The majority of COVID-19 patients had taken allopathic prophylactic medicine (n = 287, 57.1%) before contracting the infection.Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homoeopathy (AYUSH) prophylactic medicines were taken by just six (1.2%) COVID-19 patients (Table implications of the disease are being widely acknowledged.COVID-19 patients, from fear of severe disease consequences, may experience anxiety, depression, PTSD, and other psychiatric complaints.The survivors of the pandemic are at risk of developing significant physical, cognitive, and psychological morbidities after recovery from COVID-19.The present study focused on the psychological impact of COVID-19, especially PTSD and depression, on patients who got infected with the virus but recovered after treatment.Very few studies have been conducted across the globe and specifically in India to assess the prevalence of PTSD and depression in recovered COVID-19 patients.The National Mental Health Survey of India (NMHS) 2015-16 reported the overall prevalence varied demographic profiles need to be planned to understand the attributes and damaging effects of the pandemic in recovered COVID-19 subjects.Mental health support and psychological services should be tailored in light of the enforced restrictions and preventive methods.Certain limitations to the present study shall be considered.First, this study was conducted on COVID-19 patients who had recovered from the infection in Imphal, a city in Manipur state, India, and, further, these subjects were recruited from a database of patients maintained by the health authorities, thus limiting the results to a certain socio-demographic and cultural profile.Assessment of a wider population of recovered COVID-19 patients must be done for an accurate picture of their psychological problems.Second, a convenience sampling method may bias the data and may not be representative of the population.Third, the data were collected over the telephone so there are possibilities of information bias and also selection bias due to network connectivity.Fourth, history of previous mental illness was not collected, limiting association of symptoms to COVID-19.Finally, being a cross-sectional study, followup of the subjects could not be undertaken.Studies are needed to determine the possible long-term adverse consequences for the psyche of recovered COVID-19 patients.Despite these limitations, this study presents an epidemiological analysis of COVID-19 cases that generates robust evidence on psychological problems faced by patients after recovery from COVID-19 and it is important that these findings need to be confirmed in a larger sample of patients.Implications COVID-19 has infected a significant number of people globally and the psychological impact on recovered patients could also be a major concern.Mental illness may be compounded by the fear associated with a disease that leads to social isolation of the affected individuals.PTSD and depression have emerged as psychological morbidities of worrisome nature and the severity of COVID-19 is proportional to the severity of mental illness, as detailed in this study.The physical illness compounded by psychological morbidity may result in deterioration of the individual's quality of life.This study has generated evidence that presents implications for formulating an effective strategy for screening of recovered COVID-19 patients who developed mental illness.Efforts should be made to provide easily accessible psychological counselling services for such individuals and proper healthcare facilities for those who require medical treatment.The present study also highlighted the importance of generating further evidence on the long term psychological effects of COVID-19 and to further assess the correlation between the severity of COVID-19 and mental illness.Disseminating credible information about the probable psychological consequences of the disease to COVID-19 patients in particular and to the public in general should also be a priority for healthcare providers and public health authorities.ConclusionThis study has found that COVID-19 patients suffered from a significant amount of PTSD and depression after recovery and thus has helped by addressing major psychological concerns faced by them.The results obtained from this study could contribute to formulating effective strategies for comprehensive health care for recovered COVID-19 patients with specific emphasis on the psychological aspect.Considering the alarming impact of COVID-19 on the mental health of recovered patients, it may be suggested that their psychopathology should be assessed and their psychiatric conditions diagnosed and treated to reduce the disease burden.It is assumed that the outcomes of this study will work as a baseline for future studies in this context.

Table 3 -
Post-hoc analysis of NSESSS and PHQ-9 scores for presence of PTSD and depression in recovered COVID-19 patients