Anxiety and depressive symptoms among home isolated patients with COVID-19: A cross-sectional study from Province One, Nepal

Home isolated patients infected with COVID-19 might be at increased risk of developing mental health problems. The study aimed to identify the prevalence and factors associated with anxiety and depression among COVID-19 home isolated patients in Province One, Nepal. This was a cross-sectional study conducted between February 17, 2021, to April 9, 2021. A total of 372 home isolated patients from Province One were phone interviewed in the study. Anxiety and depression were measured using a 14-items Hospital Anxiety and Depression Scale (HADS). Multivariable logistic regression analysis was done to determine the risk factors of anxiety and depression. Among home isolated COVID-19 infected participants, 74.2% and 79% had symptoms of anxiety (borderline: 48.7% and abnormal: 25.5%) and depression (borderline: 52.7% and abnormal: 26.3%), respectively. Watching television was significantly associated with lower odds of experiencing symptoms of anxiety and depression. Females had significantly higher odds of having depression symptoms compared to males while ever married, those with COVID-19 related complications, and those taking medicine for the treatment of COVID-19 symptoms had a higher likelihood of exhibiting symptoms of anxiety. A focus on improving the mental health well-being of COVID-19 infected patients in home settings with connection to the health services is warranted with timely psychological interventions.


Introduction
The rapid emergence of Coronavirus-19 disease (COVID-19) is altering the psychology and interpersonal connections of millions of people all over the world. The initial emotional response to a pandemic is dread and uncertainty, which can be overpowering and can rise to isolation of 14 days was recommended for patients infected with COVID-19. The study participants were from Province One, Nepal. Province One is one of the seven provinces of the country and has 14 districts. It was the second most affected province in terms of number of COVID-19 infected cases after Bagmati province [21]. Among the 14 districts, Morang, Sunsari and Jhapa were the most affected districts-all plain districts bordering to India [21]. During the data collection period (February-April 2021), Nepal experienced an increase in COVID-19 cases due to the second wave, hospitals ran out of beds and oxygen along with other essential supplies was in critical shortage [22]. As hospitals were overwhelmed with the patients, those with mild or no symptoms were suggested to stay at home isolation. Data were collected between February 17, 2021, and April 9, 2021.

Sampling strategy and data collection methods
The sampling frame of COVID-19 home isolated patients was available from the database developed by the Ministry of Social Development of Province One, Nepal. The database included the RT-PCR test positive cases whose test was performed between April 17, 2020, to January 23, 2021. RT-PCR test positive cases reported during the period were 30316 among which contact detail was available of 11543 COVID-infected patients. The sample size was calculated using the formula of a cross-sectional survey. The total sample size required was 372 considering the prevalence of anxiety at 41%, a margin of error of 5% and a level of confidence at 95%. Since the study was not conducted in this population, we took the prevalence from a previous study done among health workers in Nepal [23]. A simple random sampling technique using the RAND command in Microsoft Excel was used to select the participants from the sampling frame of 11543 COVID-infected patients. A total of 372 participants were recruited for the study. Those who were hospitalized or unable to speak or were not available or were unwilling to participate were excluded from the study. Enumerators with previous data collection experience and academic background in public health were recruited and trained by the study team. All confirmed home isolated patients were contacted by telephone with an invitation to join the study. Those providing consent were interviewed using a structured questionnaire at their convenient time.

Data collection measures
The anxiety and depression status of the participants were assessed using the 14-item Hospital Anxiety and Depression Scale (HADS). The HADS is a commonly used tool for measuring anxiety and depression in different settings in many countries including Nepal [23][24][25][26]. The Nepali version of the HADS has satisfactory psychometric properties with construct validity achieved for both sub-scales of anxiety and depression [27]. It has seven items each for measurement of anxiety and depression with each item scoring from 0 to 3, and the total score ranging from 0 to 21. The total scores of these tools were interpreted as normal (0-7), borderline abnormal (8)(9)(10) and abnormal (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21). For further analysis, a score of more than 7 was considered as the presence of anxiety and depression [28].
The socio-demographic section of the questionnaire consisted of information on the participant's sex (male, female), age in years, education (No schooling, secondary, higher secondary, and graduation or above), family type (Nuclear and Joint/Extended), Occupation (employee and unemployed), and marital status (Ever married and never married). COVID-19 and behavioral related characteristics consisted of information of participants having health workers in family members, presence of COVID-19 symptoms, presence of comorbidity, complication during COVID-19, taking medicine for COVID-19 symptoms, use of the internet during isolation, watching TV during isolation, use of social media for COVID-19 information, use of Ministry of Health and Population (MOHP)/WHO site for COVID-19 information, smoking and alcohol history.

Data analysis
Descriptive analysis was done by calculating frequency and percentages for categorical variables. The Chi-square test was used to determine the association between categorical variables. To determine potential factors associated with the outcome variable, a multivariable logistic regression analysis was performed, and adjusted odds ratio (AOR) and 95% confidence interval (CI) were calculated. For adjusted regression analysis, those variables which were significant at a 10% significance level in bivariate analysis were included in the multivariable logistic regression analysis [29].
In multivariable logistic regression models, the effect of sex, age, marital status, presence of COVID-19 symptoms, presence of chronic comorbidity, complications during COVID-19, taking medicine for COVID-19 symptoms, use of the internet during isolation, watch TV during isolation, smoking history and alcohol history was adjusted to identify the factors associated with anxiety symptoms. Similarly for depression, the effect of sex, age, education, family type, occupation, marital status, having health workers in family members, presence of COVID-19 symptoms, complications during COVID-19, taking medicine for COVID-19 symptoms, use of the internet during isolation, watch TV during isolation, get information from WHO/MOHP, and smoking history was adjusted.

Ethics
Ethical approval for the study was given by the Nepal Health Research Council (825/2020). Informed consent was taken from study participants before the interview and after carefully explaining the study's objectives. As the data was collected through the telephone call, informed consent was taken orally. Personal identifiers such as name were not collected during the study. Table 1 shows the level of anxiety and depression among home isolated patients. Out of 372 participants, 74.2% (n = 276) had symptoms of anxiety (borderline: 48.7% and abnormal: 25.5%). Similarly, 79% (n = 294) of the participants experienced symptoms of depression (borderline: 52.7% and abnormal: 26.3%). There was a significant difference in depression status (p = 0.01) across male and female home isolated patients.  Table 2 shows the association between socio-demographic characteristics of the home isolated COVID-19 patients and their mental health status. There was a significant difference in anxiety (p = 0.04) and depression (p = 0.004) levels across gender with females reporting a higher proportion of anxiety and depression symptoms than males. Marital status was also significantly associated with both anxiety (p = 0.004) and depression (p<0.001). Age (p = 0.004), educational status (p<0.001) and occupation (p = 0.006) was significantly associated with anxiety. Table 3 shows the association of anxiety and depression symptoms with COVID-19 related as well as behavioral characteristics of the study participants. The presence of COVID symptoms, complications during COVID-19, taking medicines for COVID-19 symptoms, watching TV during COVID-19, and smoking history was associated with the presence of both anxiety and depression symptoms (p<0.05). Likewise, alcohol history was associated with anxiety while having any chronic morbidity and use of the internet during isolation was associated with depression (p<0.05).

Factors associated with anxiety and depression among home isolated COVID-19 patients
Watching TV during the home isolation was significantly associated with lowers odds of experiencing symptoms of anxiety (AOR:0.3; 95% CI:0.2-0.7), and depression (AOR:0.4;  education, having health workers in family members, presence of chronic comorbidities, use of the internet during home isolation, smoking history, alcohol history, and use of the MOHP/ WHO website for the information was not significantly associated with the symptoms of anxiety and depression (Table 4).

Discussion
To the best of our knowledge, this is the first study to identify the prevalence of anxiety and depressive symptoms among the home isolated COVID-19 patients and its associated factors in Nepal. The prevalence of anxiety and depressive symptoms was found in the majority of the home isolated patients with more than half having borderline symptoms and one in four having abnormal symptoms. This prevalence rate was higher than that reported in a recent metaanalysis which showed the prevalence of anxiety and depressive symptoms among patients with COVID-19 were 47% and 45%, respectively [30]. Compared to the previous studies in developing countries among COVID-19 patients in isolation, the prevalence of anxiety symptoms in the present study was higher than study conducted in Iran; 29.3% [31] and Wuhan, China; 18.6% [32] while lower than study conducted in Iran 100% [33]. The variation among countries could be due to different health system responses, sociodemographic compositions and different psychometric instruments used to measure anxiety and depression. Importantly, the study findings reinforce that the mental health burden during the pandemic should not be neglected, and thus mental health services should be a core part of the COVID-19 response plan. Considering that the mental health resources are scarce at primary health care level [34] and the pandemic saw an increase in suicide rate [35], we suggest for the deployment of trained mid-level health workers and psychological counsellors for offering consultation as well as linkage to hospitals and centers with treatment facilities.
Our study findings indicated that females had higher odds of having depression symptoms as compared to males. This finding is in line with the result of previous studies conducted in Italy [36], China [37], Spain [38] and Bangladesh [39]. These differences could be due to greater exposure to stresses during the pandemic and/or heightened response to stress in females. As females in Nepal are usually the caregivers in a family and are involved in domestic works, infection could further traumatize them for not being able to perform their role Likewise, females are more prone to develop internalizing symptoms following exposure to stress and trauma, even accounting for the specific event [40].
The present study found that COVID-19 home isolated patients who watched television during isolation were more likely to have low anxiety and depressive symptoms than those who did not watch television. This result contradicts the Italian study, which showed that people who spent more time watching TV series during the pandemic lockdown reported higher levels of anxiety [41]. A study from Netherland also found that computer use and television viewing were linked to anxiety and/or depressive symptoms [42]. Exposure to social media and thinking about the pandemic for a long time could have worse psychological consequences [43,44]. In our study participants, watching television could have provided an opportunity to avert patients from overthinking and thus possible mental health problems. However, we did not measure the content and intensity of exposure to television and thus it is only the author's assumption. Although not significant, those using internet also had lower odds of experiencing depression symptoms. Further studies could investigate the association of mental health symptoms with exposure to content among those watching mass media and social media.
The current study showed that the relationship status can contribute to anxiety. Married people had greater odds of anxiety symptoms during home isolation. This can stem from dissatisfaction or the perception of a support imbalance [45]. Married persons are more likely to think about their family members and have more incumbents which might have resulted in having higher anxiety and depression. On other hand, never married person enjoy their freedom and have carefree lifestyles.
Likewise, participants who had COVID-19 complications during home isolation had higher odds of having anxiety as compared with participants who did not have any complications. This finding is in line with the previous study conducted in Cameroon [46]. The observed association of high levels of anxiety with COVID-19 complications has been demonstrated in a study by Mazza et al [47]. In their study, it was postulated that increased levels of anxiety as a long-term sequela of COVID-19 infection could be explained by the inflammatory changes caused by the infection.
Our analysis revealed that having COVID-19-related symptoms was associated with depressive symptoms among COVID-19 home isolation patients. This finding was supported by a similar study conducted in Bangladesh which reported that having COVID-19-related physical symptoms was associated with depressive symptoms among inpatients in COVID-19 isolation facilities. This could be explained because COVID-19 symptoms like fever, shortness of breath, and headache can produce mental effects among patients [48]. Studies elsewhere also have shown that psychological distress symptoms such as anxiety and depression are common in patients with more clinical symptoms and illness severity [49,50]. Patients with clinical symptoms could also be more worried about the prognosis of the disease.

Study limitation
There are some limitations of this study, which need to be acknowledged. This study was conducted during the early phase of the pandemic when treatment and vaccines were not available and thus could have affected the presence of anxiety and depression symptoms. Similarly, mental health outcomes might still reflect conditions existing before this pandemic. Besides, the present study lacked clinical interviews to confirm the diagnosis of anxiety and depression and the study findings may not be generalizable to study participants from other provinces of Nepal. Also, we have not included the history of mental illness and medications taken for any kind of mental illness before the pandemic. Despite these limitations, this study provides evidence on mental health status among home COVID-19 isolated patients. To the best of our knowledge, this is the first study in Nepal and could aid to scarce evidence available regarding the mental health status among home isolated COVID-19 patients. This evidence could be of interest to policymakers, and various stakeholders who are involved in the response to COVID-19 or any future epidemic.

Conclusion
In summary, the findings have shown that a substantial proportion of COVID-19 patients in Nepal experienced depressive and anxiety symptoms during home isolation with more than half having borderline and one out of four having abnormal mental health symptoms. Female and those with COVID-19 symptoms had higher odds of exhibiting depression symptoms while ever married, those with COVID-19 related complications and those who took medicines for treatment of symptoms were at higher odds of developing anxiety symptoms. Interestingly, watching Television during isolation was associated with lower odds of developing anxiety and depression symptoms. Considering the burden of mental health symptoms during the pandemic, we urge the Government of Nepal for mobilizing mental health human resources such as psychiatrists, psychologists, psychiatric nurses, and trained health workers and community mobilizers with appropriate linkage to treatment services. We suggest that more attention and timely psychological interventions be given to the COVID-19 home isolated patients with connection to mental health services.