Psychological consequences and the related factors among COVID‐19 survivors in southeastern Iran

Abstract Introduction Coronavirus disease‐2019 (COVID‐19) is a new viral disease that has spread rapidly worldwide since December 2019 and there is no effective treatment for it. The current study aimed to investigate the psychological consequences and related factors among COVID‐19 survivors. Methods This descriptive analytical study was conducted on 152 patients with COVID‐19 referred to referral hospitals in southeastern Iran in 2020. Data collection tools were three questionnaires of demographic and background information, Depression Anxiety stress Scale (DASS‐21) and Impact of Events Scale‐Revised (IESR). Descriptive and inferential statistics and SPSS25 were used to analyze the data. Results The mean age of patients was 39.52 ± 13.16 years. The patients were mostly female (63.8%). Seventy‐three percent of the patients had severe posttraumatic stress disorder, 26.3% had moderate depression and 26.3% had severe anxiety. The mean scores of posttraumatic stress, depression, and anxiety among patients with COVID‐19 were 41.59 ± 17.28, 12.13 ± 9.16, and 12.45 ± 10.71, respectively. Intensive care unit (ICU) admission, divorce, illiteracy, and retirement were all associated with higher psychological load among patients. Discussion and Conclusion The results showed that patients with COVID‐19 had different levels of anxiety, depression, and posttraumatic stress. These results may direct the attention of the medical staff to the mental health of COVID‐19 patients, necessitating timely psychological care and intervention during an epidemic.


| INTRODUCTION
Coronavirus disease-2019 (COVID-19) is a new viral disease that has spread rapidly worldwide since December 2019, with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as its primary cause. 1 The disease manifests itself in a variety of ways, ranging from very mild symptoms to acute respiratory distress syndrome and death. 2 Approximately 144,358,956 cases with COVID-19 and 3066113 deaths were recorded worldwide on April 23, 2021. 3 COVID-19 is a special and rare condition that is rapidly transmitted from person to person through respiratory droplets. Symptoms typically include cough, fever, shortness of breath, tiredness, muscle pain, lung infection, lymphocytopenia, and loss of taste or smell. 4 What makes COVID-19 so prevalent is the absence of effective treatment, the severity of the risk, the unpredictability of the condition, and the confusion surrounding when to control the disease.
Quarantine and social restrictions are far more stringent than in similar circumstances due to concerns about the rapid transmission of the virus to others. 5 People under quarantine lose personal and social communication, as well as traditional and even religious ceremonies, which can be stressful and lead to resentment and loneliness. These challenges in combination with some disinformation, exaggeration of risks, or suspicion about public health and personal safety increase anxiety and contribute to psychological disorders such as stress, anxiety, and depression. Paying attention to psychological issues in the face of the COVID-19 crisis is an important part of health, as long-term increases in cortisol levels and sympathetic stimulation will be detrimental, leading to a weakened immune system and a decreased body's ability to fight diseases, including COVID-19. 6,7 In India, a study investigated the psychological impact of COVID-19 disease. The results showed that a rapid increase in fear and anxiety due to closures and quarantines could lead to serious psychological disorders among these patients. 8 According to a study conducted in China, 10.8% of the COVID-19 patients showed posttraumatic stress disorder. 9  Given the wide range of stressors among survivors of infectious diseases, it seems that their stress does not decrease over time and may intensify, having a severe impact on their quality of life, function, and mental health. 12 As COVID-19 continues to spread, and given its psychological consequences as well as its emergence, the current study aimed to determine the psychological consequences and related factors among COVID-19 patients referred to hospitals in southeastern Iran in 2020.

| Study design and setting
This descriptive-analytical study investigated the psychological consequences and related factors among COVID-19 survivors referred to referral hospitals in southeastern Iran.

| Sample and sampling
The study population was all patients with COVID-19 referred to referral hospitals who were selected through convenience sampling. According to the literature review, the correlation coefficient between depression and anxiety (0.512) in previous studies, 10 the 99% confidence and 90% test power as well as taking into account the effect factor of 1.5 and the probability of dropout, 152 patients with COVID-19 were included.
Inclusion criteria were patients aged at least 18 years old, with normal speech, vision, and hearing, who had been sick for at least 1 month.
Failure to complete more than one-third of the questionnaire and psychological crises such as the death of a loved one or the birth of a child were considered as exclusion criteria. The DASS21 was developed by Lovibond and Lovibond in 1995 13 to assess symptoms of stress, 5,7,10,11,13,14 anxiety, 3,6,8,[15][16][17] and depression. 2,4,9,12,18-20 A score of 0-14 was considered as normal stress, 15-18 was considered as mild, 19-25 was considered as moderate, and 26-33 was considered as severe. A score of 0-9 was considered as normal depression, 10-13 was considered as mild, 14-20 was considered as moderate, and 21-27 was considered as severe. A score of 0-7 was considered as normal anxiety, 8-9 was considered as mild, 10-14 was considered as moderate, and [15][16][17][18][19] was considered as severe. These subscales are scored by the addition of the total item scores. Scoring was based on a four-point Likert scale (never = zero and always = 3). Since DASS21 is the short form of the original scale (42 items), the total score of each subscale had to be doubled and the severity of the symptoms was calculated. The validity of the DASS21 in the Tran study was 0.77. 15 Beck Depression Inventory, Zung Self-Rating Anxiety Scale, and Perceived Stress Scale were used simultaneously to evaluate the scale validity. The correlation between depression subscale of the DASS and Beck Depression Inventory was 0.70, the correlation between anxiety subscale of the DASS21 and Zung Self-Rating Anxiety Scale was 0.67, and the correlation between stress subscale of the DASS21 and Perceived Stress Scale was 0.49. Factor analysis confirmed the threefactor structure of this questionnaire. 18 Dahm measured the reliability of the questionnaire. First, Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were presented to a large sample of students. The correlation between BAI and anxiety subscale of DASS was high (r = 0.81) and BDI was highly correlated with DASS depression subscale (r = 0.74). 19 The Impact of Event Scale-Revised (IESR) was developed by Weiss (1997)

| Data analysis
Descriptive statistics (frequency, percentage, mean and standard deviation) were used to describe demographic characteristics and mean scores.
Inferential statistics (Pearson correlation coefficient, independent t-test, and analysis of variance) were used to determine the relationship between variables. In addition, a multiple regression test was used to determine more accurate relationships and predictors.

| RESULTS
The present study examined 152 patients with COVID- 19 There was a significant difference between the posttraumatic stress, marital status, level of education, family life, and type of ward. The mean score of posttraumatic stress was higher among the COVID-19 patients who were divorced, illiterate, were not living with family members, and admitted to the ICU. There was a significant difference between the mean anxiety, marital status, level of education, and type of ward. Therefore, the mean anxiety was higher among patients who were widowed, illiterate, and admitted to ICU. There was a significant difference in the mean depression, marital status, level of education, and type of ward among patients with COVID-19. The highest mean score of depression was related to patients who were married, widowed, and illiterate. In addition, patients admitted to the ICU showed a higher mean score of depression, which was significantly different from patients not admitted or admitted to the infectious ward (Table 1).
Other results of this study include factors related to the psychological consequences of COVID-19 survivors. ICU admission, divorce, illiteracy, and retirement were some of the factors associated with higher psychological load among patients and showed more posttraumatic stress, anxiety, and depression. Table 3 showed that among the predictors affecting stress,  showed a significant relationship between depression, female gender, post-discharge respiratory symptoms, concern about recurrence and transmission of infection to others, and home quarantine. 24 Home quarantine, on the other hand, might cause boredom and in some circumstances depression. Although the coronavirus brings families together, they may develop posttraumatic stress disorder, anxiety, and depression throughout the quarantine period. 33 In the present study, there was a significant difference in mean anxiety, marital status, level of education, and type of ward among patients. The mean anxiety was higher in widowed, uneducated, and ICU patients. Vahedian-Azimi et al. showed a relationship between anxiety and gender among COVID-19 patients, so men had more anxiety than women. 21 Mohammadi et al. showed higher anxiety scores among men in the whole population (people with COVID-19 and healthy people) compared to women. In addition, the anxiety of COVID-19 patients with mental illness was significantly higher than that of patients without mental illness. 17 Wang et al. indicated that up-to-date and accurate health information (such as disease treatment and prevalence) and specific precautions (such as hand hygiene and wearing a mask) could reduce stress, depression, and anxiety. 29 Liu et al. reported a significant association between clinical levels of anxiety and high levels of loneliness and concern about COVID-19. 28 The coronavirus, on the other hand, is a source of concern in the current scenario and requires special attention and care. It is normal for people to experience anxiety and fear, especially when they feel threatened and do not have the ability to deal with it.

| CONCLUSION
The results of this study showed that COVID-19 survivors had severe anxiety, moderate depression, and severe posttraumatic stress disorder. These results may draw the attention of the medical staff to the mental health of patients with COVID-19, and timely psychological care and intervention may be required for patients during an epidemic to maintain individuals' mental health with appropriate psychological strategies and techniques.

TRANSPARENCY STATEMENT
The lead author (Neda Asadi) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

AUTHOR CONTRIBUTIONS
Esmat