Mid-term Psychiatric Outcomes of Patients Recovered From COVID-19 From an Italian Cohort of Hospitalized Patients

Neuropsychiatric symptoms of patients two years after experiencing severe COVID-19: A mixed observational study

BACKGROUND

The impact of SARS-CoV-2 infection (COVID-19) on mental health has not been extensively studied in the medium and long term. This study assessed how clinical, biological, and social factors affect mental health in patients who recovered from severe COVID-19. The evaluation was done 90 days after hospital discharge and followed up at 12 and 24 months.

METHODS

A retrospective-prospective cohort mixed observational study was conducted on patients over 18 years of age who required hospitalization in Internal Medicine or ICU for severe COVID-19 pneumonia during 2020 and 2021. Demographic information, clinical variables, and data for the scales were obtained from electronic medical records and telephone interviews. For comparisons of the different variables in each clinical variable (insomnia, depression, anxiety), the Student's t-test for independent samples has been used (normal distribution); otherwise, the Mann-Whitney test will be used. All tests and intervals will be performed with a confidence level of 95. Fisher's exact or Pearson's Chi-square test has been used as appropriate for qualitative variables.

RESULTS

201 patients were recruited. 37.3% presented insomnia, 22.4% anxiety, and 21.4% depressive symptoms. A direct association was established between female sex and depressive symptoms. Psychotropic history, fatigue, and C-reactive protein levels (CRP) were correlated with depression. Anosmia and ageusia, CRP, cognitive symptoms, and dyspnea predicted insomnia. Sex, orotracheal intubation (OTI), pain, fatigue, mental health history, and academic level were independent predictors of anxiety. High percentages of depressive, anxiety, and insomnia symptoms were detected in the second month after discharge and persisted at 12 and 24 months. The fatigue variable maintained a significant relationship with depressive symptoms at 2, 12 and 24 months. A possible limitation could be recall bias in retrospective data collection.

CONCLUSIONS

This is a novel study to follow up on mental health for two years in patients with severe COVID-19. Clinical, biological, and psychosocial variables could be predictors of depressive symptoms, anxiety, and insomnia. The psychiatric symptoms persisted throughout the 2-year follow-up. These findings are critical for the follow-up of these patients and open the possibility of further studies in the medium and long term.

Trauma Shaping the Psychopathological Correlates of Patients with Long-COVID: A 6-Months Longitudinal Study with Repeated Measures Mixed Models

This research aimed at investigating how the experience of trauma can influence the psychological correlates of long-COVID over time in a clinical sample of patients hospitalized because of COVID-19. Through a longitudinal research design, 70 post-acute patients with COVID-19 were followed-up after hospital discharge in 3-time points up to 6 months and completed the Post-traumatic Stress Disorder Checklist for DSM-5 (PCL-5) and the Symptoms Checklist-90-Revised (SCL-90 R). Repeated measures mixed models with random intercept were used to evaluate the effect of trauma (yes/no) over time (T1, T2, T3) on the SCL-90-R scales. Results showed that patients with trauma display significantly worse psychological outcomes in all the SCL-90-R dimensions [all padj < .05 for the principal effects of trauma(y)], especially in symptoms of depression [time 2 vs time 1*trauma(y): b = -3.86, 95%CI (-7.18, -0.53), padj = .035; time 3 vs time 1*trauma(y): b = -4.77, 95%CI (-8.10, -1.45), padj = .011], anxiety [time 3 vs time 1*trauma(y): b = -4.54, 95%CI (-7.72, -1.37), padj = .011], and obsessive-compulsive difficulties [time 3 vs time 1*trauma(y): b = -4.03, 95%CI (-7.20, -0.86), padj = .027]. These findings shed light on the long-term psychological consequences of COVID-19 among hospitalized patients and highlight the key role of trauma, suggesting its assessment to tailor psychological interventions.

Psychiatric symptoms in Long-COVID patients: a systematic review

Objective

People who have been infected by COVID-19 showing persistent symptoms after 4 weeks from recovery are thought to suffer from Long-COVID syndrome (LC). There is uncertainty on the clinical manifestations of LC. We undertook a systematic review to summarize the available evidence about the main psychiatric manifestations of LC.

Method

PubMed (Medline), Scopus, CINHAL, PsycINFO, and EMBASE were searched until May 2022. Studies reporting estimation of emerging psychiatric symptoms and/or psychiatric diagnoses among adult people with LC were included. Pooled prevalence for each psychiatric condition was calculated in absence of control groups to compare with.

Results

Thirty-three reports were included in the final selection, corresponding to 282,711 participants with LC. After 4 weeks from COVID-19 infection recovery, participants reported the following psychiatric symptoms: depression, anxiety, post-traumatic symptoms (PTS), cognitive and sleeping disturbances (i.e., insomnia or hypersomnia). The most common psychiatric manifestation resulted to be sleep disturbances, followed by depression, PTS, anxiety, and cognitive impairment (i.e., attention and memory deficits). However, some estimates were affected by important outlier effect played by one study. If study weight was not considered, the most reported condition was anxiety.

Conclusions

LC may have non-specific psychiatric manifestations. More research is needed to better define LC and to differentiate it from other post-infectious or post-hospitalization syndromes.

Systematic review registration

PROSPERO (CRD42022299408).

Long COVID in the context of social determinants of health

The COVID-19 pandemic has been a challenge for the public health system and has highlighted health disparities. COVID-19 vaccines have effectively protected against infection and severe disease, but some patients continue to suffer from symptoms after their condition is resolved. These post-acute sequelae, or long COVID, continues to disproportionately affect some patients based on their social determinants of health (SDOH). This paper uses the World Health Organization's (WHO) SDOH conceptual framework to explore how SDOH influences long COVID outcomes.

Determinants of long COVID among adults hospitalized for SARS-CoV-2 infection: A prospective cohort study

Rationale

Factors associated with long-term sequelae emerging after the acute phase of COVID-19 (so called "long COVID") are unclear. Here, we aimed to identify risk factors for the development of COVID-19 sequelae in a prospective cohort of subjects hospitalized for SARS-CoV-2 infection and followed up one year after discharge.

Methods

A total of 324 subjects underwent a comprehensive and multidisciplinary evaluation one year after hospital discharge for COVID-19. A subgroup of 247/324 who consented to donate a blood sample were tested for a panel of circulating cytokines.

Results

In 122 patients (37.8%) there was evidence of at least one persisting physical symptom. After correcting for comorbidities and COVID-19 severity, the risk of developing long COVID was lower in the 109 subjects admitted to the hospital in the third wave of the pandemic than in the 215 admitted during the first wave, (OR 0.69, 95%CI 0.51-0.93, p=0.01). Univariable analysis revealed female sex, diffusing capacity of the lungs for carbon monoxide (DLCO) value, body mass index, anxiety and depressive symptoms to be positively associated with COVID-19 sequelae at 1 year. Following logistic regression analysis, DLCO was the only independent predictor of residual symptoms (OR 0.98 CI 95% (0.96-0.99), p=0.01). In the subgroup of subjects with normal DLCO (> 80%), for whom residual lung damage was an unlikely explanation for long COVID, the presence of anxiety and depressive symptoms was significantly associated to persistent symptoms, together with increased levels of a set of pro-inflammatory cytokines: interferon-gamma, tumor necrosis factor-alpha, interleukin (IL)-2, IL-12, IL-1β, IL-17. In logistic regression analysis, depressive symptoms (p=0.02, OR 4.57 [1.21-17.21]) and IL-12 levels (p=0.03, OR 1.06 [1.00-1.11]) 1-year after hospital discharge were independently associated with persistence of symptoms.

Conclusions

Long COVID appears mainly related to respiratory sequelae, prevalently observed during the first pandemic wave. Among patients with little or no residual lung damage, a cytokine pattern consistent with systemic inflammation is in place.

Relationship between attitudes toward COVID-19 infection, depression and anxiety: a cross-sectional survey in Japan

BACKGROUND

Although negative attitudes are known to develop with experiences of COVID-19 infection, it remains unclear whether such attitudes contribute to depression and anxiety as sequelae of COVID-19. We aimed to investigate the relationships between attitude towards COVID-19 infection and post-COVID-19 depression and anxiety.

METHODS

A cross-sectional survey of COVID-19 recovered patients was conducted from July to September 2021 in Japan. Outcome variables, depression and anxiety were assessed using the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7); scores of 10 and above were identified as having symptoms of depression and anxiety, respectively. Exposure variables were whether participants were experiencing the following attitude strongly: threat to life due to COVID-19 infection, helplessness regarding COVID-19 infection, blaming a third party who did not restrain from going outside, blaming themselves for their COVID-19 infection, worry about spreading the infection to others, and self-stigma (Self-Stigma Scale-Short). Modified Poisson regression analyses were performed to analyze the findings.

RESULTS

A total of 6016 responses were included in the analyses. The proportion of depression was 19.88%, and anxiety was 11.47%. The threat of life due to COVID-19 infection, helplessness regarding COVID-19 infection, blaming oneself for their COVID-19 infection, and self-stigma were significantly associated with depression and anxiety after adjusting covariates. Blaming the third party who did not restrain from going outside was associated with anxiety. There was no association between the worry about spreading infection to others and depression or anxiety.

CONCLUSION

Negative attitudes, including self-stigma with the experience of COVID-19 infection, were related to depression and anxiety. Further studies confirming whether countermeasures for preventing or decreasing the negative attitude towards COVID-19 infection mitigate these symptoms are needed.

Sequelae of COVID-19 among previously hospitalized patients up to 1 year after discharge: a systematic review and meta-analysis

OBJECTIVE

Although complications and clinical symptoms of COVID-19 have been elucidated, the prevalence of long-term sequelae of COVID-19 is less clear in previously hospitalized COVID-19 patients. This review and meta-analysis present the occurrence of different symptoms up to 1 year of follow-up for previously hospitalized patients.

METHODS

We performed a systematic review from PubMed and Web of Science using keywords such as "COVID-19", "SARS-CoV-2", "sequelae", "long-term effect" and included studies with at least 3-month of follow-up. Meta-analyses using random-effects models were performed to estimate the pooled prevalence for different sequelae. Subgroup analyses were conducted by different follow-up time, regions, age and ICU admission.

RESULTS

72 articles were included in the meta-analyses after screening 11,620 articles, identifying a total of 167 sequelae related to COVID-19 from 88,769 patients. Commonly reported sequelae included fatigue (27.5%, 95% CI 22.4-33.3%, range 1.5-84.9%), somnipathy (20.1%, 95% CI 14.7-26.9%, range 1.2-64.8%), anxiety (18.0%, 95% CI 13.8-23.1%, range 0.6-47.8%), dyspnea (15.5%, 95% CI 11.3-20.9%, range 0.8-58.4%), PTSD (14.6%, 95% CI 11.3-18.7%, range 1.2-32.0%), hypomnesia (13.4%, 95% CI 8.4-20.7%, range 0.6-53.8%), arthralgia (12.9%, 95% CI 8.4-19.2%, range 0.0-47.8%), depression (12.7%, 95% CI 9.3-17.2%, range 0.6-37.5%), alopecia (11.2%, 95% CI 6.9-17.6%, range 0.0-47.0%) over 3-13.2 months of follow-up. The prevalence of most symptoms reduced after > 9 months of follow-up, but fatigue and somnipathy persisted in 26.2% and 15.1%, respectively, of the patients over a year. COVID-19 patients from Asia reported a lower prevalence than those from other regions.

CONCLUSIONS

This review identified a wide spectrum of COVID-19 sequelae in previously hospitalized COVID-19 patients, with some symptoms persisting up to 1 year. Management and rehabilitation strategies targeting these symptoms may improve quality of life of recovered patients.

Differences in the Course of Depression and Anxiety after COVID-19 Infection between Recovered Patients with and without a Psychiatric History: A Cross-Sectional Study

BACKGROUND

This study aimed to examine the course of depression and anxiety in COVID-19 survivors with a psychiatric history compared with those without a psychiatric history.

METHODS

A web-based cross-sectional survey for COVID-19 survivors was conducted from July to September 2021. A total of 6016 COVID-19 survivors, the accuracy of whose responses was determined to be assured, were included in analyses. Exposures included psychiatric history and time since COVID-19 infection, and the main outcomes and measures included severity of depression and anxiety, as assessed using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), respectively.

RESULTS

Mean severity of PHQ-9 and GAD-7 were significantly higher in participants with a psychiatric history than in those without a psychiatric history. Two-way analysis of covariance for PHQ-9 showed a significant main effect of the presence of psychiatric history and a significant interaction effect of psychiatric history × time since infection. Two-way analysis of covariance for the GAD-7 score revealed a significant main effect of the presence of psychiatric history and time since COVID-19 infection and the interaction effect of these factors.

CONCLUSIONS

The course of depression and anxiety was more severe in COVID-19 survivors with a psychiatric history than in those without a psychiatric history.

Acute and chronic neuropsychiatric symptoms in novel coronavirus disease 2019 (COVID-19) patients: A qualitative review

The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was declared a global pandemic by the World Health Organization (WHO) on March 11th, 2020. It has had unprecedented adverse effects on healthcare systems, economies, and societies globally. SARS-CoV-2 is not only a threat to physical health but has also been shown to have a severe impact on neuropsychiatric health. Many studies and case reports across countries have demonstrated insomnia, depressed mood, anxiety, post-traumatic stress disorder (PTSD), and cognitive change in COVID-19 patients during the acute phase of the infection, as well as in apparently recovered COVID-19 patients. The goal of this narrative review is to synthesize and summarize the emerging literature detailing the neuropsychiatric manifestations of COVID-19 with special emphasis on the long-term implications of COVID-19.

Predictors of long-term anxiety and depression in discharged COVID-19 patients: A follow-up study

BACKGROUND

Patients who were hospitalized for coronavirus disease 2019 (COVID-19) faced an extremely stressful experience that challenged their mental health and the long-term effects are not definitely known yet.

AIM

To identify both the course of mental symptoms (anxiety and depressive symptoms) and the related risk factors of recovered patients at the 20-22 mo follow-up.

METHODS

One hundred and seventy-two patients were enrolled. The patients were evaluated with a telepsychiatry interview and the Hospital Anxiety and Depression Scale (HADS). Sociodemographic and clinical features were analyzed by regression analysis.

RESULTS

The mean HADS-Anxiety (HADS-A) score was 9.08 ± 4.90, and the mean HADS-Depression (HADS-D) score was 8.55 ± 4.39. The mean HADS-A (P = 0.484) and HADS-D (P = 0.011) scores were increased compared to scores during hospitalization. Being over 50 years old, having lower financial status, and being vaccinated were associated with symptoms of depression (adjusted R² = 0.168) while being over 50 years old, female sex, being vaccinated, and dyspnea were associated with higher anxiety (adjusted R² = 0.245).

CONCLUSION

To prevent the deterioration of mental health, psychiatrists should play an active role in identifying emerging mental problems as soon as possible, more vulnerable groups should be characterized, and psychological support should be sustained after discharge.

Anxiety, Stress and Depression in COVID-19 Survivors From an Italian Cohort of Hospitalized Patients: Results From a 1-Year Follow-Up

Background

Mental health-related symptoms can persist over time beyond the most common respiratory clinical features of COVID-19. A recent meta-analysis underlined that mental health sequalae may be relevant for COVID-19 survivors and reported the following prevalence rates: 20% for post-traumatic stress disorder, 22% for anxiety, 36% for psychological distress, and 21% for depression. In the context of a multi-disciplinary follow-up project, we already investigated the mid-term (4 months) psychiatric outcomes in a sample of COVID-19 survivors. Patients were re-assessed after 1-year since hospital discharge.

Methods

Follow-up conducted after 1 year involved 196 individuals recovered from COVID-19. Patients were assessed with a multi-disciplinary approach; including both a clinical interview performed by an experienced psychiatrist, trained in the use of the Mini-International Neuropsychiatric Interview (MINI) to assess the presence of anxiety, stress, and depressive symptoms and the following self-administered questionnaires: Beck Anxiety Inventory, Beck Depression Inventory-II, Resilience Scale for Adults, Impact of Event Scale, and COVID-19 Peritraumatic Distress Index (CPDI).

Results

Anxiety (p < 0.0001) and depressive (p < 0.0003) symptoms registered at the clinical interview showed a significant improvement from the 4 to 12-months follow-up. Logistic regression model showed that female gender (p = 0.006), arterial hypertension (p = 0.01), obesity (0.04), anxiety (p < 0.0001), and depressive (p = 0.02) symptoms at 4-months follow-up were associated with persistence of anxiety symptoms at 12 months. At logistic regression analysis female gender (p = 0.02) and depressive symptoms at 4-months follow-up (p = 0.01) were associated with depressive symptoms after 12 months.

Conclusion

Severity of the disease in the acute phase, in this study, was not a determining factor in identifying subjects at risk of developing clinically relevant anxiety and depression as a consequence of COVID-19 disease. Findings from the logistic regressions suggest that the factors most affecting depression and anxiety in COVID survivors after 12 months were female gender, the presence of anxiety and depression after 4 months and some physical symptoms, not necessarily COVID-related. Impact of infection and consequent hospitalization for COVID-19 did no longer represent a relevant issue for depressive symptoms, compared to other general factors.