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STUDY OF THE PREVALENCE OF ANXIETY AND DEPRESSION AMONG COVID-19 PATIENTS:
SYSTEMATIC REVIEW AND META-ANALYSIS
Tuychiev Sh.,
Assistant of the Department of Psychiatry, Narcology, pediatric Psychiatry, Medical Psychology and Psychotherapy. Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
Abdullaeva V.,
Doctor of Medical Sciences, Associate Professor,
Head of the Department of Psychiatry, Narcology and pediatric Psychiatry, Medical Psychology and Psychotherapy. Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
Matveeva A.
Assistant of the Department of Psychiatry, Narcology, pediatric Psychiatry, Medical Psychology and Psychotherapy. Tashkent Pediatric Medical Institute, Tashkent, Uzbekistan
Abstract
In December 2019, an infectious disease of a coronavirus spread in Wuhan, China, and swiftly spread globally. The World Health Organization (WHO) as a public health emergency of international concern declared the Coronavirus disease (COVID-19). Moreover, the WHO announced the COVID-19 outbreak as a "pandemic" on 11 March 2020. (Harapan, et al. 2020) (Burki 2020)
Depression could worsen the prognosis of many diseases, as well as COVID-19. Psychological distress and depression may have a negative impact on patients' immune system response (Leonard, 2001). Patients with depression may also have negative attitudes towards antiviral therapy, which may reduce their treatment adherence and recovery. Previous studies found that patients could experience persistent depression even after the outbreak of infectious diseases. For instance, the prevalence of depression among patients with SARS were 18% at 1 month after their discharge (Wu et al., 2005), and 15.6% at 30-month assessment after SARS outbreak (Mak et al., 2009).
To date there have been some studies on prevalence of anxiety and depression among COVID-19 survivors. Therefore, we set out to examine the prevalence of depression and anxiety among COVID-19 survivors.
Systematic review and meta-analysis were done in two databases (PubMed and Web of Science) to examine prevalence of depression and anxiety among COVID-18 survivors.
In summary, among COVID-19 survivors the prevalence of anxiety was 34.66% (95% CI: 25.19; 44.78), the prevalence of depression was 30.11% (95% CI: 21.65; 39.30).
Keywords: SARS-CoV-2, COVID-19, anxiety, depression, prevalence
Introduction. In December 2019, an infectious disease of a coronavirus spread in Wuhan, China, and swiftly spread globally. The Coronavirus disease (COVID-19) was declared by the World Health Organization (WHO) as a public health emergency of international concern. Moreover, the WHO announced the COVID-19 outbreak as a "pandemic" on 11 March 2020. (Harapan, et al. 2020) (Burki 2020). As with the two other coronaviruses that caused major outbreaks in humans in recent years (namely, severe acute respiratory syndrome and the Middle Eastern Respiratory Syndrome) (WHO. 2020) (Yin Y. 2018), COVID-19 is transmitted from human-to-human through inhalation of respiratory droplets from each symptomatic and asymptomatic infectious people. (Bai Y. 2020).
Patients infected with COVID-19 experienced physical discomfort, fear of developing complications, and discrimination by the mass media (e.g., WeChat and Weibo) (Lu et al., 2020; Shigemura et al., 2020). These negative feelings could lead to elevated risk of psychiatric problems, particularly, depressive symptoms (depression hereafter) (Bondade et al., 2019; Ren et al., 2019; Xiang et al., 2020). Moreover, isolation in designated hospital for COVID-19 for treatment, the loneliness during treatment could trigger depression as well (Li et al., 2020).
Depression could worsen the prognosis of many diseases, as well as COVID-19. Psychological distress and depression may have a negative impact on patients' immune system response (Leonard, 2001). Patients with depression may also have negative attitudes towards antiviral therapy, which may reduce their treatment adherence and recovery. Previous studies found that patients could experience persistent depression even after the outbreak of infectious diseases. For instance, the prevalence of depression among patients with SARS were 18% at 1 month after their discharge (Wu et al., 2005), and 15.6% at 30-month assessment after SARS outbreak (Mak et al., 2009).
To date there have been some studies on prevalence of anxiety and depression among COVID-19 survivors. Therefore, we set out to examine the prevalence of depression and anxiety among COVID-19 survivors.
Aim of the study: Identify prevalence of the anxiety and depression among COVID-19 infection patients.
Materials and methods
Data source and study selection
Database searches were done by manual search in PubMed and Web of Science. Studies reporting prevalence of anxiety and / or depression among COVID-19 infection patients published from 2019 were included. Studies reporting prevalence among whole population, healthcare workers, among students, meta-analysis, case studies, case reports were excluded. A complete list of the search queries is shown in Supplementary Table. The last search was conducted on June 4th, 2021, and records on English or Russian were eligible. Search results were downloaded as .csv file. After removing duplicates using Endnote records were screened based on their title and abstracts. Screening were done by two authors independently (T.Sh.T and M.A.A.) and conflicts were resolved by third author (A. V.K.)
Data extraction
A pre-piloted standardized electronic data extraction form was used to extract relevant data: authors names, year of publication, study setting, study design, study period, characteristics of study subjects (age, sex, location), sample size. In this paper, a "report" refers to any document mentioning prevalence of anxiety and/or depression among COVID-19 patient's data,
Data analysis
A meta-analysis of proportion was performed using the 'meta' and 'metafor' packages in the statistical program R. Data were transformed using the Freeman-Tukey double arcsine method to account for small proportions. The Dersimonian and Laird method, based on the random-effects model, was used to perform the meta-analysis, and summarize data in a forest plot. Confidence-interval (CI) for individual studies proportions were calculated using the Clopper-Pearson method.
Ethical approval
This research does not require ethical approval.
Results
Search results
A total of 955 records were identified from the PubMed and 1347 records were identified from Web of Science databases. After duplicates exclusion and titles and abstracts screening, 41 reports were selected for full-text review. Of these, 20 met the inclusion criteria. The selection process is summarized in Figure 1. Search strategy summarized in Table 1.
Figure 1. Flow diagram of systematic review and meta-analysis.
Table 1.
Search strategy of systematic review
# Database Search strategy Number of articles
1 Web of science ((ALL=(Prevalence)) AND (ALL=(COVID-19) OR ALL=(SARS-CoV-2))) AND (ALL=(Anxiety) OR ALL=(Depression)) 1347
2 PubMed ("covid 19"[All Fields] OR "covid 19"[MeSH Terms] OR "sars cov 2"[All Fields] OR "sars cov 2"[MeSH Terms] OR "severe acute respiratory syndrome coronavirus 2"[All Fields]) AND ("depression"[All Fields] Or "anxiety"[All Fields] OR "depression"[MeSH Terms] OR "anxiety"[MeSH Terms]) AND ("prevalence"[All Fields] OR "prevalence"[MeSH Terms]) 995
Study characteristics
The details about the characteristics of each study are reported in Table 2. Studies were conducted between 2019 and 2021. Total 1837 COVID-19 infection patients reported anxiety in 19/20 records and 1837 patients reported depression in 18/20 records involved in review. 6/20 articles published in 2020, 14/20 articles published in 2021.
Study Events Total
Ma YF etal, 2020 332 770
Tomasoni □ etal. 2021 12 105 -■
NieXD etal. 2021 28 78
□ai LLetal. 2020 41 307
JeongSJ etal, 2020 37 234 -
LIT etal, 2021 72 183
BeckKetal. 2021 10 126
Wang Met al, 2021 246 460
ChenYetal, 2021 189 898
HuQetal. 2021 323 867
Li L etal. 2021 216 782
KongXetal, 2020 41 144
Khademl Metal, 2021 30 602
PelusoMJ etal. 2021 64 179
ZandifarA et al. 2020 103 106
LiXetal, 2020 29 99
ParkerCetal. 2021 17 58
MendezR et al, 2021 48 179
Random effects model 6177
Heterogeneity:/ = 0.(1413, p < 0.(11
Events per 100 observations
Events
4312 1143 35.90 13.36 15.81 39.34 7.94 53.43 21.05 37.25 27.62 28.47 4.93 35.75 97.17 29.29
29.31
26.32
9'5%-CI Weight
r
[39.59 [6.05 [25.34 [9.76 [11.38 [32.22 [ 3.87 [48. SO [18.42 [34.03 [24.51 [21.27: [3.39 [23.74: [91.95 [20.57 [18.09 [20.48
46.70" 19.11]
47.56] 17.68] 21.13] 46.82] 14.11] 58.11" 23.86]
40.57] 30.90'
36.58] : 7-04] 43.25] 99.41" 39.29] 42.73] 33.94-]
5.7% 5.4% 5.3% 5.6% 5.6% 5.6% 5.5% 5.7% 5.7% 5.7% 5.7% 5.5% 5.7% 5.6% 5.4% 5.4% 5.2% 5.6%
1-1-1
20 40 60 80
Figure 2 Prevalence of anxiety among COVID-19 survivors
30.11 [21,65; 39.30] 100.0%
Among region 9/20 records reported China, 3/20 records in USA, Iran 2/20 records and Italy, England, South Korea, Switzerland, France, Spain 1/20 records each. Diagnostic strategy was used Hamilton anxiety and depression scale (HADS) 6 records, different versions of Patient's health questionary -7 (PHQ), General Anxiety Disorder - 5 (GAD), Zung self-rating anxiety scale and Zung self-rating depression scale - 3, Symptom checklist 90 - 1, Depression, Anxiety and Stress
Scale - 1, Perceived Stress Scale - 1, phone call - 1. Some studies used different diagnostic strategy for anxiety and depression. Thus, total number of questionar-ies more than number of records.
The prevalence of anxiety among COVID-19 patients was from 5.80% (among both hospitalized and non-hospitalized patients) to 100% (among hospitalized patients with ICU). The pooled prevalence of anxiety was 34.66% (95% CI: 25.19; 44.78). (Fig.2)
Study Events Total
Tomasoni □ etal, 2021 30 105
NieXD etal, 2021 30 73
□ai LLetal. 2020 57 307 +
Jeong SJ etal. 2020 24 234
Li J etal, 2021 173 296
LiTetal, 2021 103 133
BeckKetal, 2021 22 126 ■
Wang Metal. 2021 213 460
ChenYetal, 2021 147 898
HuQetal. 2021 330 367
Li L etal, 2021 247 732
KongXetal, 2020 50 144
Khademi M etal, 2021 35 602
PelusoMJ etal. 2021 100 179
ZandifarAetal. 2020 106 106
LiXetal, 2020 15 99
ParkerCetal, 2021 21 53
etal. 2021 81 311
MendezR etal. 2021 53 179
Random effects model 6014
Heterogen&ity:,' = &S%, r = 0.0510. p < 0.01 '
Events per 100 observations
T
Events
23.57 38.46 13.57 10.26
53.45 56.23
17.46 46.30 16.37 33.06 31.59 34.72
5.31 55.37 100.00 15.15 36.21 26.05 29.61
95%-CI Weight
[20.13; [27.66 [14.33 [6.63 [52.60 [48.77 [11.28 [41.63 [14.01 [34.32 [23.34 [26.99: [4.03;
33.21" 50.17] 23 38]
14.38] 64.12] 63.59] 2523] 50.93] 1&.95]
41.39] 34.97]
43.10;
7.99]
[48.27; 63.27] [96.58; 100.00] [8.74; 23.76] [23.99: 49.38] [21.26; 31.30" [23.03; 36.38]
5.2% 5.1% 5.3% 5.3% 5.3% 5.3% 5.2% 5.4% 5.4% 5.4% 5.4% 5.2% 5.4% 5.3% 5.2% 5.2% 5.0% 5.3% 5.3%
1
~1-T
20 40 60 30 100
Figure 3 Prevalence of depression among COVID-19 survivors
34,66 [25,19; 44,70] 100.0%
The prevalence of depression among COVID-19 patients was from 7.90% (among both hospitalized and non-hospitalized patients) to 97.2% (among hospitalized patients with ICU). The pooled prevalence of depression was 30.11% (95% CI: 21.65; 39.30). (Fig.3)
Summary
In summary, among COVID-19 survivors the prevalence of anxiety was 34.66% (95% CI: 25.19; 44.78), the prevalence of depression was 30.11% (95% CI: 21.65; 39.30). These numbers are higher in relation to the general population. More research is needed on the effect of depression and anxiety among COVID-19 survivors.
Supplementary table. Characteristics of eligible studies for systematic review and meta-analyses
© z Title First author, year Country Study year Study design Subject Total number of patients Diagnostic strategy Prevalence of anxiety % Number of patients with anxiety Prevalence of depression % Number of patients with depression
1 Prevalence of depression and its association with quality of life in clinically stable patients with COVID-19. Ma YF et al, 2020 China 2021.02-2021.03 Cross-sectional Patients in isolation hospitals 0 r-r- PHQ-9 43.10% 2 m 3
2 Anxiety and depression symptoms after viro-logical clearance of COVID-19: A cross-sectional study in Milan, Italy. Tomasoni D et al, 2021 Italy 2020.04-2020.06 Cross-sectional Clinical recovery and virological clearance Hosüital- iO © HADS 29.00% © m 11.00% <N
o vo 00 On
Prevalence and predictors of posttraumatic stress disorder, depression and anxiety among hospitalized patients with Coronavirus disease 2019 in China. Acute psychological impact on COVID-19 patients in Hu-bei: a multicen-ter observational study. Prevalence and factors associated with psychological burden in COVID-19 patients and their relatives: A prospective observational cohort study. Prevalence and Risk Factors for Anxiety and Depression in Patients With COVID-19 in Wuhan, China. The psychological symptoms of patients with mild symptoms of coronavirus disease (2019) in China: A cross-sectional study. Clinical characteristics and online mental health care of asymptomatic or mildly symptomatic patients with coronavirus disease 2019. Anxiety and depressive symptoms among COVID-19 patients in Jianghan Fang-cang Shelter Hospital in Wuhan, China. Anxiety and depression and its correlates in patients with coronavirus disease 2019 in Wuhan.
ChenYetal, 2021 Wang M et al, 2021 BeckKetal, 2021 Li T et al, 2021 Li J et al, 2021 Jeong SJ et al, 2020 Dai LL et al, 2020 Nie XD et al, 2021
China China Switzerland United States China South Korea China England
22 Mar-24 May 2020 2 Feb-5 March 2020 March-June 2020 Jan.-Feb 2020 3-5 March 2020 15.03-10.04.2020 Feb. March 2020
Cross-sectional Cross-sectional Cohort Cross-sectional Cross-sectional Cross-sectional Cross-sectional Cross-sectional
After hospital patients patients Adult patients Patients with COVID-19 Mild symptomatic Asymptomatic and mild symptomatic patients Recovered patients
898 460 126 183 296 234 307 78
PHQ 9 GAD 7 PHQ 9 PHQ 15 GAD 7 HADS Zung SAS, SDS Symptom check list 90 HADS Self rating anxiety & Self rating depression scale Zung SDS
16.40% 46.30% 17.50% 56.30% 58.40% 10.30% 18.60% 38.50%
147 213 22 103 173 24 57 30
21.00% 53.48% 7.90% 39.30% 15.80% 13.40% 35.90%
189 246 10 72 37 41 28
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Depression, Anxiety, and Acute Stress Disorder Among Patients Hospitalized With COVID-19: A Prospective Cohort Study. The Associated Factors of Anxiety and Depressive Symptoms in COVID-19 Patients Hospitalized in Wuhan, China. Prevalence and severity of depression, anxiety, stress and perceived stress in hospitalized patients with COVID-19. Rapid implementation of a cohort for the study of post-acute sequelae of SARS-CoV-2 infec- tion/COVID-19. Prevalence of Mental Health Problems and Its Associated Factors Among Recovered COVID-19 Patients During the Pandemic: A Single-Center Study. Effect of Psy-chological-Be-havioral Intervention on the Depression and Anxiety of COVID-19 Patients. A Follow-Up Investigation of Mental Health Among Discharged COVID-19 Patients in Wuhan, China. Mental Health Outcomes Among Civil Servants Aiding in Coronavirus Disease 2019 Control.
Parker C et al, 2021 Li X et al, 2020 Zandifar A et al, 2020 Peluso MJ et al, 2021 Khademi M et al, 2021 Kong X et al, 2020 Li Let al, 2021 Hu Q et al, 2021
USA China Iran USA Iran China China China
24 Apr. -1 June 2020 18 Mar -18 Apr 2020 Apr. 2020 21 Apr-31 Dec 2020 20 Apr-20 June 2020 23 Feb-13 Mar.2020 3-10 Apr 2020 9-11 April 2020
Cohort Cross-sectional Cross-sectional Cohort Cross-sectional Cross-sectional Cross-sectional Cross-sectional
ICU patients after 2 weeks Hospitalized patients Hospitalized patients Patients after more than 2 weeks Hospitalized and non hospitalized patients Chinese civil servants
58 99 106 179 602 144 782 867
HADS HADS DASS 21 PSS 4 GAD 7 PHQ 8 PHQ 4 PTSD checklist HADS PHQ 9 GAD 8 PHQ 9 GAD 7
36.00% 15.20% 100.00% 56.00% 5.80% 34.72% 31.59% 38.06%
21 15 106 100 35 50 247 330
29.00% 29.30% 97.20% 36.00% 5.00% 28.47% 27.62% 37.25%
17 29 103 64 30 41 216 323
Prevalence and e aln - -a p
characteristics of 1 en s
19 persistent symptoms after non-severe COVID-19: a prospective cohort study. et al, 202 France 3 Mar.-23 J 2020 tc CJ M - M M 2 o Non severe tients 3 26.20% 00
20 Short-term neu-ropsychiatric outcomes and quality of life in COVID-19 survivors. Mendez R et al, 2021 Spain 8 Mar-25 Apr 2020 Cross-sectional Hospitalized patients 9 t- Phone call 29.65% m «1 26.80% 00
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