DOI: 10.5061/dryad.vq83bk3vc
title: Psychiatric manifestations and associated risk factors among hospitalized patients with COVID-19 in Edo State, Nigeria: A Cross-sectional Study

description: The Coronavirus Disease 2019 (COVID-19) has had devastating effects
 globally. These effects are likely to result in mental health problems at
 different levels. Although studies have reported the mental health burden
 of the pandemic on the general population and frontline health workers,
 the impact of the disease on the mental health of patients in COVID-19
 treatment and isolation centres have been understudied in Africa. We
 estimated the prevalence of depression and anxiety and associated risk
 factors in hospitalized persons with COVID-19. A cross-sectional survey
 was conducted among 489 patients with COVID-19 at the three
 government-designated treatment and isolation centres in Edo State,
 Nigeria. The 9-item Patient Health Questionnaire (PHQ-9) and the
 Generalized Anxiety Disorder-7 (GAD-7) tool were used to assess depression
 and anxiety respectively. Binary logistic regression was applied to
 determine risk factors of depression and anxiety. Results Of the 489
 participants, 49.1% and 38.0% had depressive and anxiety symptoms
 respectively. The prevalence of depression, anxiety, and combination of
 both were 16.2%, 12.9% and 9.0% respectively. Moderate-severe symptoms of
 COVID-19, ≥14 days in isolation, worrying about the outcome of infection
 and stigma increased the risk of having depression and anxiety.
 Additionally, being separated/divorced increased the risk of having
 depression and having comorbidity increased the risk of having anxiety. A
 substantial proportion of our participants experienced depression, anxiety
 and a combination of both especially in those who had the risk factors we
 identified. The findings underscore the need to address modifiable risk
 factors for psychiatric manifestations early in the course of the disease
 and integrate mental health interventions and psychosocial support into
 COVID-19 management guidelines. --
description: <strong>Setting and
 study design </strong> A descriptive cross-sectional study was
 conducted from 15<sup>th</sup> April to
 11<sup>th</sup> November 2020. The participants were COVID-19
 Real Time-Reverse Transcriptase -Polymerase Chain Reaction (rRT-PCR)
 positive persons who were hospitalized at the three government- designated
 treatment and isolation centres in Edo State, Nigeria.
 <strong>Participants and data collection
 procedure</strong> All eligible and consenting persons who were
 COVID-19 rRT-PCR positive and hospitalized at any of the study
 institutions within the period of the survey were recruited. The inclusion
 criteria comprised of persons with confirmed COVID-19, hospitalized at any
 of the study institutions who consented to participate in the study and
 were eleven years and above. Exclusion criteria comprised of
 hospitalized persons who tested
 positive for COVID-19 but declined or were unable to give consent to
 participate in the study and persons below 11 years due to the
 inappropriateness of the assessment tools for anxiety and depression in
 this age group. Medical records/registers at the treatment and isolation
 centres were reviewed daily in order to identify new admissions and
 discharges in the centres and ineligible patients due to age (less than 11
 years). A total of 796 persons with confirmed COVID-19 were hospitalized
 at the three government designated treatment and isolation centres in Edo
 State over the study period. All patients were informed and acknowledged a
 detailed description of the study, eligibility requirements and
 voluntariness to participate in the study. Nineteen of them were below 11
 years and were excluded, and 265 patients either refused to give consent
 or were too ill (critically ill) to consent and participate in the study.
 A total of 512 were therefore recruited for the study. Semi-structured and
 structured questionnaires incorporating socio-demographics, basic clinical
 history/information and an assessment of anxiety and depression were
 administered to recruited participants on the fifth day of
 admission into the treatment and isolation centres. The questionnaires
 were self - administered except for those who opted for
 interviewer-administered questionnaires (mainly those with severe COVID-19
 infection). Questionnaires were administered in the English language as
 all participants had some levels of formal education and were literate
 enough to understand the language. Those who were critically ill with
 COVID-19 infection were unable to consent and participate in the study.
 Online survey and hard copies of the
 questionnaires were made available for completion. All the
 participants preferred hard copies of the questionnaires and a copy of the
 signed consent form was retained by each participant and one by the
 researchers. Clinical information on severity of COVID-19 infection and
 presence and type of comorbidity were obtained from their medical records
 (case files). Length of stay in treatment and isolation centres was
 obtained from their case files after discharge from the centres as the
 questionnaires were coded for ease of identification.
 <strong>Measurements</strong>
 <strong>The
 socio-demographic/clinical history
 questionnaire</strong> This was designed to provide information about
 the participant’s age, gender, religion, marital status, employment status
 and the highest level of formal education. Clinical variables such as COVID-19
 rRT-PCR status, previous/family history of mental illness, the severity of
 COVID-19 infection, the
 number of days in isolation, comorbidity were ascertained as well. To
 ascertain the worry factor, the question “what is your greatest worry
 about being COVID-19 positive” was asked.
 <strong>The 9-item
 Patient Health Questionnaire (PHQ‑9)</strong>
 This consists of nine items,
 each of which is scored 0 to 3, providing a 0 to 27 severity score.[15]
 PHQ‑9 severity is calculated by assigning scores of 0, 1, 2, and 3, to the
 response categories of: Not at all, several days, more than half the days,
 and nearly every day, respectively. It consists of the nine criteria for
 depression from the Diagnostic and Statistical Manual of Mental Disorders,
 fourth edition (DSM‑IV). The PHQ‑9 is comparable or superior in operating
 characteristics, and valid as both a diagnostic and severity measure.[16] 
 Scores of 5, 10, 15, and 20 represent cut-off points for mild, moderate,
 moderately severe, and severe depression respectively. A PHQ-9 score of 10
 or greater is recommended if a single screening cut-off is to be used,
 this cut-off point has a sensitivity for major depression of 88% and a
 specificity of 88%. The modified version for adolescents PHQ-A was used
 for participants within the ages of 11 and 17 years. A cut-off score of ≥
 10 was used to represent cases of depression. The PHQ-9 can be
 self-administered or clinician administered.
 <strong>The Generalized
 Anxiety Disorder-7 (GAD-7)</strong>
 This is a 7-item self-report
 questionnaire that allows for the rapid detection of GAD, the validity is
 not compromised if the clinician reads the questions to the client.[17]
 Participants are asked if they were bothered by anxiety-related problems
 over the past two weeks by answering seven items on a 4-point scale. The
 total scores range from 0 to 21. At a cut-off score of 10, the GAD-7 had a
 sensitivity of 89 % and a specificity of 82 % for detecting GAD compared
 with a structured psychiatric interview.[17]  Notably, among clinical and
 general population samples, the GAD-7 has demonstrated good reliability
 and cross-cultural validity as a measure of GAD (16).  Its use has been
 validated in adolescents.[18] A cut-off score of ≥ 10 was used to
 represent cases of anxiety. 
 <strong>Ethics</strong>
 Ethical clearance was obtained
 from our Research Ethics Committee of the Irrua Specialist Teaching
 Hospital, Irrua. Informed
 written consent was obtained from each participant and from the parents or
 guardians of participants who were less than 18 years. Participants who
 were less than 18 years also assented to the study. Confidentiality and
 anonymity were ensured by not indicating the names of the participants on
 the questionnaires. 
 <strong>Statistical
 analysis</strong> The collected data were analysed using the Statistical Package for
 Social Sciences (SPSS) version 21. Dependent variables were depression and anxiety.
 Independent variables were sociodemographic and clinical characteristics.
 Descriptive statistics were used to summarise
 socio-demographic and clinical related data and mean with standard deviation for continuous
 variables. Chi-square (χ2) tests were used to test the association of
 independent variables with dependent variables. Fisher's exact test
 was used for cells with expected frequencies &lt; 5.
 The student's t- test
 was used to compare
 means. Binary logistic
 regression was applied to identify predictors of depression and anxiety
 that were significant at
 bivariate analysis. All tests were 2-tailed, and the level of
 significance was set at a P-value of &lt;0.05.