Front. PsychiatryFrontiers in PsychiatryFront. Psychiatry1664-0640Frontiers Media S.A.10.3389/fpsyt.2022.863215PsychiatryOriginal ResearchPrevalence of depression and its associated factors among patients with confirmed COVID-19 in Makkah, Saudi ArabiaAlqurashiEid1AldobyanyAhmad1*ToumanAbdelfattah1AlqahtaniAbdullah1AlsaggafRajaa1AlnashiwaatyOmar1GhalebNabil1MabarHanan1AlbannaAmr S.231Department of Medicine, King Abdullah Medical City, Makkah, Saudi Arabia2Department of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia3Department of Medicine, McGill University, Montreal, QC, Canada
Edited by: Alessandro Colasanti, Brighton and Sussex Medical School, United Kingdom
Reviewed by: Marianna Mazza, Agostino Gemelli University Polyclinic (IRCCS), Italy; Siraj Wali, King Abdulaziz University, Saudi Arabia; Beata Gavurova, Tomas Bata University in Zlín, Czechia
*Correspondence: Ahmad Aldobyany, ahmad2145@hotmail.com
This article was submitted to Mood Disorders, a section of the journal Frontiers in Psychiatry
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Background
In early December 2019, a cluster of acute pneumonia of viral etiology had been identified in Wuhan, China. Later on, it has been named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing a worldwide pandemic. This pandemic triggered unprecedented health-related psychiatric sequalae. We aim in this study to evaluate the prevalence of depression and its associated factors among confirmed patients with COVID-19.
Methodology
This is a cross-sectional study, we included adult patients more than 18 years old who have been diagnosed with PCR-confirmed COVID-19 and managed in a hospital, home, or hotel. A self-administered online questionnaire based on Patient Health Questionnaire (PHQ-9) Quick Depression Assessment questionnaire was used.
Results
A total of 143 subjects completed the PHQ-9 questionnaire. The prevalence of moderate to severe depression was 34%. Prevalence of depression was positively associated with the female gender (p-value = 0.013). Location of COVID-19 management and financial status did not affect the prevalence of depression.
Conclusion
The prevalence of depression among patients with COVID-19 is high, which underscores the importance of active screening and management of depression in this population.
The prevalence of depression among patients with COVID-19 is high at 33.6%.
Prevalence of depression was positively associated with the female gender.
Location of COVID-19 management and financial status did not affect the prevalence of depression.
Introduction
In early December 2019, a cluster of acute pneumonia of unknown etiology had been identified in Wuhan, China. The pathogen was identified as a new RNA virus, which was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (1). After the rapid global spread of this virus, the WHO declared COVID-19 a pandemic on 12 March 2020 (1).
This outbreak triggered unprecedented health-related anxiety (2). During the pandemic, the rapid spread of SARS-CoV-2 during the pandemic resulted in a great burden on health and the economy, which prompted countries and health agencies to apply strict measures to decrease viral transmission. These measures included community lockdown, social distancing, and other strict measures which resulted in psychosocial and health-related sequences.
It has been demonstrated in various research that infection outbreaks affect people’s mental and psychosocial health significantly. In the initial phase of COVID-19 spread, people started to have symptoms of anxiety especially younger individuals with chronic diseases. These psychosocial and mental symptoms increased particularly after implementing the community lockdown (3), affecting both general populations and healthcare workers. The effect was more prominent among persons who lack social support and those who have been living with a suspected case of COVID-19 (4). As opposed to an influenza outbreak, where the anxiety was ranging from 10 to 33% in the general population (5). Alsaqri and colleagues found that around 67% of the study population were suffering from a degree of social anxiety during the COVID-19 pandemic (6).
In addition to the COVID-19-related strict precautionary measures that can cause mental health problems, COVID-19 disease itself can trigger mental health disorders like depression. It has been found that the prevalence of depression was 43% in clinically stable patients with COVID-19 (7). In a systematic review that evaluated infected patients with COVID-19, the pooled prevalence of depression was 45% (8).
Different studies have shown that depression can be associated with a depressed immune system, especially cellular immunity, which may have a negative impact on COVID-19 disease progression (9). This underscores the importance of screening patients with COVID-19 for any sign of depression. Symptoms of depression can persist even after the resolution of the disease. In one study that evaluated patients with COVID-19 after one month of their discharge from the hospital, the prevalence of depression was 18% (10). A substantial percentage of patients with COVID-19 have persistent symptoms of depression 3–6 months after COVID-19 symptoms onset (11). Thus, awareness and effective management of mental health-related disorders in patients with COVID-19 is strongly required.
The location of isolation either at home or in hospital settings may also have an impact on mental health. This, however, was not sufficiently evaluated in previous studies. We aim in this study to evaluate the prevalence of depression and its associated factors among COVID-19 confirmed patients and the factors, including isolation location that may influence mental health.
Materials and methods
This is a cross-sectional study that included adult patients more than 18 years old who have been diagnosed with SARS-CoV-2 PCR confirmed COVID-19 and managed based on Saudi ministry of health guidelines in hospitals, homes, or hotels were involved. Patients were recruited from the COVID-19 clinic over a period of 3 months (March, April, and May, 2020). Critically ill patients, patients with previous diagnoses of depression, and patients with cognitive impairment such as dementia or delirium were excluded. A self-administered online questionnaire based on Patient Health Questionnaire (PHQ-9) Quick Depression Assessment questionnaire was used. This questionnaire has been validated, and it relies on patient self-report (12, 13). An electronic questionnaire was sent to 300 patients using their e-mails and cell phones. A total of 143 patients out of 300 patients (47.7%) responded and completed the questionnaire. The questionnaire contains questions related to demographic, social, educational, and financial status. We used PHQ-9 which is categorized as the following: A score of 1–4 is minimal depression, a score of 5–9 is mild depression, a score of 10–14 is moderate depression, a score of 15–19 is moderately severe depression, and a score of 20–27 is severe depression.
Statistical analysis
Data were analyzed by using Statistical Package for Social Studies (SPSS 22; IBM Corp., New York, NY, United States). Continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as percentages. The t-test and the one-way ANOVA were used for continuous variables. The chi-square test was used for categorical variables. A p-value of <0.05 was considered statistically significant.
Ethics and confidentiality
Ethical approval, as well as the informed consent form for the study, was taken from the KAMC Institutional Review Board (Approval number: 20-643).
Results
A total of 143 subjects completed the PHQ9 questionnaire and were included. The baseline demographic and disease characteristics are shown in Table 1. The mean age is 41 years, and the majority (78%) of the subjects were women. Most of the subjects (73%) were diagnosed with COVID-19 for more than 1 week and half of them (49.7%) were hospitalized. Subjects with a previous diagnosis of depression represented only 2%.
Patient’s characteristics (n = 143).
Number
%
Gender
Male
65
45.5
Female
78
54.5
Age (Mean, SD)
41.57
15.08
Education
Illiterate
16
11.2
Primary
10
7.0
Intermediate
14
9.8
Secondary
29
20.3
University
53
37.1
Post-bachelor
21
14.7
Chronic disease
DM
Yes
38
26.6
HTN
Yes
36
25.2
Heart diseases such as ischemic heart disease, heart failure, or other
Yes
6
4.2
Chronic lung disease
Yes
15
10.5
Chronic kidney disease
Yes
3
2.1
Stroke
Yes
1
0.7
Cancer (any type)
Yes
1
0.7
Other chronic diseases not mentioned above
Yes
12
8.4
When have you been diagnosed with COVID-19?
1 day
2
1.4
2 days
3
2.1
3 days
4
2.8
4 days
9
6.3
5 days
10
7.0
6 days
10
7.0
One week ago, or more
105
73.4
Where were you treated for COVID-19?
Stayed at home
61
42.7
Admitted at a hospital
71
49.7
In a hotel or other place designated for quarantine
11
7.7
What is your assessment of your current financial status?
Good
60
42.0
Average
69
48.3
Low
14
9.8
The prevalence of different depression severity categories is shown in Table 2. The prevalence of moderate to severe depression was 34%. The distribution of subjects across different degrees of depression severity is shown in Figure 1.
The severity degree of depression among confirmed patients with COVID-19.
Number
Prevalence (%)
Minimal depression (1–4)
37
25.9
Mild depression (5–9)
46
32.2
Moderate depression (10–14)
30
21.0
Moderately severe depression (15–19)
13
9.1
Severe depression (20–27)
5
3.5
Prevalence and severity degree of depression among confirmed patients with COVID-19.
The severity degree of depression among confirmed patients with COVID-19 by their characteristics is shown in Table 3. The mean score of PHQ-9 for confirmed patients with COVID-19 by their characteristics is shown in Table 4. The prevalence of depression was positively associated with the female gender (p-value = 0.013). Location of COVID-19 management and financial status did not affect the prevalence of depression.
The prevalence and severity degree of depression among confirmed patients with COVID-19 by their characteristics.
Minimal depression
Mild depression
Moderate depression
Moderately severe depression
Severe depression
P-value
Number
%
Number
%
Number
%
Number
%
Number
%
Gender
Male
21
32.31
17
26.15
13
20.00
4
6.15
1
1.54
0.247
Female
16
20.51
29
37.18
17
21.79
9
11.54
4
5.13
Education
Illiterate
5
31.25
4
25.00
1
6.25
3
18.75
1
6.25
0.137
Primary
2
20.00
6
60.00
2
20.00
0
0.00
0
0.00
Intermediate
2
14.29
4
28.57
6
42.86
0
0.00
0
0.00
Secondary
12
41.38
4
13.79
6
20.69
2
6.90
0
0.00
University
9
16.98
20
37.74
11
20.75
6
11.32
4
7.55
Post-bachelor
7
33.33
8
38.10
4
19.05
2
9.52
0
0.00
Chronic disease
DM
Yes
8
21.05
15
39.47
4
10.53
2
5.26
2
5.26
0.274
No
29
27.62
31
29.52
26
24.76
11
10.48
3
2.86
HTN
Yes
8
22.22
13
36.11
6
16.67
1
2.78
2
5.56
0.484
No
29
27.10
33
30.84
24
22.43
12
11.21
3
2.80
Heart diseases such as ischemic heart disease, heart failure, or other
Yes
0.00
3
50.00
2
33.33
0
0.00
0
0.00
0.439
No
37
27.01
43
31.39
28
20.44
13
9.49
5
3.65
Chronic lung disease
Yes
3
20.00
6
40.00
2
13.33
1
6.67
0
0.00
0.801
No
34
26.56
40
31.25
28
21.88
12
9.38
5
3.91
Chronic kidney disease
Yes
0.00
1
33.33
2
66.67
0
0.00
0
0.00
0.425
No
37
26.43
45
32.14
28
20.00
13
9.29
5
3.57
Stroke
Yes
0.00
1
100.00
0
0.00
0
0.00
0
0.00
0.761
No
37
26.06
45
31.69
30
21.13
13
9.15
5
3.52
Cancer (any type)
Yes
0.00
1
100.00
0
0.00
0
0.00
0
0.00
0.761
No
37
26.06
45
31.69
30
21.13
13
9.15
5
3.52
Other chronic diseases not mentioned above
Yes
1
8.33
4
33.33
5
41.67
1
8.33
0
0.00
0.320
No
36
27.48
42
32.06
25
19.08
12
9.16
5
3.82
Non-chronic disease
23
28.40
22
27.16
19
23.46
9
11.11
3
3.70
0.517
When have you been diagnosed with COVID-19?
1 day
1
50.00
0
0.00
0
0.00
1
50.00
0
0.00
0.599
2 days
0
0.00
1
33.33
1
33.33
0
0.00
0
0.00
3 days
1
25.00
3
75.00
0
0.00
0
0.00
0
0.00
4 days
2
22.22
2
22.22
1
11.11
0
0.00
1
11.11
5 days
3
30.00
3
30.00
2
20.00
1
10.00
0
0.00
6 days
1
10.00
3
30.00
1
10.00
3
30.00
0
0.00
One week ago or more
29
27.62
34
32.38
25
23.81
8
7.62
4
3.81
Where were you treated for COVID-19?
Stayed at home
17
27.87
19
31.15
11
18.03
7
11.48
3
4.92
0.646
Admitted at a hospital
15
21.13
25
35.21
16
22.54
6
8.45
2
2.82
In a hotel or other place designated for quarantine
5
45.45
2
18.18
3
27.27
0.00
0.00
What is your assessment of your current financial status?
Good
17
28.33
19
31.67
11
18.33
6
10.00
2
3.33
0.979
Average
16
23.19
24
34.78
16
23.19
6
8.70
2
2.90
Low
4
28.57
3
21.43
3
21.43
1
7.14
1
7.14
Mean score of PHQ-9 depression questionnaire for confirmed patients with COVID-19 by their characteristics.
Mean**
SD
P-value
Gender
Male
6.42
4.92
0.013*
Female
8.73
5.91
Education
Illiterate
8.06
7.08
0.290
Primary
7.20
3.43
Intermediate
7.50
5.23
Secondary
5.83
5.12
University
8.92
6.04
Post-bachelor
7.14
4.39
Chronic disease
DM
Yes
6.76
5.63
0.239
No
8.01
5.55
HTN
Yes
7.03
5.79
0.421
No
7.90
5.52
Heart diseases such as ischemic heart disease, heart failure, or other
Yes
7.50
5.01
0.731
No
7.69
5.62
Chronic lung disease
Yes
6.13
5.17
0.259
No
7.86
5.62
Chronic kidney disease
Yes
11.00
3.61
0.299
No
7.61
5.60
Stroke
Yes
6.00
0.00
0.764
No
7.69
5.60
Cancer (any type)
Yes
9.00
0.813
No
7.67
5.60
Other chronic disease not mentioned above
Yes
9.17
4.51
0.236
No
7.54
5.66
When have you been diagnosed with COVID-19?
1 day
9.00
9.90
0.874
2 days
6.67
6.11
3 days
5.25
3.30
4 days
6.22
8.00
5 days
6.70
4.90
6 days
8.90
6.59
One week ago or more
7.88
5.39
Where were you treated for COVID-19?
Stayed at home
7.84
6.09
0.519
Admitted at a hospital
7.83
5.30
In a hotel or other place designated for quarantine
5.82
4.38
What is your assessment for your current financial status?
Good
7.45
5.68
0.845
Average
7.96
5.51
Low
7.29
5.85
Overall score
7.68
5.58
*Significant p-value.
**Out of 27.
Discussion
We found that around one-third (34%) of patients diagnosed with COVID-19 suffered from moderate to severe depression, which was positively associated with the female gender. Location of COVID-19 management (hospital, home, or hotel) and financial status did not affect the prevalence of depression.
Our findings are consistent with what has been found in other studies. Ma and colleagues found that the prevalence of depression among patients with COVID-19 using the PHQ-9 questionnaire was 43.1%. Female gender and family history of severe COVID-19 disease have been found to be strong predictors of depression (7). In another cross-sectional study that was conducted on 1,002 patients with COVID-19 using PHQ-9, the prevalence of moderate to severe depression was as high as 48%. Depression was positively associated with lower family income, sleep disturbance, lack of physical activity, fear of COVID-19 re-infection, and persistent COVID-19 symptoms (14). In our study, female gender was a significant risk factor for depression. Other factors including financial status, comorbidities, duration of having COVID-19, and location of isolation did not affect the prevalence of depression.
Prevalence of depression has been found to be higher in patients with COVID-19 as compared to the general population. Alamri and colleagues found that the prevalence of depression among the general population in Saudi Arabia during the COVID-19 pandemic is 17% (15). It is low as compared to our finding in this study which is 34%. In a systematic review that involved multiple studies in different countries, the overall prevalence of depression in the general population was ranging from 14.6 to 48.3% (16). While in patients with COVID-19, the prevalence was higher as demonstrated in a systematic review and meta-analysis that evaluated infected patients with COVID-19, which found that the pooled prevalence of depression was 45% (8).
During the COVID-19 pandemic prevalence of depression was relatively high compared to the pre-pandemic period. The prevalence of depression symptoms in the United States of America was more than threefold higher during the COVID-19 pandemic compared to the pre-pandemic period (17). In one survey of the general population before the COVID-19 pandemic in Saudi Arabia, the prevalence of depression was 3.8% (18), which increased significantly during the pandemic as indicated in this study is 34%.
Some studies showed a higher prevalence of depression in actively hospitalized patients. Samrah and colleagues did a survey on patients with COVID-19 after 10 days of hospital isolation which showed a very high prevalence of 44% (19). In another study, 97.2% of hospitalized patients with COVID-19 with stable conditions had some degree of depression (20). In our study, the location where the patient received COVID-19 management at home, hotel, or hospital did not affect the prevalence of depression.
Although the high prevalence of depression among patients with COVID-19 could be explained by the quarantine and fear of disease, the inflammatory process of COVID-19 has been found to play a role in the psychiatric sequalae. Baseline systemic immune-inflammation index has positively associated with the prevalence of depression in 402 adults surviving COVID-19 at 1-month follow-up after hospital treatment (21).
It is important to acknowledge the limitations of our study, which include small sample size and an online self-assessment questionnaire rather than a face-to-face meeting and evaluation. Also, the absence of a control group from the general population during the same period is one of the limitations. On the other hand, we used a well-validated questionnaire and assessed different important variables that might affect the mental status.
Our study findings have important clinical implications as they indicate that the prevalence of depression is high in patients with COVID-19 as compared to the general population during the COVID-19 pandemic. This raises the importance of good assessment and evaluation of those patients for health-related psychiatric sequalae. This can be conducted through telemedicine or web-based care. In one study, digitally enabled remote care for people with long COVID-19 syndrome showed promising results; and there are ongoing studies to assess the online cognitive behavioral therapy that will be more accessible with less cost (22–24).
Conclusion
The prevalence of depression among patients with COVID-19 is high (34%), which underscores the importance of active screening and management of depression in this population that can be provided through telemedicine or web-based care. Depression was positively associated with the female gender in our population; however, the location of COVID-19 management and financial status did not influence the prevalence of depression.
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Ethics statement
The studies involving human participants were reviewed and approved by The Institutional Review Board (IRB) of King Abdullah Medical City (KAMC) (Approval number: 20-643). The patients/participants provided their written informed consent to participate in this study.
Author contributions
EA and AA designed and supervised the study. EA, AMA, AT, ASA, and RA contributed to protocol development, data collection, interpretation of the analyzed data, and manuscript writing. OA, NG, and HM were involved in data collection and entry as well as manuscript editing. All authors reviewed and approved the final version of the manuscript.
We acknowledge the commitment and sacrifice of all healthcare providers during the COVID-19 pandemic.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
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