https://orcid.org/0000-0001-9320-7411
Figures
Abstract
Objective
To improve the mental health of isolated patients with COVID-19 by face-to-face psychological rehabilitation program.
Participants
109 patients (52 in experimental group, 57 in control group) with COVID-19 were recruited from May 27 to September 17, 2021.
Interventions
A psychological rehabilitation program that consists of education, craft, and physical activity. The activity program was provided by a multidisciplinary rehabilitation team of doctors, nurses, occupational therapists, and physical therapists. The purpose of the education was to provide accurate information about COVID-19, and craft and physical activity were for improving physical health, occupational balance, participation in activities, and reducing boredom.
Main outcome measures
The primary outcome was degree of anxiety assessed using the Zung Self-Rating Anxiety Scale (SAS). Secondary outcomes were severity of depression, and quality of sleep assessed using the Zung Self-Rating Depression Scale (SDS), Patient Health Questionnaire-9 (PHQ-9), Visual Analysis Scale (VAS), and the Korean version of the Insomnia Severity Index (ISI-K).
Results
Isolated patients complained of anxiety, depression, and insomnia the most in the early stages of hospitalization and isolation. In addition, the psychological rehabilitation program significantly improved mental health scale, including scores of SAS (F = 12.46, p = .001), SDS (F = 6.76, p = .01), and ISI-K (F = 4.41, p = .04).
Citation: Jung JH, Won JJ, Ko JY (2022) Psychological rehabilitation for isolated patients with COVID-19 infection: A randomized controlled study. PLoS ONE 17(12): e0278475. https://doi.org/10.1371/journal.pone.0278475
Editor: Walid Kamal Abdelbasset, Prince Sattam Bin Abdulaziz University, College of Applied Medical Sciences, SAUDI ARABIA
Received: May 11, 2022; Accepted: October 28, 2022; Published: December 27, 2022
Copyright: © 2022 Jung et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the article and its Supporting Information files.
Funding: This research was supported by the Accountable Care Hospital Connected Care(ACHCC) Project funded by the Ministry of Health and Welfare of Korea (Project Number: 2022-ACHCC-L26).
Competing interests: The authors declare that they have no competing interest.
Introduction
The COVID-19 pandemic is known to have caused mental health problems among the general population [1] and healthcare providers [2]. Although the mental health problems of hospitalized COVID-19 patients have not been studied in depth, it is known that COVID-19 patients suffer from psychological problems such as depression, anxiety and sleep disturbances due to hospitalization and isolation [3,4].
Due to the fear of physical contact and lack of protective materials, face-to-face interaction was limited. Although some kinds of telecommunication was done in the case of isolated patients [5,6], there are several barriers such as technical difficulties, limited familiarity with telemedicine, and loss of non-verbal communication that normally occurs in face-to-face interactions [7,8]. Owing to these barriers and depending on the social environment, patients may not be able to fully express their emotional and mental health problems [9].
The main objective of the study, therefore, was to measure the effects of newly developed face-to-face psychological rehabilitation program among isolated patients with COVID-19.
Method
Design and participants
A total of 160 patients with confirmed COVID-19, admitted to a single community-based hospital from May 27 to September 17, 2021, were included in the study (Fig 1). A priori analysis was conducted by G Power 3.1 software (f = 0.25, α = 0.05, 1-β = 0.95, ANOVA: repeated measures), and the results were calculated to show a sample size of 86. We tried to recruit a minimum of 108 subjects to account for a dropout rate of 20%. The study was also approved by the IRB as minimal risk, and enrollment continued for the duration of the study. The patients were randomly divided into experimental and control groups according to their bed number. Block randomization method was used and block size were 6, 8, 10, 12, and 14. The patients were recruited according to the following inclusion criteria: (1) diagnosed as COVID-19 positive as per the polymerase chain reaction (PCR) test; (2) oxygen saturation of 95% or higher and hemodynamically stable; (3) admitted to the isolation ward; (4) no history of psychiatric diagnosis; (5) at least 18 years of age; (6) able to understand the purpose of the research and consent. Participants were excluded if they: (1) were not medically stable; (2) had difficulty using Korean or other communication problems. (3) had a history of serious, diagnosed psychiatric disease: depression, anxiety disorder, insomnia, bipolar disorder, and schizophrenia. Subjects in this study were part of a clinical trial(KCT0007222). The study protocol was approved by the institutional review board of Seoul National University Bundang Hospital(B-2104-678-301), which waived written informed consent due to the risk of virus transmission. The research team provided information regarding the aim of the study and received online consent by clicking “I agree” button from all participants before starting the study.
Outcome measure
The Zung Self-Rating Anxiety Scale (SAS) [10] and Visual Analysis Scale (VAS) were used to assess the level of anxiety, and the Zung Self-Rating Depression Scale (SDS), [11] Patient Health Questionnaire-9 (PHQ-09), [12] and Visual Analysis Scale (VAS) were used to evaluate the degree of depression. Also, to assess the quality of sleep, we used the Korean version of the Insomnia Severity Index(ISI-K) [13]. The SAS and SDS contain 20 items each, rated on a 4-point Likert scale ranging from 1 (a little of the time) to 4 (most of the time). The SAS is divided into four levels: no anxiety (≤44), mild to moderate (45–59), severe (60–74), and extremely severe (≥75). The SDS is divided into four levels: no depression (≤49), mild to moderate (50–59), severe (60–69), and extremely severe (≥70). The PHQ-9 has nine questions rated on a 4-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). It is divided into four levels: no depression (≤4), mild (5–9), moderate (10–19), and severe (≥20). The ISI–K has seven questions rated on a 5-point Likert scale ranging from 0 (no problem) to 4 (very severe). It is divided into four categories: absence of insomnia (≤7), sub-threshold mild (8–14), moderate (15–21), and severe (≥22). Participants completed the outcome measurement at the initial and post-interventions.
Intervention protocol
Fig 2 displays the protocols for the intervention used in this study. Both the experimental and the control group were screened for mental health risk, symptomatic treatment for COVID-19-related symptoms, and antiviral therapy. A psychological rehabilitation program, comprising COVID-19 education, craft, and physical activities was conducted only for the experimental group. The purpose of the COVID-19 education, imparted by a nurse, was to debunk misinformation about COVID-19 and to provide accurate information about it. The education included epidemiologic characteristics, symptoms, treatment methods, prognosis, and precautions against COVID-19 [14,15]. A 20-minute session was conducted after the pre-evaluation. Next, a craft activity was organized by an occupational therapist. The purpose of this activity was occupational balance, participation in activities, and reducing boredom during hospitalization. The procedure was as follows: Step 1. A list of possible craft activities that could be done in the isolation ward was provided. An occupational therapist visited the isolation ward to discuss the activity options with the patient. Step 2. An activity was selected according to the patient’s preference gauged through an interview conducted by the occupational therapist. Craft activities included knitting, jewel cross-stitching, coloring, block-making, etc. The craft activity list was composed of a wide variety taking into consideration factors such as age, gender, nature of disease, and the facilities available at the program venue. Step 3. The occupational therapist visited the isolation room and provided emotional support while observing and conversing with the patient during the selected activity. Conversations mainly centered around the hospital stay. The craft activity was provided for 8 days, 20 mins each day. Next, the patients trained in exercises guided by a physical therapist, for 8 days, 20 mins each day. Physical activities included stretching, strength training, and breathing exercises. For stretching, neck stretch, side stretch, chest stretch, hip stretch, and waist stretch were performed. Strength training consisted of wall push-ups, squats, and heel raisers. Breathing exercises included diaphragmatic breathing, pursed-lip breathing technique, and square box breathing. The activity started as an exercise for improving joint range of motion and gradually progressed to exercise for strengthening. The patient’s symptoms such as muscle pain and breathing difficulties were observed. All physical activity was performed with reference to modules 3 and 4 of the WHO COVID-19 rehabilitation guidelines, and all psychological rehabilitation programs were conducted in the patient’s isolation ward. For protection against the virus, the therapist, carried out the intervention wearing a powered aid purifying respirator [16].
Patients were screened for high-risk mental health conditions. Psychiatric linkage was performed on patients who were evaluated as high-risk in the initial evaluation. This was done for members of both the experimental and control groups. The range of the high-risk group was set at 60 points or higher for SAS, SDS, 10 points or higher for PHQ-9, and 15 points or higher for ISI-K [17,18]. If the patient declined the service, the connection was not made, and the researcher continuously monitored levels of anxiety, depression, and insomnia for signs of deterioration during the interviews. Patients evaluated as high-risk groups in the discharge evaluation were referred to a community mental health institution to receive medical care, after obtaining their consent.
Statistical analysis
Data analysis was performed using SAS statistical software version 9.4 (SAS Institute, Cary, NC). To compare descriptive data of the two groups, we used independent t-test, chi-square and Fisher’s exact test.
The repeated measures ANOVA was used to measure changes over time between groups for the pre-post repeated measures of VAS, SAS, SDS, PHQ-9, ISI-K. The repeated covariance type was used for unstructured, and fixed effects included group (experimental and control group) and time (pre- and post-intervention). The difference between the two groups over time was analyzed by assessing the interaction between the groups using the measurement time points. The level of statistical significance was set at P < 0.05.
Results
Participant flow
A total of 160 patients with COVID-19 were recruited from May 27 to September 17, 2021. They were randomly allocated to the experimental (n = 80) or control group (n = 80). During the program, 28 patients in the experimental group and 23 patients in the control group were excluded. In the experimental group, 16 patients had decreased oxygen saturation (90–95%), 11 patients declined program, and 1 patient was transferred to another hospital. In the control group, 18 patients had decreased oxygen saturation (90–95%), 1 patient declined the program, 2 patients were transferred to other hospitals, and 2 patients were discharged early. In total, 109 patients (52 patients in the experimental group, 57 patients in the control group) completed the trial (Fig 1).
Patient demographics
Table 1 summarizes the demographic and clinical characteristics of the participants. The experimental group consisted of 28 males and 24 females, with an mean age of 51.06±16.42 years and mean isolation duration of 13.54±3.27days. The control group consisted of 24 males and 44 females, with an mean age of 45.96±17.20 years and mean isolation duration of 14.00±4.18 days. HTN and dyslipidemia were the most common underlying diseases in both groups. Additionally, the most common clinical symptoms were pneumonia, myalgia, cough & sputum, headache, and sore throat in both groups. No significant difference was found between the groups in demographic and clinical characteristics (p>.05).
Anxiety
The VAS of anxiety (F = 10.46, p = .002) and the total score of SAS (F = 12.46, p = .001) significantly decreased in the experimental group compared with the control group in the time × group analysis (Table 2, Fig 3). The VAS of anxiety (F = 24.29, p < .001) and SAS total score (F = 45.04, p < .001) significantly decreased over time in both groups.
When analyzing within-group changes, the VAS of anxiety (p < .001) and total score of SAS (p < .001) in the experimental group significantly decreased. In the control group, the VAS of anxiety (p = .23) and total score of SAS (p = .03) decreased.
Depression
In the time × group analysis, the VAS of depression (F = 23.42, p < .001), total score of SDS (F = 6.76, p = .01), and PHQ-9 (F = 8.58, p = .004) significantly decreased in the experimental group compared with the control group (Table 2, Fig 3). The VAS of depression (F = 16.30, p < .001), SDS (F = 25.30, p < .001), PHQ-9 total score (F = 8.58, p = .004) significantly decreased over time in both groups.
When analyzing within-group changes, the VAS of depression (p < .001), total score of SDS (p < .001), and PHQ-9 (p < .001) significantly decreased in the experimental group. In the control group, the VAS of depression (p = .56), total score of SDS (p = .08), and PHQ-9 (p = 1.00) decreased, but not significantly.
Insomnia
In the time × group analysis, the total score of ISI-K (F = 4.41, p = .04) significantly decreased in the experimental group compared with the control group (Table 2, Fig 3). ISI-K total score significantly decreased with time in both groups.
The ISI-K total score in the experimental group decreased from 8.69±7.77 to 5.92±4.57 after the intervention (p < .001). In the control group, ISI-K total score decreased from 8.12±5.69 to 7.33±4.15(p = .14) post- intervention.
Discussion
To our knowledge, this is one of the first studies on psychological rehabilitation for COVID-19 patients admitted to the hospital isolation ward. According to our results, patients complained of anxiety, depression, and insomnia the most in the early stages of hospitalization and isolation. In addition, psychological rehabilitation programs reduced mental health problems such as anxiety, depression, and insomnia.
Previous research has shown that patients isolated from COVID-19 are vulnerable to mental illness, including anxiety, and experience social guilt about infecting others[19]. And also hospitalization and isolation are known to cause physical inactivity, boredom, sleep deprivation, and stress [3,20]. In particular, boredom is known to cause psychological problems such as depression, aggression, and suicidality [21].
The effect of psychological rehabilitation on mental illness can be explained by the effects of education, physical activity, and craft activity, which are sub-items of psychological rehabilitation. There have been prior studies on physical exercise and activity participation. Exercise and body relaxation therapy was observed to improve the mental health of isolated people [22–24]. Participation in activities is known to relieve boredom [25], and daytime activities are effective to improve sleep quality [26]. However, the most of studies were conducted on incarcerated individuals [22,27] or self-isolated rather than being isolated in hospitals or treatment centers [23]. Therefore, this study has clinical significance in that it targeted patients isolated by COVID-19 infection.
In addition, due to strict adherence to quarantine rules, therapists’ fear of being infected with COVID-19 was not observed at all during the intervention. Researchers did not complain of COVID-19-related symptoms during the intervention, nor were they diagnosed with COVID-19. Exercise, education, and participation in activities are considered to have improved the mental health of patients in an environment that guarantees the safety of medical staff and therapists as part of a complex program.
This study has several limitations. First, the results of this study may not reflect the information of all patients depending on the acceptance rate and exclusion rate. This may result in a selection bias affecting the validity and generalizability of result. Second, there were no baseline assessments of the patients’ anxiety and depression levels prior to admission, so it is possible that they were already high due to the pandemic, whether hospitalized or not. Third, although our findings may be generalized to Korean patients, they may not be applicable to other countries. Additionally, we did not evaluate the patients’ conditions after discharge. Therefore, it was not possible to determine whether their mental health changed post-discharge. Further research, including patient follow-up, is required.
Conclusion
According to the results of this study, among COVID-19 patients who were hospitalized, mental health deterioration occurred, and a psychological rehabilitation program was required to actively prevent and treat it. Based on these findings, it is recommended that isolated patients with COVID-19 should undergo a psychological rehabilitation program.
Supporting information
S1 Checklist. CONSORT 2010 checklist of information to include when reporting a randomised trial*.
https://doi.org/10.1371/journal.pone.0278475.s001
(DOCX)
References
- 1. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China. Int J Environ Res Public Health. 2020;17(5). Epub 2020/03/12. pmid:32155789; PubMed Central PMCID: PMC7084952.
- 2. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3(3):e203976. Epub 2020/03/24. pmid:32202646; PubMed Central PMCID: PMC7090843.
- 3. Dorman-Ilan S, Hertz-Palmor N, Brand-Gothelf A, Hasson-Ohayon I, Matalon N, Gross R, et al. Anxiety and Depression Symptoms in COVID-19 Isolated Patients and in Their Relatives. Front Psychiatry. 2020;11:581598. Epub 2020/11/17. pmid:33192727; PubMed Central PMCID: PMC7591814.
- 4. Mengin A, Allé MC, Rolling J, Ligier F, Schroder C, Lalanne L, et al. Psychopathological consequences of confinement. Encephale. 2020;46(3s):S43–s52. Epub 2020/05/07. pmid:32370983; PubMed Central PMCID: PMC7174176.
- 5. Carvalho PMM, Moreira MM, de Oliveira MNA, Landim JMM, Neto MLR. The psychiatric impact of the novel coronavirus outbreak. Psychiatry Res. 2020;286:112902. Epub 2020/03/09. pmid:32146248; PubMed Central PMCID: PMC7133679 interests.
- 6. Jiang X, Deng L, Zhu Y, Ji H, Tao L, Liu L, et al. Psychological crisis intervention during the outbreak period of new coronavirus pneumonia from experience in Shanghai. Psychiatry Res. 2020;286:112903. Epub 2020/03/09. pmid:32146245; PubMed Central PMCID: PMC7112608.
- 7. Jefee-Bahloul H, Moustafa MK, Shebl FM, Barkil-Oteo A. Pilot assessment and survey of Syrian refugees’ psychological stress and openness to referral for telepsychiatry (PASSPORT Study). Telemed J E Health. 2014;20(10):977–9. Epub 2014/09/05. pmid:25188281.
- 8. Inman AG, Soheilian SS, Luu LP. Telesupervision: Building bridges in a digital era. J Clin Psychol. 2019;75(2):292–301. Epub 2018/12/28. pmid:30589439.
- 9. Duan C, Falender C, Goodyear R, Qian M, Jia X, Jiang G. Telesupervision-of-supervision across national boundaries: United States and China. J Clin Psychol. 2019;75(2):302–12. Epub 2018/12/28. pmid:30589436.
- 10. Zung WW. A rating instrument for anxiety disorders. Psychosomatics. 1971;12(6):371–9. Epub 1971/11/01. pmid:5172928.
- 11. Zung WW. A SELF-RATING DEPRESSION SCALE. Arch Gen Psychiatry. 1965;12:63–70. Epub 1965/01/01. pmid:14221692.
- 12. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. Epub 2001/09/15. pmid:11556941; PubMed Central PMCID: PMC1495268.
- 13. Cho YW, Song ML, Morin CM. Validation of a Korean version of the insomnia severity index. J Clin Neurol. 2014;10(3):210–5. Epub 2014/07/22. pmid:25045373; PubMed Central PMCID: PMC4101097.
- 14. Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review. Jama. 2020;324(8):782–93. Epub 2020/07/11. pmid:32648899.
- 15. Sung HK, Kim JY, Heo J, Seo H, Jang YS, Kim H, et al. Clinical Course and Outcomes of 3,060 Patients with Coronavirus Disease 2019 in Korea, January-May 2020. J Korean Med Sci. 2020;35(30):e280. Epub 2020/08/04. pmid:32743995; PubMed Central PMCID: PMC7402927.
- 16. Howard BE. High-Risk Aerosol-Generating Procedures in COVID-19: Respiratory Protective Equipment Considerations. Otolaryngol Head Neck Surg. 2020;163(1):98–103. Epub 2020/05/13. pmid:32396451.
- 17. Kroenke K, Spitzer RL, Williams JB, Löwe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345–59. Epub 2010/07/17. pmid:20633738.
- 18. Morin CM, Belleville G, Belanger L, Ivers H. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601–8. pmid:21532953; PubMed Central PMCID: PMC3079939.
- 19. Kent EE, Ornstein KA, Dionne-Odom JN. The Family Caregiving Crisis Meets an Actual Pandemic. Journal of pain and symptom management. 2020;60(1):e66–e9. pmid:32283220; PubMed Central PMCID: PMC7151363.
- 20. Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. Journal of the American Geriatrics Society. 2009;57(9):1660–5. pmid:19682121.
- 21. Ben-Zeev D, Young MA, Depp CA. Real-time predictors of suicidal ideation: mobile assessment of hospitalized depressed patients. Psychiatry research. 2012;197(1–2):55–9. pmid:22397912.
- 22. O’Toole S, Maguire J, Murphy P. The efficacy of exercise referral as an intervention for Irish male prisoners presenting with mental health symptoms. International journal of prisoner health. 2018;14(2):109–23. pmid:29869583.
- 23. Schuch FB, Bulzing RA, Meyer J, Lopez-Sanchez GF, Grabovac I, Willeit P, et al. Moderate to vigorous physical activity and sedentary behavior changes in self-isolating adults during the COVID-19 pandemic in Brazil: a cross-sectional survey exploring correlates. Sport sciences for health. 2022;18(1):155–63. pmid:34108999; PubMed Central PMCID: PMC8179086.
- 24. Liu K, Chen Y, Wu D, Lin R, Wang Z, Pan L. Effects of progressive muscle relaxation on anxiety and sleep quality in patients with COVID-19. Complementary therapies in clinical practice. 2020;39:101132. pmid:32379667; PubMed Central PMCID: PMC7102525.
- 25. Danckert JA, Allman AA. Time flies when you’re having fun: temporal estimation and the experience of boredom. Brain and cognition. 2005;59(3):236–45. pmid:16168546.
- 26. Nixon GM, Thompson JM, Han DY, Becroft DM, Clark PM, Robinson E, et al. Falling asleep: the determinants of sleep latency. Archives of disease in childhood. 2009;94(9):686–9. pmid:19633062.
- 27. Psychou D, Kokaridas D, Koulouris N, Theodorakis Y, Krommidas C, Psycho C. Impact of exercise intervention on anxiety levels and mood profile of Greek prison inmates. 2020.