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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 9
| Issue : 1 | Page : 43-53 |
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A comparison of post-COVID-19 psychiatric manifestations among adults and elderly
Mrugesh Vaishnav1, Sandeep Grover2, Parth Vaishnav1, G Prasad Rao3, Gautam Saha4, Ajit Avasthi5
1 Samvedana Happiness Hospital and Institute of Psychological and Sexual Research, Ahmedabad, Gujarat, India
2 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Asha Hospital, Hyderabad, Telangana, India
4 Clinic Brain Neuropsychiatric Institute and Research Center, Barasat, West Bengal, India
5 Fortis Hospital, Mohali, Punjab, India
| Date of Submission | 04-Jul-2022 |
| Date of Acceptance | 04-Jul-2022 |
| Date of Web Publication | 03-Aug-2022 |
Correspondence Address:
Dr. Mrugesh Vaishnav
Samvedana Happiness Hospital, Institute of Psychological and Sexual Research, Ahmedabad, Gujarat
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jgmh.jgmh_35_22
Aim: This study aimed to estimate the prevalence of psychiatric morbidity in elderly patients recovered from coronavirus disease-2019 (COVID-19) infection, the present study aimed to compare the prevalence of psychiatric morbidity among elderly (aged ≥60 years) and adult patients (aged 18–59 years). Methodology: Two hundred and three elderly patients and 1714 adult participants had completed the Patient Health Questionnaire-9, generalized anxiety disorder-7 (GAD-7), Fear of COVID-19 Scale, Brief Resilient Coping Scale, The Brief Resilience Scale, and a self-designed questionnaire to assess the neuropsychiatric symptoms. Results: In the whole sample, the prevalence of depression was 34.4%, GAD was 32.6%, sleep disturbances were 58.3%, suicidal ideations were 23%, COVID-19-related fear was 32.1%, low resilience was 18.7%, and low resilient coping was 49.5%. Compared to adult participants, elderly participants had significantly higher prevalence and severity of depression, anxiety, COVID-19 fear score, low resilience, and low resilient coping. In the whole sample, the prevalence of posttraumatic stress disorder (PTSD) symptoms was 23.8%–25.3%, panic attacks were 17%, loneliness was 23.2%, forgetfulness was 21.8%, and cognitive slowing was 19%. Compared to the adult participants, significantly higher proportion of the elderly reported PTSD symptoms, cognitive slowing, and forgetfulness. Conclusions: Compared to adult subjects, elderly subjects who have recovered from COVID-19 infection have significantly higher prevalence of depression, anxiety, fear, post-traumatic symptoms, and cognitive symptoms. Hence, there is an urgent need to assess psychiatric morbidity among the elderly subject who have recovered from COVID-19 infection and institute interventions at the earliest to improve their mental health outcomes.
Keywords: Anxiety, COVID-19, depression, elderly, fear, mental health, resilience
How to cite this article:
Vaishnav M, Grover S, Vaishnav P, Rao G P, Saha G, Avasthi A. A comparison of post-COVID-19 psychiatric manifestations among adults and elderly. J Geriatr Ment Health 2022;9:43-53 |
How to cite this URL:
Vaishnav M, Grover S, Vaishnav P, Rao G P, Saha G, Avasthi A. A comparison of post-COVID-19 psychiatric manifestations among adults and elderly. J Geriatr Ment Health [serial online] 2022 [cited 2023 Jun 4];9:43-53. Available from: https://www.jgmh.org/text.asp?2022/9/1/43/353167 |
| Introduction | |  |
The novel coronavirus disease-2019 (COVID-19) pandemic has emerged as a major crisis for the elderly. Since the beginning of the pandemic, it was stated that elderly subjects are more vulnerable to the COVID-19 infection, and are at a higher risk of mortality. Due to this since the beginning of the pandemic, many of the elderly deliberately separated themselves from others to avoid COVID-19 infection. During the pandemic, the elderly also experienced other adverse consequences such as lack of access to the health-care services due to the closure of routine health-care services or difficulty in adapting to the tele-health care services.[1] As the pandemic progressed, a huge amount of literature accumulated on the adverse mental health outcomes of the pandemic on the general population, health-care workers, and various high-risk groups. A meta-analysis of 5 studies which included data of 9074 persons reported the prevalence of stress to be 29.6% (confidence interval [CI]: 24.3%–35.4%). The same meta-analysis reported the prevalence of anxiety in 17 studies involving 63,439 persons to be 31.9% (95% CI: 27.5–36.7) and that of depression in 14 studies involving 44,531 participants at 33.7% (95% CI: 27.5–40.6).[2] Another meta-analysis which included pooled data from 65 studies involving 97,333 health-care workers from 21 countries reported the pooled prevalence of depression to be 21.7% (95% CI, 18.3%–25.2%). The same meta-analysis reported pooled prevalence of anxiety to be 22.1% (95% CI, 18.2%–26.3%), and that of post-traumatic stress disorder (PTSD) to be 21.5% (95% CI, 10.5%–34.9%). In terms of countries, the prevalence rated for depression and anxiety were reported to be highest in studies from Middle-East (34.6%; 28.9%) countries.[3] A recent meta-analysis reported the pooled prevalence to be 45% (95% CI: 37–54) for depression, 47% (95% CI: 37%–57%) for anxiety, and 34% (95% CI: 19%–50%) for sleep disturbances in patients with COVID-19 infection.[4]
Emerging data also suggested a high prevalence of psychiatric morbidity among the persons who suffered from the COVID-19. A review of data which included information from 34 studies with a follow-up duration up to 3 months, reported prevalence of anxiety to vary from 6.5%–63%, depression to vary from 4% to 31%, and that of post-traumatic stress disorder to vary from 12.1% to 46.9%. Higher prevalence of anxiety and depression were reported by females and individuals admitted to the intensive care units (ICUs).[5] These studies included persons of all age groups, with the mean age of the study sample in some of the studies to be close to 60 years, and the sample size varied from 14 to 895 participants, with almost all studies having a sample size <200 participants. None of the studies included in this review emerged from India. However, none of these studies compared the psychiatric morbidity among the elderly and adult patients.[5] Another systematic review and meta-analysis that included data from 51 studies involving 18,917 patients with a mean duration of follow-up of 77 days (range 14–182 days) reported that sleep disturbance was the most common psychiatric morbidity with a pooled prevalence of 27.4% (95% confidence interval [CI]: 21.4%%–34.4%), followed by fatigue (24.4% [CI: 17.5%–32.9%]), objective cognitive impairment (20.2% [CI: 10.3%–35.7%]), anxiety (19.1% [CI: 13.3%–26.8%]), post-traumatic stress (CI: 15.7% [9.9%–24.1%]), and depression [CI: 13% (7%–22%)][6] (Badenoch et al., 2021). The clinical variables such as hospitalization, severity of COVID-19 infection, and duration of follow-up did not influence the prevalence of psychiatric morbidity.[6] A large sample size study involving 236,379 patients evaluated the incidence of neurological and psychiatric disorders after 6 months of diagnosis of COVID-19 infection, reported the incidence (new onset or first onset) of anxiety disorders to be 7.11% (6.82–7.41), depressive disorders to be 4.22% (3.99–4.47), and psychotic disorders to be 1.4% (1.30–1.51). The prevalence of dementia, anxiety disorders, and psychotic disorders was higher among those admitted to ICUs.[7]
There are limited data from India on the psychiatric morbidity among persons who have recovered from COVID-19. A previous survey from Chandigarh that evaluated 206 participants estimated the prevalence of anxiety to be 24.8%, depressive symptoms to be 23.8%, PTSD to be 30%, fatigue to be 61.2%, and 38% of the patients reported at least one cognitive symptom.[8] Considering the fact there is limited data on the prevalence of psychiatric morbidity in elderly patients who recovered from COVID-19 infection, the present study aimed to compare the prevalence of psychiatric morbidity among elderly (aged ≥60 years) and adult patients (aged 18–59 years).
| Methodology | | |
This cross-sectional web-based study was done from July 24 to September 24, 2021, during the downslide of the second wave of the COVID-19 in India after obtaining approval from an independent ethics committee (IBIOMEIECECR/40/INDT/GJ2013/RR1, IORG no. IORG0005548). The survey was done in three languages (English, Hindi, and Gujarati) using Google forms and was circulated using WhatsApp, Email, text message, Facebook, and Instagram using the snowball sampling technique. The recipients of the survey link were requested to forward the survey link further. The link was designed to generate a single response by entering one phone number even with multiple devices. The completion of the survey implied providing informed consent.
The survey link mentioned that the survey should only be completed by those persons, who were aged between 18 and 75 years and had suffered from the COVID-19 infection themselves, or one of their close relatives had suffered COVID-19 infection and they had witnessed the same. The present paper included the data of only those persons who had suffered from the COVID-19 infection. The survey invitation clearly indicated that the recipients of the link have the right not to participate in the survey. It was mandatory for participants to enter their phone numbers. Confidentiality of the data obtained was maintained. Data for checked for duplicate entries by screening the IP addresses of the responses.
The survey questionnaires included:
Sociodemographic details
The section of the survey collected information with respect to age, gender, educational qualification, marital status, profession, resident area, and religion.
Previous psychiatric illness-related data
The section included information about previous psychiatric illnesses and starting of sleep medications.
Medical illnesses and COVID-19-related data
The third section collected the information related to medical comorbidities. Data was also collected for treatment-related variables with respect to the COVID-19 infection.
Patient Health Questionnaire (PHQ)-9 items version (Patient Health Questionnaire-9)
This is a self-administered version of the PRIME-MD diagnostic instrument used for screening of depression. It has 9 items corresponding to the 9 diagnostic criteria of depression as per the DSM-IV. Each item is rated on a 4-point scale of “0” (not at all) to “3” (nearly every day). The Patient Health Questionnaire-9 (PHQ-9) has excellent reliability and validity, sensitivity, and specificity for major depression. A cut score of ≥10 is considered to be an indicator of depression. Other cut-offs used to grade the severity of depression include mild depression,[5],[6],[7],[8],[9] moderate depression,[10],[11],[12],[13],[14] moderately severe depression (15-19), and severe depression (≥20).[9]
Generalized Anxiety Disorder-7 scale
This is a 7-item anxiety scale used to assess generalized anxiety disorder (GAD). A score of 10 is considered to indicate the presence of GAD. The cutoff scores of 5, 10, and 15 are interpreted as representing mild, moderate, and severe levels of anxiety on the GAD-7. The scale has good reliability as well as criterion, construct, factorial, and procedural validity.[10]
Fear of COVID-19 Scale
The Fear of COVID-19 Scale is a seven-item scale, with each item rated on a 5-point Likert scale (strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree, and strongly agree). Scores are categorized as low and high levels of fear based on the mean score, which was taken as a cut-off. In the current study, the cut-off of 12 or higher was considered as indicator of a high level of fear. This scale has been validated and tested for reliability in a few recent studies.[11]
A self-designed questionnaire
A self-designed questionnaire was also included to document the effect of COVID-19, in the form of PTSD, panic attack, obsessive–compulsive features, worry, and loneliness. Neurological and cognitive symptoms such as brain operating slowly, forgetfulness, difficulty in holding things, tremors, seizures, headache, and dizziness were also assessed as part of this section of the survey.
Brief Resilient Coping Scale
It is a 4-item measure designed to capture tendencies to cope with stress in a highly adaptive manner. Its validity and reliability had also been tested in earlier studies. Each item is evaluated on a 5-point Likert scale (does not describe me at all, does not describe me, neutral, describes me, describes me very well), and the scores are categorized as low (score 4–13), medium (score 14–16), and high (score 17–20).[12]
The Brief Resilience Scale
The brief resilience scale is a six-item scale, with a 5-point Likert rating (strongly disagree, disagree, neutral, agree, and strongly agree). Some of the items are reverse-coded (items 2, 4, and 6). The scale has acceptable internal consistency in both samples, with Cronbach's α values equal to 0.76 and 0.72, respectively.[13],[14]
Statistical analysis was done using software IBM SPSS v.21. Continuous variables were expressed as mean and standard deviations, whereas categorical variables were defined as a percentage. The Chi-square test and t-test were used for comparison. A correlation analysis between the variables was determined using Pearson's correlation test. Statistical significance was accepted at the level of P < 0.05.
| Results | | |
The study included data of 1917 participants, out of whom 203 (10.6%) were aged 60 years or more. For further analysis, the study sample was divided into elderly (aged 60 years or more) and those aged between 18 and 59 years (adult group).
When the demographic variables were compared for the elderly and the adult group, significantly higher proportion of those in the elderly group were married and were educated up to graduation [Table 1]. | Table 1: Comparison of sociodemographic profile of the adult and elderly participants
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Compared to the adult participants, significantly higher proportion of the elderly reported fear of getting infected with the Mucor mycosis after recovering from the COVID-19 infection. However, there was no significant difference between the two groups with respect to prevalence of past psychiatric illness, and starting of new sleeping medications after the COVID-19 infection, and new-onset sexual difficulty [Table 2]. | Table 2: Comparison of prevalence of past psychiatric illness and starting of sleep medications among elderly and adult participants
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Compared to adult participants, significantly higher proportion of the elderly participants have the presence of medical comorbidity, required hospitalization for the COVID-19 infection and required hospitalization for more than 2 weeks [Table 3]. | Table 3: Comparison of prevalence of medical comorbidities and details of coronavirus disease-2019infection among elderly and adult participants
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Psychiatric morbidity, fear related to COVID-19, resilient coping, and resilience
In the whole sample, the prevalence of depression was 34.4%, GAD was 32.6%, sleep disturbances were 58.3%, suicidal ideations were 23%, COVID-19-related fear was 32.1%, low resilience was 18.7 and low resilient coping to be 49.5%. Compared to adult participants, elderly participants had significantly higher PHQ-9 score, GAD-7 score, and COVID-19 fear score. However, compared to adults, elderly had significantly lower scores on the brief resilience score and brief resilient coping scale [Table 4]. The prevalence of depression and GAD was significantly higher for the elderly participants when compared to adult participants. Similarly, significantly higher proportion of the elderly had “moderately severe or very severe” depression, when compared to adult participants [Table 5]. The prevalence of “moderate or severe anxiety” was also significantly higher among the elderly participants, when compared to adult participants. Compared to adults, significantly higher proportion of the elderly had a higher level of fear related to COVID-19 infection, lower level of resilience, and resilient coping [Table 4]. | Table 4: Prevalence of psychiatric morbidity among the among elderly and adult participants
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 | Table 5: Comparison of other neuropsychiatric issues among elderly and adult participants
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In the whole sample, the prevalence of PTSD symptoms was 23.8 to 25.3%, panic attacks were 17%, loneliness was 23.2%, forgetfulness was 21.8%, and cognitive slowing was 19%. Compared to the adult participants, significantly higher proportion of the elderly reported flashbacks, presence of repeated, disturbing, and unwanted memories of the stressful experience, presence of avoiding memories, thoughts, or feelings related to the stressful experiences, brain operating slowly, and forgetfulness. In contrast, a significantly higher proportion of adults reported increased energy or constant urge to do many things [Table 5].
When the prevalence of psychiatric morbidity was done only by the participants without the past history of psychiatric disorders (n = 1659), severity and prevalence of depression, anxiety, fear, sleep disturbances were significantly higher among the elderly, compared to the adult population. Further compared to adult participants, the elderly had lower level and lower prevalence of high resilience and resilience coping [Table 6]. | Table 6: Prevalence of psychiatric morbidity among the elderly and adult participants
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Similarly, compared to adult patients, elderly had a higher prevalence of symptoms of PTSD, brain operating slowly, and forgetfulness; and lower prevalence of manic symptoms [Table 7]. | Table 7: Comparison of other neuropsychiatric issues among elderly and adult participants
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Correlation between depression, anxiety, fear, resilience, and resilient coping
In both the groups (i.e., adult and elderly), higher severity of depression was associated with higher severity of anxiety and COVID-19-related fear; and lower level of resilience and resilient coping [Table 8]. Similarly higher severity of anxiety was associated with a higher level of COVID-19-related fear; and lower level of resilience and resilient coping. A higher level of COVID-19-related fear was associated with lower level of resilience and resilient coping. Lower resilient coping was associated with lower level of resilience [Table 8]. | Table 8: Association between patient health questionnaire-9, generalized anxiety disorder-7, Fear of Corona Virus Disease-2019 Scale, Brief Resilience Scale, Brief Resilient Coping Scale among elderly
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| Discussion | | |
This survey aimed to compare the prevalence of psychiatric morbidity in among elderly and adult subjects who had recovered from COVID-19 infection. In the present survey, in the whole sample, the prevalence of depression was 34.4%, GAD was 32.6%, sleep disturbances were 58.3%, suicidal ideations were 23%, COVID-19-related fear was 32.1%, low resilience was 18.7%, and low resilient coping was 49.5%. In addition, in the whole sample, the prevalence of PTSD symptoms was 23.8–25.3%, panic attacks were 17%, loneliness was 23.2%, forgetfulness was 21.8%, and cognitive slowing was 19%. Available data from different countries suggest that the prevalence of anxiety varies from 6.5% to 63%, depression varies from 4% to 31%, and of PTSD varies from 12.1% to 46.9%.[5] The systematic review and meta-analysis of studies estimated the pooled prevalence of sleep disturbance to be 27.4%, objective cognitive impairment to be 20.2%, PTSD to be 15.7%, and that of depression to be 13%.[6] When we compare the findings of the present survey with these studies, our findings are in the reported range. This higher prevalence of psychiatric morbidity in persons who have recovered from COVID-19 infection across the globe suggests that there is an urgent need to establish separate clinical services for this group of persons to assess and manage the psychiatric morbidity.
In addition, the present survey suggests that compared to adult participants, elderly participants had significantly higher prevalence and severity of depression, anxiety, COVID-19 fear score, PTSD symptoms, cognitive slowing, forgetfulness, low resilience, and low resilient coping. As none of the previous surveys has compared the elderly and adult persons who have recovered from COVID-19 infection, it is not possible to compare the findings of the present survey with the existing literature. The higher prevalence of various psychiatric symptoms among the elderly is understandable considering the presence of higher vulnerability factors such as comorbid physical illnesses. This finding suggests that there is an increased need to increase the awareness about this among the clinicians, general population, elderly, and policymakers so that appropriate provisions can be made to identify these outcomes and the mental health treatment gap can be reduced.
In the present study, about 13.5% were diagnosed with psychiatric disorders in the past and were on treatment for the same. Hence, we assessed the prevalence of psychiatric morbidity among those who were not diagnosed with any psychiatric morbidity in the past. In those without the past psychiatric history, the prevalence of depression was 32%, GAD was 29.8%, sleep disturbances were 53.8%, suicidal ideations were 24.35%, COVID-19-related fear was 33.1%, low resilience was 17% and low resilient coping was 44.96%. In addition, the prevalence of PTSD symptoms was 25%–26.5%, panic attacks were 18.1%, loneliness was 24.3%, forgetfulness was 22.1%, and cognitive slowing was 20%. These figures can be interpreted in different ways. First, the prevalence of psychiatric symptoms as assessed by different scales was not affected by the past psychiatric history. Second, these figures can be understood as new-onset psychiatric morbidity. The previous study that evaluated the incidence and prevalence of psychiatric morbidity in 2,36,379 in persons 6 months after the diagnosis of COVID-19 infection, reported the incidence (new onset or first onset) of anxiety disorders to be 7.11% (6.82–7.41), depressive disorders to be 4.22% (3.99–4.47), and psychotic disorders to be 1.4% (1.30–1.51).[7] When we compare these figures with our findings, it can be said that the incidence of psychiatric morbidity among persons who have recovered from COVID-19 infection is higher in India when compared to the United States. However, no specific conclusion should be drawn for this difference, as this difference can also be attributed to the difference in the sample sizes, and method used to consider the presence of psychiatric morbidity. The previous study estimated the incidence of psychiatric morbidity based on the new psychiatric diagnosis as per the health-care records, whereas the present study findings are based on the self-report measure in an online survey.
When the prevalence/incidence of psychiatric morbidity between elderly and adult subjects with no past history of psychiatric disorder was compared, similar trends as seen in the whole sample were seen. These findings suggest that the significant differences noted between the elderly and adult participants cannot be attributed to the past psychiatric history.
In the present study, in both the groups (i.e., adult and elderly), higher severity of depression was associated with higher severity of anxiety and COVID-19-related fear; and lower level of resilience and resilient coping. A higher severity of anxiety was also associated with higher level of COVID-19-related fear; and lower level of resilience and resilient coping. A higher level of COVID-19-related fear was also associated with lower level of resilience and resilient coping. All these findings suggest that psychiatric symptoms in the post-COVID infection phase manifest in a cluster. Hence, while evaluating psychiatric morbidity in persons who have recovered from COVID-19 infection, the clinicians should not limit themselves to the self-reported symptoms, and rather should evaluate the whole range of symptoms.
The present survey has certain limitations, which must be kept in mind while interpreting the findings. The present study was a web-based cross-sectional survey that relied on snow-ball sampling method and used a screening questionnaire to assess psychiatric morbidities. The study sample in the elderly group was relatively small when compared to the adult sample size. Further, some of the variables such as loneliness, PTSD, and cognitive deficits were assessed using 1–3 questions, rather than using a detailed questionnaire. We did not assess the post-COVID or long COVID symptoms involving other body organs which can have a significant impact on the psychiatric morbidity. The future research with a longitudinal study design and larger sample size must attempt to overcome these limitations.
| Conclusions | | |
To conclude, the present survey, suggests that about one-third of the persons who have recovered from COVID-19 infection exhibit depression, anxiety, and fear of COVID-19 infection, about two-fifth have sleep disturbances, one-fourth have suicidal ideations, features of PTSD and loneliness, one-fifth have features of cognitive disturbances and one-sixth exhibit panic attacks. The prevalence of all the psychiatric measures is significantly higher among the elderly compared to the adult subjects and the prevalence is not affected significantly by past history of psychiatric disorders. Accordingly, it can be said that there is an urgent need to assess psychiatric morbidity among the elderly subject who have recovered from COVID-19 infection and institute interventions at the earliest to improve their mental health outcomes.
Acknowledgement
Chanakya Sahay, Project Coordinator, Sr. Executive, Institute of Psychological and Sexual Research, and Samvedana Happiness Hospital and Research Centre. Ahmedabad.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
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