An Evaluation Of Mental and Social Health Among Saudi Individuals Recovered from Covid-19: A Cross-Sectional Study

Introduction

The coronavirus disease-2019 (COVID-19) epidemic began in Wuhan, China, as an unusual acute respiratory illness caused by the severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2) 1. On March 11, 2020, the sickness has spread to 215 nations, with over four million confirmed cases. COVID-19 was deemed a worldwide pandemic by the World Health Organization at the time 2. SARS-CoV-2 may infect people of all ages and genders, although elderly individuals with underlying comorbidities are at a higher risk of developing serious diseases 3. COVID-19 is largely a respiratory condition, although it may also have a negative impact on cardiovascular, renal, and mental health 4-6. COVID-19 has been observed to have an impact on patients' psychological health in addition to its physical effects 7.

Similarly, earlier viral epidemics – SARS and Middle East respiratory disease (MERS) – had an impact on psychological health. SARS infections have been linked to sadness, anxiety, panic attacks, delirium, and suicidal ideation.8. Furthermore, approximately 70.8% of MERS patients experienced psychiatric symptoms, and 41.7% had a definitive psychiatric diagnosis and treatment 8. COVID-19 is thought to have a considerably bigger influence on psychological health, which is exacerbated by the dissemination of disinformation on social media 9.

Several variables are thought to impact COVID-19 patients' psychological wellbeing. Discrimination and stigmatization for being infected with this virus may be among these issues 10 . Furthermore, the patients' seclusion after their diagnosis has an effect. The health officials want for the quarantine to be agreeable to the patients; nonetheless, being isolated may be a devastating experience for some of them. Quarantine has already been demonstrated to have an impact on mental health, and a longer stay in isolation was connected with more psychiatric disorders 11, 12. Furthermore, patients may become concerned about the absence of an appropriate therapy for the new ailment. Isolation from family, friends, and society may have a negative impact on the patients' social health 13. Several research, on the other hand, suggest that the psychological influence of COVID-19 is due to physical factors. COVID-19 has been shown to directly damage patients' central nervous systems and to cause a cytokine storm by stimulating the immune system 14, 15. There was also a link found between oxygen saturation and sadness and anxiety symptoms 16.

The psychological effect of the COVID-19 pandemic has already been recorded; 72 percent of the general population in Spain suffered psychological anguish 17. This effect, however, is substantially stronger in COVID-19 patients than in the overall population 18. Patients were found to have depression, anxiety, and suicidal attempts 6, 19, 20. The medical literature on the physical effects of COVID-19 is quickly expanding, but psychological health is not given much attention. During the last SARS pandemic, patients' psychological problems persisted for a long period after they were discharged from the hospital 21, 22. Therefore, this cross-sectional study aimed to assess the mental and social health of Saudi patients who recovered from COVID-19, and to identify factors affecting mental and social health.

Methods

Study design and participants:

We conducted a quantitative cross-sectional study on Saudi individuals who recovered from laboratory-confirmed COVID-19. The study was conducted between November and December 2021. The research pooled a total of 109 samples using a non-probable, convenience sampling strategy. COVID-19 recovered individuals over 18 years of age, Saudi and living in Saudi Arabia, were included in this study. SARS-CoV-2 infection was confirmed in the laboratory through positive reverse transcription-polymerase chain reaction. No restrictions regarding the severity of COVID-19 were applied. Recovery was defined as discharge from hospital for hospitalized patients, three days of complete fade of the symptoms for mildly to moderately symptomatic no hospitalized patients and passing 14 days from confirming the disease for asymptomatic patients. Only individuals who gave their informed consent were included in this investigation.

Data collection method:

Data were collected using an online self-administered questionnaire. The questionnaire was designed by the authors after an extensive review of the relevant literature. The experts psychiatrists then revised and edited the questionnaire. Thereafter, piloting of the questionnaire was done, and its face validity was checked. Cronbach's alpha value was 0.835 for the mental health scale and 0.864 for the social health scale, indicating a high level of internal consistency. The questionnaire was spread as a Google form through different social media platforms, websites, and blogs that are popular in Saudi Arabia.

Study measures:

General demographic data were collected from the included participants, including age, sex, residence, number of family members, and any physical comorbidity. Additionally, demographic data related to COVID-19 were collected. Participants were asked about the severity of their symptoms of COVID-19, if they were quarantined in hospitals, the number of affected family members and if any from them died of COVID-19 and contacted family members who did not get the disease. Vaccine-related demographics included their vaccination status, type of vaccine, number of doses received, and whether the infection followed their vaccination.

The participants' mental health was evaluated in ten questions that assess different aspects. Social health was evaluated in ten questions as well. Questions evaluating mental and social health were answered using the 5-Likert scale; never / rarely / sometimes / often / always. Each answer for each question was coded with a value from one to five, then we have calculated the overall social and mental health scores. After that, we have transformed these scores into percentages, with social health > 50% means severe social affection, 50-75% as moderate affection, < 75% as mild affection. While for mental health, > 50% means mild mental affection, 50-75% as moderate affection, < 75% as severe affection.

Ethical approval:

The ethical approval of this study was obtained from the institutional review board committee at University of Bisha, faculty of applied medical science. Additionally, on the first page of the questionnaire, the participants were informed of the aim of this study, and their consent to participate by filling the questionnaire was taken.

Statistical analysis:

Descriptive statistics with frequency and percentage were applied to general demographics, vaccines and COVID-19 related. Furthermore, all answers to mental and social-related questions were described as frequency and percentage. Spearman correlation was used to test the correlation between mental and social scores, and all demographics. Also, Pearson's correlation was used to test the correlation between mental scores, social scores, and receiving any kind of support. A two-sided p < 0.05 was considered statistically significant. We analyzed the data using the SPSS statistical package of social sciences software SPSS (version 22).

Results

Characteristics of the participants:

Our study was based on data collected from 109 Saudi individuals who recovered from a confirmed COVID-19 infection. Most of the participants were women and the highest proportion of them was between 36 and 41 years old. The majority belonged to a family of over three members and resided in urban areas. Bronchial asthma was the most frequent chronic comorbidity, followed by diabetes mellitus and hypertension.

Regarding COVID-19, asymptomatic infection was the most frequent, followed by moderate, and mild infections. Severe infection was the least frequent form in our sample. The highest proportion of the patients reported no other affected family members. Among those who had infected family members, the infection did not lead to death in most of them. Most of participants were fully vaccinated. The Pfizer vaccine was the most received, followed by AstraZeneca. Detailed demographic data of the participants are provided in Table 1.

Mental health:

The majority of the study participants (64%) had their mental health mildly affected, a lesser proportion (29%) had their mental health moderately affected, and much fewer ones (7%) had their mental health severely affected. More than half (58%) of the participants reported feeling easily agitated. About 63% of the participants reported experiencing stress, 64% reported feeling despair, 65% lost interest in their daily activities, and 60% felt unable to manage their important daily activities. Furthermore, approximately 43% of the individuals had a fear of being hospitalized, 83% had their appetite affected, and 61% experienced sleep disturbances. Over half of the participants felt detached from their surroundings (55%) and overreacted to normal situations (52%). Participants' responses to each question on the 5-Likert scale are summarized in Table 2.

Mental health was significantly correlated with the sex of the participants (r = 0.210, p = 0.038), the age group (r = -0.298, p = 0.003), the severity of COVID-19 (r = 0.288, p = 0.004) and being quarantined (r=-0.23, p=0.022) with females, younger, and severely symptomatic participants suffered from more deteriorated mental health. However, no significant correlation was detected between mental health and receiving social support (p = 0.08). The correlations between mental health and different demographic variables are summarized in Table 4.

Social health:

The highest proportion of the participants (44%) suffered from severe deterioration of their social health, a lesser proportion (39%) had their social health moderately affected, and much fewer participants (17%) had their social health mildly affected. A proportion of 21% of the participants did not communicate with their friends or relatives, 26% did not practice sport, and 25% did not go for a walk. Furthermore, 36% did not practice writing, drawing or photography, 19% did not practice reading, 18% did not watch television, 17% did not watch videos such as on YouTube, 36% did not play games, and 29% did not do any entertainment. Additionally, about 9% of the participants were not even cleaning their own environment. The participants' responses to each question on the 5-Likert scale are summarized in Table 3.

Social health was found to be significantly correlated with receiving social support (r=0.231, p=0.016) with less probability for social health affection for those who received social support. Regarding the correlation between mental and social health, no significant correlation was detected between the two scores (p=0.224). The correlations between mental and social health and different demographic variables are summarized in Table 4.

Discussion

Several studies had assessed the impact of COVID-19 on the mental and social health of patients. However, there is a paucity of data regarding the persistence of this effect after recovery from COVID-19. To our knowledge, this is the first study that evaluates the mental and social health among Saudi individuals who recovered from a confirmed COVID-19 infection.

The psychological impact of COVID-19 on patients during the illness is widely reported in the literature 15, 23. Furthermore, Liu et al. 2020 reported that one out of eight patients who had post-traumatic stress disorder during their active COVID-19 period continued to suffer from it even for a month after being discharged 24. This finding had suggested the possibility of continued psychological health affection even after recovering from COVID-19. Furthermore, previous studies on SARS had reported continued psychological disturbances up to four years of recovery 21, 25, 26. As SARS and COVID-19 were nearly similar, the long-term psychological impact should be studied efficiently. Our study came to prove that the mental and social health of the recovered COVID-19 patients was still affected.

With COVID-19, previous studies reported that Saudi and non-Saudi women are more susceptible to mental health deterioration than men 15, 27, 28. The findings of our study indicate that this association remains significant even after recovering from COVID-19. Furthermore, the literature highlighted the association between mental health deterioration and younger age with COVID-19 29. Our study came to prove that this association is significant even for recovered COVID-19 patients. This encourages taking special care of the mental health of these vulnerable individuals during COVID-19 infection and after recovery. Although support was reported to be associated with better mental health during COVID-19 infection 30, our study did not demonstrate a significant correlation between the two variables after recovery. Support from family and friends may be much needed to improve mental health during the active disease period rather than after recovery. However, the effect of receiving support after recovery becomes much clearer in terms of social health. People tend to avoid these patients even after recovery, as previously reported during the SARS epidemic 31. Therefore, patients may feel stigmatized, isolated, and detached. Receiving support from family and friends through this period can help the patients in returning to their normal social life. Our study proved that receiving social support during this period was correlated with improvement in social health.

Our study is the first to assess the mental and social health among Saudi individuals who recovered from COVID-19. Additionally, we have evaluated possible correlations. However, this study might be limited by its cross-sectional design with limited sample size that does not allow for observing the dynamic change in mental and social health through time. More multinational studies with a larger sample are required to support our findings on psychological health among individuals who recovered from COVID-19.

Conclusion

This cross-sectional study evaluated mental and social health among Saudi individuals who recovered from a laboratory-confirmed COVID-19 infection. Our results showed that the highest proportion of participants had a mildly affected mental health, but their social health was severely affected. Females, younger, and severely symptomatic participants had much more deterioration in their mental health. Furthermore, receiving social support was correlated with improved social health. Our findings describe the impact of COVID-19 on psychological health even after recovery and necessitates paying attention for those recovered individuals and especially the ones who have one of the aforementioned risk factors. Additionally, social support should be encouraged to help these individuals in returning to their normal social lives.

References:

1. Qu YM, Kang EM, Cong HY. Positive result of Sars-Cov-2 in sputum from a cured patient with COVID-19. Travel medicine and infectious disease. 2020 Mar;34:101619.

2. WHO Director-General’s Opening Remarks at the Media Briefing on COVID-19—11 March 2020, https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-mediabriefing-on-covid-19---11-march-2020 (accessed 4 January 2022).

3. Zhou X, Li Y, Li T and Zhang W. Follow-up of asymptomatic patients with SARS-CoV-2 infection. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases 2020; 26: 957-959. 2020/04/03. DOI: 10.1016/j.cmi.2020.03.024.

4. Ronco C, Reis T and Husain-Syed F. Management of acute kidney injury in patients with COVID-19. The Lancet Respiratory medicine 2020; 8: 738-742. 2020/05/18. DOI: 10.1016/s2213-2600(20)30229-0.

5. Ranard LS, Fried JA, Abdalla M, Anstey DE, Givens RC, Kumaraiah D, Kodali SK, Takeda K, Karmpaliotis D, Rabbani LE, Sayer G, Kirtane AJ, Leon MB, Schwartz A, Uriel N and Masoumi A. Approach to Acute Cardiovascular Complications in COVID-19 Infection. Circulation Heart failure 2020; 13: e007220. 2020/06/06. DOI: 10.1161/circheartfailure.120.007220.

6. Rogers JP, Chesney E, Oliver D, Pollak TA, McGuire P, Fusar-Poli P, Zandi MS, Lewis G and David AS. Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic. The lancet Psychiatry 2020; 7: 611-627. 2020/05/22. DOI: 10.1016/s2215-0366(20)30203-0.

7. Zhou SJ, Zhang LG, Wang LL, Guo ZC, Wang JQ, Chen JC, Liu M, Chen X and Chen JX. Prevalence and socio-demographic correlates of psychological health problems in Chinese adolescents during the outbreak of COVID-19. European child & adolescent psychiatry 2020; 29: 749-758. 2020/05/05. DOI: 10.1007/s00787-020-01541-4.

8. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T and Ng CH. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. The lancet Psychiatry 2020; 7: 228-229. 2020/02/08. DOI: 10.1016/s2215-0366(20)30046-8.

9. Mian A and Khan S. Coronavirus: the spread of misinformation. BMC medicine 2020; 18: 89. 2020/03/20. DOI: 10.1186/s12916-020-01556-3.

10. Hossain MM, Sultana A and Purohit N. Mental health outcomes of quarantine and isolation for infection prevention: a systematic umbrella review of the global evidence. Epidemiology and health 2020; 42: e2020038. 2020/06/10. DOI: 10.4178/epih.e2020038.

11. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N and Rubin GJ. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet (London, England) 2020; 395: 912-920. 2020/03/01. DOI: 10.1016/s0140-6736(20)30460-8.

12. Reynolds DL, Garay JR, Deamond SL, Moran MK, Gold W and Styra R. Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiology and infection 2008; 136: 997-1007. 2007/07/31. DOI: 10.1017/s0950268807009156.

13. Institute of Medicine (US) Division of Health Promotion and Disease Prevention. Social Isolation Among Older Individuals: The Relationship to Mortality and Morbidity. In: Berg RL CJ (ed) The Second Fifty Years: Promoting Health and Preventing Disability. Washington, DC, USA, 1992.

14. Hu Y, Chen Y, Zheng Y, You C, Tan J, Hu L, Zhang Z and Ding L. Factors related to mental health of inpatients with COVID-19 in Wuhan, China. Brain, behavior, and immunity 2020; 89: 587-593. 2020/07/19. DOI: 10.1016/j.bbi.2020.07.016.

15. Deng J, Zhou F, Hou W, Silver Z, Wong CY, Chang O, Huang E and Zuo QK. The prevalence of depression, anxiety, and sleep disturbances in COVID-19 patients: a meta-analysis. Annals of the New York Academy of Sciences 2021; 1486: 90-111. 2020/10/04. DOI: 10.1111/nyas.14506.

16. Leigh-Hunt N, Bagguley D, Bash K, Turner V, Turnbull S, Valtorta N and Caan W. An overview of systematic reviews on the public health consequences of social isolation and loneliness. Public health 2017; 152: 157-171. 2017/09/16. DOI: 10.1016/j.puhe.2017.07.035.

17. Gómez-Salgado J, Andrés-Villas M, Domínguez-Salas S, Díaz-Milanés D and Ruiz-Frutos C. Related Health Factors of Psychological Distress During the COVID-19 Pandemic in Spain. International journal of environmental research and public health 2020; 17 2020/06/06. DOI: 10.3390/ijerph17113947.

18. Wu T, Jia X, Shi H, Niu J, Yin X, Xie J and Wang X. Prevalence of mental health problems during the COVID-19 pandemic: A systematic review and meta-analysis. Journal of affective disorders 2021; 281: 91-98. 2020/12/15. DOI: 10.1016/j.jad.2020.11.117.

19. Guo Q, Zheng Y, Shi J, Wang J, Li G, Li C, Fromson JA, Xu Y, Liu X, Xu H, Zhang T, Lu Y, Chen X, Hu H, Tang Y, Yang S, Zhou H, Wang X, Chen H, Wang Z and Yang Z. Immediate psychological distress in quarantined patients with COVID-19 and its association with peripheral inflammation: A mixed-method study. Brain, behavior, and immunity 2020; 88: 17-27. 2020/05/18. DOI: 10.1016/j.bbi.2020.05.038.

20. Hossain M, Tasnim S, Sultana A, McKyer EL and Ma P. COVID-19 and suicide of an army soldier in India: perspectives on psychosocial epidemiology of suicidal behavior. 2020.

21. Hong X, Currier GW, Zhao X, Jiang Y, Zhou W and Wei J. Posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: a 4-year follow-up study. General hospital psychiatry 2009; 31: 546-554. 2009/11/07. DOI: 10.1016/j.genhosppsych.2009.06.008.

22. Mak IW, Chu CM, Pan PC, Yiu MG and Chan VL. Long-term psychiatric morbidities among SARS survivors. General hospital psychiatry 2009; 31: 318-326. 2009/06/27. DOI: 10.1016/j.genhosppsych.2009.03.001.

23. Hossain MM, Tasnim S, Sultana A, Faizah F, Mazumder H, Zou L, McKyer ELJ, Ahmed HU and Ma P. Epidemiology of mental health problems in COVID-19: a review. F1000Research 2020; 9: 636. 2020/10/24. DOI: 10.12688/f1000research.24457.1.

24. Liu D, Baumeister RF, Veilleux JC, Chen C, Liu W, Yue Y and Zhang S. Risk factors associated with mental illness in hospital discharged patients infected with COVID-19 in Wuhan, China. Psychiatry research 2020; 292: 113297. 2020/07/25. DOI: 10.1016/j.psychres.2020.113297.

25. Cheng SK, Wong CW, Tsang J and Wong KC. Psychological distress and negative appraisals in survivors of severe acute respiratory syndrome (SARS). Psychological medicine 2004; 34: 1187-1195. 2005/02/09. DOI: 10.1017/s0033291704002272.

26. Kwek SK, Chew WM, Ong KC, Ng AW, Lee LS, Kaw G and Leow MK. Quality of life and psychological status in survivors of severe acute respiratory syndrome at 3 months postdischarge. Journal of psychosomatic research 2006; 60: 513-519. 2006/05/03. DOI: 10.1016/j.jpsychores.2005.08.020.

27. Alamri HS, Mousa WF, Algarni A, Megahid SF, Al Bshabshe A, Alshehri NN, Bashah DM, Alosaimi R, Alshehri A, Alsamghan A and Alsabaani A. Mental Health of COVID-19 Patients-A Cross-Sectional Survey in Saudi Arabia. International journal of environmental research and public health 2021; 18 2021/05/06. DOI: 10.3390/ijerph18094758.

28. Aghagoli G, Gallo Marin B, Katchur NJ, Chaves-Sell F, Asaad WF and Murphy SA. Neurological Involvement in COVID-19 and Potential Mechanisms: A Review. Neurocritical care 2021; 34: 1062-1071. 2020/07/15. DOI: 10.1007/s12028-020-01049-4.

29. Chew NWS, Lee GKH, Tan BYQ, Jing M, Goh Y, Ngiam NJH, Yeo LLL, Ahmad A, Ahmed Khan F, Napolean Shanmugam G, Sharma AK, Komalkumar RN, Meenakshi PV, Shah K, Patel B, Chan BPL, Sunny S, Chandra B, Ong JJY, Paliwal PR, Wong LYH, Sagayanathan R, Chen JT, Ying Ng AY, Teoh HL, Tsivgoulis G, Ho CS, Ho RC and Sharma VK. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain, behavior, and immunity 2020; 88: 559-565. 2020/04/25. DOI: 10.1016/j.bbi.2020.04.049.

30. Lei L, Huang X, Zhang S, Yang J, Yang L and Xu M. Comparison of Prevalence and Associated Factors of Anxiety and Depression Among People Affected by versus People Unaffected by Quarantine During the COVID-19 Epidemic in Southwestern China. Medical science monitor : international medical journal of experimental and clinical research 2020; 26: e924609. 2020/04/27. DOI: 10.12659/msm.924609.

31. Person B, Sy F, Holton K, Govert B and Liang A. Fear and stigma: the epidemic within the SARS outbreak. Emerging infectious diseases 2004; 10: 358-363. 2004/03/20. DOI: 10.3201/eid1002.030750.