Psychiatric impact of the novel coronavirus disease 2019 on previously mentally healthy survivors

Background The prolonged psychiatric disorders rate following coronavirus disease 2019 (COVID-19) could surpass that of severe acute respiratory syndrome (SARS) as well as Middle East Respiratory Syndrome (MERS) as a result of variations in viral disease treatment as well as societal circumstances throughout the outbreaks. This work aimed to investigate the COVID-19 prolonged psychiatric effects on survivors without psychiatric diseases before infection. Methods This cross-sectional research was conducted on 1254 patients of which 700 patients (55.8%) were positive for psychiatric complications based on the general health (GHQ-28) questionnaire and 554 patients (44.1%) were negative, aged above 18 years old who had been infected with COVID19 (PCR swab confirmed) and recovered since less than 6 months without previous history of any psychiatric disease. Results Smoking, medical comorbidities, hospitalization, and cortisone in treatment were significantly higher in GHQ-28 positive than GHQ-28 negative ( p < 0.05). Psychiatric disorders and Beck’s Depression Inventory (BDI) grades showed a significant association between smoking and hospitalization and Taylor Manifest Anxiety scales and smoking, hospitalization, and treatment with cortisone). Smoking, medical comorbidities, hospitalization, and cortisone in treatment were the most significant predictors of positive GHQ-28. However, multivariate analysis demonstrated that medical comorbidities, hospitalization, and cortisone in treatment were the best independent predictors of GHQ-28 positive ( p = 7.055, p = 0.007, p = 0.043, p = 0.047, respectively). Conclusions COVID-19 cases without pre-existing psychological disorders exhibited a significant increase in psychiatric disorders occurrence 6 months following recovery. Anxiety disorders represented the predominant mental diagnoses documented.

Individuals developing preexisting psychiatric illnesses may be more vulnerable to COVID-19 because of challenges in maintaining proper hygiene along with social distancing, as well as difficulty in recognizing the risks linked to infection [3].
Since the COVID-19 epidemic onset, existing concerns addressed that survivors could exhibit a higher chance for psychological complications [4].Information as regards COVID-19 has quickly evolved, with interim recommendations from various organizations being regularly updated as well as extended [1].Nevertheless, there is little evidence of mental disease among COVID-19 cases [5].
Negative psychological effects involve a range of emotions like fury, anxiety, boredom, confusion, fear, sadness, emotional fatigue, annoyance, impatience, and stress.Additional negative consequences involved avoidance behaviors, social detachment, subclinical symptoms of alcohol use disorder and posttraumatic stress disorder (PTSD), excessive focus on distressing symptoms, stigma, and domestic violence, along suicidal thoughts and actions [6].
Critical illness along with subsequent hospitalizations within the intensive care unit (ICU) can subject cases to severe physiological as well as psychological stresses that could be fatal and traumatic, leading to chronic mental disorders.Individuals severely affected by COVID-19 may be prone to exhibiting psychological disorder [7].
Research on COVID-19 cases admitted to hospitals revealed that about 60% exhibited neuropsychiatric symptoms, involving anxiety, delirium, sadness, dizziness, dysgeusia, headache, insomnia, and myalgias [8].The symptoms manifested either during the illness or in the weeks or months after recovery [9].The COVID-19 psychiatric consequences seem to be common, lasting for at least 6 months and perhaps much longer [9].The prolonged psychiatric disorders rate following COVID-19 could surpass that of SARS as well as Middle East Respiratory Syndrome (MERS) as a result of differences in viral disease treatment as well as societal circumstances throughout the outbreaks [10].
This work was aimed at investigating the COVID-19 prolonged psychiatric effects on survivors without psychiatric diseases before infection.

Patients and methods
Our cross-sectional research involved 1254 patients which 700 were GHQ-28 positive and 554 were GHQ-28 negative aged above 18 years old who had been infected with COVID-19 (PCR swab confirmed) and recovered since less than 6 months without previous history of any psychiatric disease.It commenced following the Ethical Committee's Approval at Ain Shams University Hospital (approval code: FMASU MS 722/2021), Cairo, Egypt.Participants were allowed to sign an informed consent.
The exclusion criteria were patients who were less than 18 years old, history of psychiatric diseases before COVID-19 infection, had infection with COVID-19 within ≤ 6 months at the start of the study, and who were unable to consent.
All cases were subjected to history taking, the Arabic version of the General Health Questionnaire (GHQ-28), the Arabic version of Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), the Arabic version of the Taylor Manifest Anxiety Scale, the Arabic version of Beck Depression Inventory (BDI), and the Arabic version of Positive as well as Negative Syndrome Scale (PANSS).

The Arabic version of the GHQ-28
It is a condensed version of the 60-item questionnaire.This is a self-administered tool utilized for assessing existing psychological conditions among the general population.Questions are categorized into four subscales: somatic problems, anxiety/insomnia, social dysfunction, and severe depression [11].This research utilized the Arabic version via the sample scorer approach, namely (0-0-1-1) [12].The GHQ cut-off point reached seven based on comparable prior national studies to reduce the potential errors linked to the initial low threshold score [13].Those who got a high GHQ-28 score were involved in subsequent tools, whereas those who did not were excluded.

The Arabic version of SCID-I
It represents a structured interview performed by clinicians for psychological cases.It offers extensive coverage for psychological axis I diagnosis based on DSM IV criteria.It exhibits nine diagnostic modules: mood episode, psychotic signs, psychotic condition differential, mood disorder differential, drug use, anxiety, somatoform condition, eating conditions, and adjustment disorder.The standardized interview is often utilized for confirming diagnoses within clinical trials, which is widely employed within psychiatric research.It was created to be more effective as well as user-friendly as opposed to other current tools, resulting in reduced training along with administration time [14].The Arabic translation has shown adequate validity as well as reliability [15].Participants proceeded to one or more of the following scales/ inventories based on their findings.

The Arabic version of the Taylor Manifest Anxiety Scale
It serves as a broad measure of anxiety as a characteristic of one's personality.This is not meant to be a precise indicator of anxiety as a clinical condition.The instrument is based on the Minnesota Multiphase Personality Inventory, which is available in two versions: a long version with 50 items as well as a short version with 28 items.This research utilized an Arabic translation of the long version of the scale.Each item required an answer of either true or false.Scores were assigned on a scale falling between 0 and 50.The interpretation was as follows: 0-16: normal, 17-24: mild, 25-35: moderate, and 36-50: severe [16].The Arabic version exhibited adequate validity as well as reliability [17].

The Arabic version of the BDI
The assessment consists of 21 items that assess the severity or intensity of self-reported depression experienced within the last 2 weeks.The items are rated on a scale falling between 0 (symptoms absence) and 3 (strong presence of symptom).The BDI total scores falling between 0 and 13 exhibit normal to little depression, scores falling between 14 and 19 exhibit mild depression, scores falling between 20 and 28 exhibit moderate depression, and scores falling between 29 and 63 exhibit severe depression [18].The Arabic version exhibits adequate validity as well as reliability [19].

The Arabic version of the PANSS
It was created and standardized for the typological as well as dimensional evaluation of schizophrenia.PANSS has 30 elements evaluated on a 7-point scale, representing a precise and operationalized approach, assessing positive, negative, and other symptom dimensions utilizing a formal semi-structured clinical interview and information from caregivers as well as nursing personnel.The positive scale assesses seven symptoms that are additional to a normal mental state, whereas the negative scale evaluates characteristics that are lacking in it.A bipolar composite scale determines the preponderance of one symptom over another according to the difference between these scales.The general psychopathology scale, as the fourth index, measures schizophrenia disease's overall severity by adding together the remaining 16 items [20].The Arabic scale version was employed [21].

Statistical analysis
Data underwent a statistical analysis utilizing SPSS v26 (IBM Inc., Chicago, IL, USA).Quantitative variables were displayed as mean as well as SD, and a comparison among three groups was carried out utilizing the ANOVA (F) test with post hoc test (Tukey).Qualitative variables were displayed as frequency as well as percentage (%) and then underwent analysis with the chisquare test.Univariate regression was utilized for measuring the association among a dependent variable as well as one independent variable.Additionally, multivariate regression was employed for estimating the association among a dependent variable as well as more independent variables.A two-tailed p-value of below 0.05 was deemed to show statistical significance.
Psychiatric disorders and BDI grades showed a significant between smoking and hospitalization and Taylor Manifest Anxiety scales and smoking, hospitalization, and treatment with cortisone) (Table 4).
Depression and anxiety were insignificantly associated with other studied parameters (smoking, medical comorbidities, hospitalization, hospitalization time, COVID duration, and treatment with cortisone) (Table 5).

Discussion
The COVID-19 pandemic has been identified as a significant danger to mental health since prior research has shown a deep and extensive spectrum of psychosocial effects on people, groups, and nations during earlier infectious disease epidemics [22].
The individuals impacted by COVID-19 are facing increased risk because of the continued possibility of negative consequences.During times of travel restrictions as well as event cancellations, individuals in quarantine could exhibit emotions, involving anger, loneliness, boredom, and anxiety.Physical symptoms like cough, fever, myalgia, and fatigue can also lead to emotional distress along with contracting COVID-19 fear [23].
In the current study, univariate analysis addressed, the predominant GHQ28-positive predictors involved smoking, medical comorbidities, hospitalization, and cortisone in treatment.However, multivariate analysis demonstrated that medical comorbidities, hospitalization, and cortisone in treatment were the best independent predictors of GHQ-28 positive.Nakamura et al. [24] reported that more than 30% of COVID-19 hospitalized cases could exhibit lasting cognitive impairment and sadness, along anxiety following their discharge.Our study's clinical findings showed that 41.6% of the patients suffered from anxiety, 37.4% of the patients suffered from mood disorder, 8.3% showed substance abuse, 2.4% presented with eating disorder, and 4.1% presented with adjustment disorder.A total of 1.7% exhibited mild anxiety, 71.5% exhibited a moderate degree of anxiety, and 26.8% developed severe anxiety.A total of 1.5% of cases developed minimal depression, 6.9% exhibited mild depression, 77.9% had moderate depression, and 13.7% had severe depression.Also, Tian et al. [25] addressed the depression as well as anxiety prevalence was 45.6% and 20.7%, respectively.Lai et al. [26] also addressed a depression rate of 50.4%, while anxiety reached 44.6%, and insomnia exhibited 34.0%.Our findings disagree with Chew et al. [27] observing anxiety among 142 (15.7%), 96 cases (10.6%) exhibited depression, while 47 cases (5.2%) developed stress.
The current research addressed a statistically significant association among psychiatric disorders, smoking, and hospitalization, and no statistically significant correlation was documented among psychiatric disorders with comorbidities, treatment with cortisone, and COVID-19 duration.In agreement with the current study results, both Bo H-X et al. [28], van den Borst et al. [29], Huang et al. [30], and Veazie et al. [31] reported the emergence of psychiatric symptoms after hospitalization for COVID-19 highlighting several disorders occurrence including post-traumatic stress symptoms, anxiety, and depression.However, De Lorenzo et al. [32] addressed hospitalization as a protective measure of PTSD, but this study's inclusion criteria were different as they included only the hospitalized patients.Also, our result supported by Iqbal et al. [33] revealed no correlation between disease recovery time as well as psychological symptoms.Our findings showed a significant association among Taylor Manifest Anxiety scales with smoking, hospitalization, and treatment with cortisone.Also, there was a significant association between BDI grades with smoking and hospitalization.No significant correlation was documented among depression as well as smoking, medical comorbidities, hospitalization time, COVID-19 duration, Linear regression addressed a correlation between physical symptoms and greater mean scores as regards IES-R, DASS-21 anxiety, and stress, along depression subscales.Also, Du et al. [35] reported that risk factors involved higher stress, worse sleep quality, and a lack of perceived psychological preparedness.Moreover, Parchani et al. [36] reported that anxiety exhibited greater values among quarantined individuals; the isolated along with home quarantine individuals showed greater stress levels.
A statistically significant variation was documented among the experimental group's mean pretest as well

Conclusions
COVID-19 cases without pre-existing psychological disorders exhibited a significant increase in psychiatric disorders occurrence 6 months following recovery.Anxiety disorders represented the predominant mental diagnoses documented.

Table 1
Association between GHQ-28 "positive and negative" with demographic data and risk factors and incidence of GHQ-28 "positive

Table 2
SCID-I distributions, somatic disorders, and substance use among the GHQ-28 positive group and Taylor Manifest Anxiety Scale and BDI distributions among the GHQ-28 positive group according SCID-I

Table 3
Association between GHQ-28 "positive and negative" with demographic data and risk factors Data are presented as mean ± SD or frequency (%) * Significant as P-value < 0.05.GHQ General Health Questionnaire

Table 4
Comparison between SCID-I, Taylor Manifest Anxiety Scale, and BDI and descriptive data of GHQ-28-positive group SCID severe combined immunodeficiency, GHQ General Health Questionnaire, BDI Beck Depression Inventory, ED emergency department, AD adjustment disorder * Significant as P-value < 0.05

Table 5
Logistic regression to identify factors associated with depression and anxiety No significant differences were documented as regards the mean pretest as well as posttest SAS scores among controls.Limitations of this study included a small sample size, so further research is recommended done with a larger sample size.

Table 6
Univariate and multivariate regression analysis to risk factors as predictors of positive GHQ-28 among the study group * Significant p-value < 0.05