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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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A cross-sectional study to assess the post-traumatic stress disorder among discharged coronavirus disease-19-infected individuals in Karnataka, Southern India
Kishore Shettihalli Gudegowda, Riya George, Iswarya Partheeban, Ranganath T Sobagaiah
Department of Community Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| Date of Submission | 19-Sep-2022 |
| Date of Decision | 11-Dec-2022 |
| Date of Acceptance | 12-Dec-2022 |
| Date of Web Publication | 02-Mar-2023 |
Correspondence Address:
Riya George,
Room Number B1, Bangalore Medical College and Research Institute Ladies Hostel, Victoria Hospital Campus, New Tharagupet, Bengaluru - 560 002, Karnataka
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jcrsm.jcrsm_77_22
Background: Posttraumatic stress disorder (PTSD) is a mental disorder that may develop after exposure to a horrifying or traumatic event. India reported a high number of cases worldwide during the waves of the coronavirus disease-19 (COVID-19) pandemic. Even though a high prevalence of PTSD is expected among hospitalized COVID-19 patients, only a very few studies have addressed the issue till now. The objectives of the study were to assess the prevalence and risk factors associated with PTSD among discharged COVID-19-infected individuals from a designated COVID-19 hospital in Karnataka.
Methodology: A cross-sectional study was conducted among a total of 120 patients who were discharged after recovery from a designated COVID-19 hospital in Karnataka. Multistage random sampling was done, and equal representation was ensured from all the zones as per the hospital protocol from April 2021 to June 2021. Telephonic interviews with the subjects were conducted; participants were evaluated for PTSD using a semi-structured, prevalidated questionnaire (impact of events scale-revised) after 1 month of discharge from the hospital.
Results: The prevalence of PTSD was found to be 29.16%. PTSD was more commonly associated among the middle age group, presence of comorbidities, and with an increased number of days of hospitalization stay especially in ICU with the ventilator.
Conclusions: Studying PTSD and its associated factors is necessary to inform about the COVID-19 prognosis. Physicians treating the patient and caretakers of patients should be aware of PTSD risk and should consider PTSD Screening.
Keywords: Coronavirus disease-19, mental health, pandemic, posttraumatic, stress disorders
How to cite this URL:
Gudegowda KS, George R, Partheeban I, Sobagaiah RT. A cross-sectional study to assess the post-traumatic stress disorder among discharged coronavirus disease-19-infected individuals in Karnataka, Southern India. J Curr Res Sci Med [Epub ahead of print] [cited 2023 Mar 31]. Available from: https://www.jcrsmed.org/preprintarticle.asp?id=370927 |
| Introduction | |  |
Posttraumatic stress disorder (PTSD) is a mental disorder that may develop after exposure to a horrifying or traumatic event.[1] On March 11, 2020, the World Health Organization declared the coronavirus disease-19 (COVID-19) outbreak a pandemic.[2],[3] The COVID-19 pandemic has toppled the survival and lives of the population globally.[4] India during the pandemic of COVID-19, has reported a large number of cases from 3 January 2020 to 22 July 2022, around 43,825,185 confirmed cases of COVID-19 and with 525,870 deaths.[5],[6] Patients according to their clinical conditions and oxygen requirement, will be isolated at home or admitted to either COVID Care Centre or Dedicated COVID Hospital. The hallmark symptoms of PTSD include mood disturbances, hyperarousal and reactivity, avoidance behavior, and intrusive memories.[7] The high rates of severe illness and death surrounding the outbreak of COVID-19 indicate that the pandemic outbreak may be perceived as a traumatic event.[8],[9] As a consequence, PTSD in the population can be common throughout the pandemic and may be associated with definite apprehensions related to the COVID-19 background.[10],[11],[12]
| Materials and Methods | | |
A cross-sectional study was conducted among discharged COVID-19-infected individuals from April 2021 to June 2021 at a designated COVID-19 hospital in Karnataka, Southern India. Based on the study conducted by Chang et al. by taking the prevalence of PTSD among COVID-19 patients to be 20.3% at a 95% confidence interval, the sample size was calculated to be 120.[10] A multistage random sampling method was used. Equal representation was ensured from all the zones as per the hospital protocol where patients depending upon the severity of the condition and oxygen requirement were admitted in the yellow, orange, and red zone. Forty patients each were selected from these yellow, orange, and red zones. Patients of age >18 years who gave informed verbal consent were included in the study. Informed verbal consent was taken since the study was done through telephonic interviews and patients were from different parts of Karnataka. The eligible candidates of the study were requested to provide informed consent after receiving a detailed description of the study and were given the opportunity to clarify the questions. Patients who were having a clinically evident cognitive impairment or active psychiatric disorder on medication were excluded from the study. A detailed structured interview was conducted with the patient to rule out the same. The medical records of the patient were also checked.
After obtaining clearance from the institutional ethical committee (IEC approval number - BMCRI/PS/141/2022-23), telephonic interviews with the subjects were conducted after 1 month of discharge from the hospital using a semi-structured, prevalidated questionnaire Impact of Events Scale-Revised (IES-R) scale.[13],[14]
Socio-demographic (Modified Kuppuswamy Socioeconomic scale)[15] and other details of the patient were collected including hospital history.
The IES-R is a scale containing 22 items that measure the three core phenomena of PTSD, which include denial of trauma-related memories and emotions, re-experiencing traumatic events, and defensive avoidance. An overall score over 33 represents the best cutoff for a probable diagnosis of PTSD. The questionnaire has high test reliability (r = 0.93), and adequate internal consistency (Cronbach's α for subscales being 0.87–0.94 for intrusion and 0.84–0.97 for avoidance, 0.79–0.91 for hyperarousal).[13],[14]
The data collected was entered into Microsoft Office and analyzed using IBM SPSS Statistics version 23.0. (Armonk, New York). Socio-demographic data are presented using descriptive statistics namely mean, standard deviation, median, inter-quartile range, and percentage wherever applicable. The factors associated with PTSD were analyzed using suitable descriptive and inferential statistics. The association between factors and PTSD was analyzed using the Chi-square test. A P < 0.05 was considered to be statistically significant. Data was presented in the form of Tables, Figures and Graphs wherever necessary.
| Results | | |
In the study conducted among a total of 120 participants, most of them expressed their apprehension and anxiety regarding the deaths associated with COVID-19 globally and due to the increased number of cases. From the current study, we have got the results that 35 participants (29.16%) had an IES-R score ≥33, which indicates a probable diagnosis of PTSD. The patient characteristics such as age, marital status, number of comorbidities, number of days of hospitalization, and invasive ventilation were significantly associated with the development of PTSD.
The mean age of the participants involved in the study was 42 years, with a standard deviation of 15.50, the range being 72 years. 63 (52.5%) males and 57 (47.5%) females participated in the study. The majority of the participants 52 (43.33%) belonged to the age group 40–59 years. The second most common age group was 20–39 years (40.83%) of the total population. The majority of them 61 (50.83%) belonged to lower middle socioeconomic status according to Modified Kuppuswamy's classification 2020. Among the participants, 86 of them (71.6%) were married and 34 of them (28.3%) were unmarried. 94 participants (78.3%) did not do regular physical exercise (physical exercise for at least 30 min for at least 5 days a week) before the diagnosis of COVID-19 infection. 26 participants (21.6%) of the participants did regular physical exercise before the diagnosis of COVID-19 infection. The majority of the participants 51 (42.5%) had a body mass index (BMI) in the range of 18.5–24.9.
Among the participants, any comorbid conditions such as hypertension, diabetes mellitus, dyslipidemia, thyroid dysfunction, polycystic ovarian disease (PCOD), asthma, cardiac disease, carcinoma (CA), or systemic lupus erythematosus (SLE) were present in 57 (47.5%) of the participants. Sixty-three participants (52.5%) did not have any known comorbidities [Figure 1] and [Figure 2]. The presence of the comorbidities was identified from their previous medical records and the patient's history. | Figure 1: Distribution of population according to number of comorbidities
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 | Figure 2: Distribution of population according to comorbidities. X-axis represents the comorbidities and Y-axis represents the number of patients. Among the comorbidities present in participants, the most common one was hypertension which was followed by diabetes mellitus and dyslipidemia. HTN: Hypertension, DM: Diabetes mellitus, CAD: Coronary artery disease, CA: Carcinoma thyroid, PCOD: Polycystic ovarian disease, SLE: Systemic lupus erythematosus
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Among the comorbidities present in participants, the most common one was hypertension which was present in 32 participants (26.6%), which was followed by diabetes mellitus in 21 participants (17.5%), and dyslipidemia in 21 participants (17.5%). The other comorbidities which were present among the participants were Coronary Artery Disease, CA thyroid, PCOD, and SLE.
Thirty-five participants (29.16%) of the participants had an IES-R score ≥33, which indicates a probable diagnosis of PTSD. 10 of them (8.3%) had an IES-R score of 37 or more. Which is high enough to suppress the immune system's functioning (even 10 years after an impact event).
Among the PTSD symptoms, the most commonly present symptom was that “they were still aware that they still had a lot of feelings about it, but they didn't deal with them.” The symptom was present in 53 participants (44.16%) of the study population. The other common symptoms include that “they tried not to think about it,” which was present in 48 participants (40%), and “they had thoughts about the same even when they didn't mean to,” which was reported by 46 participants (38.33%). Forty participants, that is 33.33% of the study population “tried not to talk about it.” Thirty-eight participants (31.66%) “stayed away from the remainder of it.” Thirty-seven participants (30.83%) “had waves of strong feelings about it.” Thirty-five participants (29.16%) reported that “they avoided letting themselves get upset when they thought about it or were reminded of it.”
Thirty-five participants (29.16%) had pictures about the same popping into their minds frequently. Thirty-three participants (27.5%) had “other things kept making them think about the same.” Thirty participants (25%) “had trouble concentrating.” Twenty-eight participants (23.33%) had reminders of the same caused them to have physical reactions, they also had symptoms such as trouble breathing, pounding heart, nausea, vomiting, and sweating. “Watchful and on guard” were 21 participants (17.5%). “Jumpy and easily started” symptoms were reported to be 20 (16.67%).
The least commonly present symptoms were that “they had trouble staying asleep” (15%). Seventeen participants (14.16%) had themselves “acting or feeling like they were back at that time.” Fifteen participants (12.5%) felt as if “it hadn't happened or wasn't real.” 11.66% felt “easily irritable and angry.” “Any remainder bought back feelings about it” in 9.16% of the population.
The other least commonly present symptoms like “feelings about it were kind of numb” (7.5%). Other symptoms that they were present were “they tried to remove it from their memory”. 10 participants (8.33%) reported that “they still dream about it”. Another least common symptom that was present was “they had trouble falling asleep (5.0%).”
Among the study variables analyzed, the IES-R score was significantly associated with the age category with the P value being 0.01. There is also a significant association between marital status and IES-R score, with the P value being 0.02.
Among the other study variables analyzed, the IES-R score was significantly associated with the number of comorbidities with the P value being 0.01. There is also a significant association between socioeconomic status and IES-R score, with a P value being 0.01.
There is also a significant association between the IES-R score and the number of days of hospitalization, with a P value being 0.001 and invasive ventilation (P value being 0.001). Among the other study variables analyzed, the IES-R score was not significantly associated with BMI (P value being 0.45), regular physical exercise before the diagnosis of COVID-19 (P value being 0.77), gender (P value being 0.15) and with the zone of admission yellow, orange and red (P value being 0.31).
| Discussion | | |
The coronavirus infectious disease (COVID-19) pandemic has created tremendous challenges and threats to human life and health systems globally.[16],[17] PTSD may occur in individuals who have experienced a traumatic event. The emotions, memories, and thoughts experienced during the trauma recur in the patient, leading to inconveniences and restrictions in their daily lives.[18],[19] Interestingly, an increase in the incidence of acute psychiatric symptoms has been reported in a few studies conducted before. It has been shown in one of the studies that 30%–40% of the patients display symptoms of anxiety, stress, or depression.[20] Only a few studies have addressed this important issue, although a very high prevalence of PTSD is expected. The stress of hospitalization especially ICU admission and use of ventilator support result in physiologic disturbances that leave patients vulnerable to developing stress syndrome after discharge.[21]
A few studies that investigated the prevalence of PTSD showed similar results. Chang and Park investigated the prevalence of PTSD among patients with COVID-19 who were treated and discharged from a university hospital in Daegu, Korea in 2020, found that the prevalence rate of PTSD was 20.3% in patients with COVID-19 who had been hospitalized, treated and discharged.[10]
Another similar study was conducted by Dar et al. over 2 months from September to October 2020 in Kashmir and Srinagar, North India, among the survivors of COVID-19. The hospital anxiety and depression scale was used to measure anxiety and depression. PTSDChecklist (PCL) was used to measure PTSD. The prevalence of PTSD was found to be 25.21%. When compared to the younger ones, PTSD was more prevalent among patients >50 years of age. The prevalence of anxiety was found to be 44.54% and depression was 61.34%. Some factors, such as interpersonal conflict, lower socioeconomic status, female sex, frequent use of social media, and lower resilience and social support, have been reported to increase the risk of PTSD.[22]
In a study conducted by Einvik et al. at Akershus University Hospital, Lørenskog, Norway; in 2020, the prevalence of symptom-defined PTSD was 9.5% in hospitalized and 7.0% in nonhospitalized subjects (P = 0.80). Female sex, born outside of Norway, and dyspnea during COVID-19 were risk factors for persistent PTSD symptoms.[23] Based on the study conducted by Janiri et al., at the Fondazione Policlinico Universitario Agostino Gemelli IRCCS in Rome, Italy, in 2020, PTSD was found in 115 participants (30.2%). Associated characteristics were female sex, which has been extensively described as a risk factor for PTSD, history of psychiatric disorders, and delirium or agitation during acute illness.[24]
Bonsaksen et al., in their study conducted at Oslo University in Norway, in 2020 found that the prevalence of symptom-defined PTSD was 12.5% for men and 19.5% for women. PTSD was associated with female gender, expecting an economic loss, lower age, having been in quarantine or isolation, and a range of pandemic-related variables such as economic concerns, lack of social support, being at high risk for complications from COVID-19 infection, and having concern for family and close friends.[25],[26] Patil et al. in their qualitative study conducted on psychological consequences on COVID-19 patients in a tertiary care hospital in Maharashtra from May to October 2020 found that 56% of the patients had isolation and loneliness, and 54% had adjustment issues. Females had more concern about their health. They concluded that COVID-19 infection caused psychological stress due to multiple factors.[27]
In the present study, a probable diagnosis of PTSD was present in 35 participants (29.16%). A score >37 or more, which is high enough to suppress your immune system's functioning (even 10 years after an impact event), was present in ten participants (8.33%). According to [Table 1], [Table 2], [Table 3], there is a statistically significant association between the IES-R score and age category, marital status, number of comorbidities, socioeconomic classification, number of days of hospitalization, and invasive ventilation. There is a slight increase in the prevalence of PTSD in the current study, which can be attributed to an increased number of hospital stays, and an increase in the number of comorbidities. | Table 1: Association of Impact of Events Scale-Revised score with patient characteristics (n=120)
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 | Table 2: Association of Impact of Events Scale-Revised score with patient characteristics (n=120)
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 | Table 3: Association of Impact of Events Scale-Revised score with patient characteristics (n=120)
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The COVID-19 pandemic is a community health emergency of international concern that stances a challenge to psychological resilience.[27],[28] As the pandemic is ongoing, it is important that healthcare systems and the general public must be aware of possible negative mental health outcomes and vulnerable populations.[29],[30] Further research is required to develop evidence-driven strategies to diminish the adverse psychological impacts and related psychiatric symptoms and to protect the mental health of COVID-19-infected patients. Given the disturbing impact of COVID-19 infection on the mental health of the patients, the present insights on inflammation in psychiatry, and the current observation of worse inflammation leading to worse depression, we endorse assessing the psychopathology of COVID-19 survivors and diagnosing and treating developing psychiatric conditions.[31],[32] The study clearly shows that the association between COVID-19 hospitalization and mental distress in the population globally is progressively clear as well as the escalating evidence proposes that COVID-19 has led to an increase in the prevalence of stress and trauma symptoms across geographical boundaries among diverse populations.
The current study has a few limitations. The sample size was small. In the future, studies with a larger number of COVID-19 patients will be required to discover the risk factors for PTSD in this population. Other psychiatric symptoms, including anxiety, depression, and sleep disorders, were not evaluated. Although the IES-R is a useful tool that is used for evaluating PTSD, combining it with other clinical tools that can evaluate other psychiatric symptoms, such as depression and anxiety, was not used in this study. Therefore, additional studies concerning the use of various psychological evaluation tools are needed to inspect the mental health status of patients with COVID-19.[33] Finally, there can be several factors and variables that could be potential risk factors for PTSD, such as a lack of support from family, previous history of mental illness, social support, and personal characteristics which were not inspected and examined in the present study.[34] Therefore, further studies are needed to overcome these limitations. Longitudinal studies are required further to tailor therapeutic interventions and to plan for prevention strategies. Further, follow-up studies involving the use of various psychological evaluation tools are necessary to investigate the mental health status of patients with COVID-19.
| Conclusions | | |
This study concludes that COVID-19 hospitalization and related events have negatively impacted the mental health of patients. In the present study, 29.16% of the study participants showed a probable diagnosis of PTSD which is a psychological illness that follows trauma. For survivors of COVID-19 infection particularly those patients with hospitalization and intensive care unit admission whose symptoms are longer than that of acute stress disorder psychiatric screening follow-up will be particularly important and necessary. Physicians treating the patient and their caretakers should be aware of PTSD risk and should consider PTSD screening. Studying PTSD and its associated factors is necessary to inform about the COVID-19 prognosis.
Acknowledgment
My heartfelt thanks to the Dean cum Director of our Institute, and Head of the Department of Community Medicine for giving me this opportunity. I also sincerely acknowledge all the faculty and postgraduates of the department for their support. I extend my heartfelt thanks to all the study participants who helped me in conducting this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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