|Year : 2021 | Volume
| Issue : 1 | Page : 49-53
A study of mental health status in relatives of COVID-19 inpatients in a tertiary care hospital
Minakshi Nimesh Parikh1, Kartik Srinivasa Valipay1, Mehul Brahmbhatt1, Pragna Sorani1, Vrunda Ashok Patel1, Kesha Khetani1, Nirav Patel1, Harvee Shah1, Aatman Nimesh Parikh2
1 Department of Psychiatry, BJ Medical College and Civil Hospital, Ahmedabad, Gujarat, India
2 Department of Psychiatry, GCS Medical College, Ahmedabad, Gujarat, India
|Date of Submission||04-Nov-2020|
|Date of Acceptance||01-Mar-2021|
|Date of Web Publication||30-Jul-2021|
Minakshi Nimesh Parikh
Department of Psychiatry, G-3 ward, Civil Hospital, Asarwa, Ahmedabad - 380 016, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: The global scale of COVID-19 has been enormous, with the disease affecting 20 million people worldwide and resulting in 751,154 deaths by August 14, 2020. An increase in mental health problems is expected with an event of such scale, given past experience with epidemics such as severe acute respiratory syndrome and Ebola, among various vulnerable populations. One such population may be the family members of patients affected with COVID-19. Methods: This was a cross-sectional study. Five hundred and forty-one relatives of patients admitted in the COVID-19 wing of a tertiary care hospital were studied. Sociodemographic details were recorded and a Gujarati version of General Health Questionnaire-28 (GHQ-28) was applied. A total score of ≥4 on GHQ-28 was considered indicative of “caseness” or psychiatric morbidity and the population was divided into two groups based on whether the score was <4 or ≥4. The groups were analyzed for any differences with respect to variables like age, gender. Conclusion: 5.17% of the study population had a GHQ-28 total score of ≥4 indicative of “psychiatric morbidity.” The most common symptoms were fatigue, stress, sleep disturbance, and anxiety. Male gender and advanced age were statistically significantly more likely to have a GHQ-28 total score ≥4.
Keywords: Anxiety, COVID-19, family members, fatigue, mental health, stress
|How to cite this article:|
Parikh MN, Valipay KS, Brahmbhatt M, Sorani P, Patel VA, Khetani K, Patel N, Shah H, Parikh AN. A study of mental health status in relatives of COVID-19 inpatients in a tertiary care hospital. J Mental Health Hum Behav 2021;26:49-53
|How to cite this URL:|
Parikh MN, Valipay KS, Brahmbhatt M, Sorani P, Patel VA, Khetani K, Patel N, Shah H, Parikh AN. A study of mental health status in relatives of COVID-19 inpatients in a tertiary care hospital. J Mental Health Hum Behav [serial online] 2021 [cited 2022 Nov 27];26:49-53. Available from: https://www.jmhhb.org/text.asp?2021/26/1/49/322820
| Introduction|| |
With the outbreak of COVID-19, societies over the world have been affected, with stringent public health measures and a rapidly spreading infection which seems to have no cure. In times of a medical emergency such as the COVID-19 pandemic, mental health care often takes a back seat. While mental well-being is crucial to functioning even under normal circumstances, it also affects the response and recovery from COVID-19 and causes enormous psychological distress. It becomes important to incorporate mental health care as an integral part of every country's response to COVID-19.
One such population maybe the family members of patients affected with COVID-19.
Several reasons have been proposed as contributing to the increase in mental health problems in relatives such as the role of the family in caregiving of patients, lack of contact with the patients due to current precautions, fear of having contracted the infection, fear of relatives dying, a lack of a cure, a constant bombardment of information from the media, measures for isolation leading to frustration and boredom, states of anxiety, and depression, etc. Furthermore, due to the many logistical issues faced by overwhelmed health-care systems, situations such as the family possibly not knowing about the immediate whereabouts or health status of an affected and hospitalized member can lead to a stressful situation that can lead to mental health problems. Not a lot of literature is presently discussing the impact of the virus on the mental health of relatives of patients affected with COVID-19. In our literature review, we noticed that studies on the psychological impact of COVID-19 on contacts of the affected individuals such as family members/caregivers are relatively rare, as compared to studies on mental health sequelae in COVID-19 patients and frontline healthcare workers. Since a collectivistic culture is prominent in our region, where the family members play a central role in aiding the management of illnesses in hospitals, we considered this population to be uniquely vulnerable during the current situation. The present study aims to find correlates of mental distress in this population and add to the literature.
| Methods|| |
The study was approved by an institutional ethics committee. This was a cross-sectional study, with samples being collected from a registry of relatives of patients admitted in the inpatient facility of the COVID wing of a tertiary care district hospital between April 21, 2020 and July 29, 2020. The subjects were communicated with telephonically. Every entry in the registry was attempted to be contacted and in all, 541 consenting subjects were included in the study. All of the subjects were close relatives of patients; either spouse, parent, or child, while in only two cases grandchildren were contacted. At the time of contacting them, most of the subjects were staying at a special facility constructed by the hospital for family members of COVID inpatients who had accompanied the patients to the hospital. Those unwilling to/unable to provide consent were excluded from the study [Figure 1]. After taking informed consent telephonically, sociodemographic details were recorded using a semi-structured pro forma, and a Gujarati version of General Health Questionnaire-28 (GHQ-28) was applied telephonically.
- A semi-structured pro forma which was used for recording sociodemographic data, comprising information about age, gender, marital status, family type, religion, and locality. Additional information about the duration of admission of their relative and any history of past/preexisting psychiatric illness and family history of psychiatric illness was also recorded here
- GHQ-28: Developed by Goldberg in 1978. It consists of 28 questions in which.
Questions 1–7 (subscale A) evaluate somatic symptoms
Questions 8–14 (subscale B) evaluate anxiety/insomnia
Questions 15–21 (subscale C) evaluate social dysfunction and
Questions 22–28 (subscale D) evaluate depression.
For each item, four possible answers are available (0 - not at all, 0 - no more than usual, 1 - rather more than usual, and 1 - much more than usual).
A cutoff of 4 or more was considered indicative of psychiatric morbidity or “caseness.” Validity and reliability of the scale have been shown to be satisfactory. Test-retest and inter and intrarater reliability have been found to be high. The scale has been translated into Gujarati language by Dr. G. K. Vankar et al. and has been used in multiple studies so far.
Apart from the total score, we considered responses of “rather more than usual” or “much more than usual” on specific questions on the questionnaire to be indicative of certain symptoms. The following questions were used for this purpose.
A3 – Fatigue
B1and B2 – Sleep problems
B3 – Stress
B4 – Irritability
B5 and 7 – Anxiety
C6 – decision making
D2 – Hopelessness
D3–D7: Death wishes/suicidal ideation.
The data were tabulated using Microsoft Excel. Based on total GHQ-28 score, the population was then divided into 2 groups based on the cut-off value of 4 – one group with GHQ-28 <4, and the second with GHQ-28 ≥4. Data were further analyzed for differences between groups using Chi-square test on Graphpad Prism Software (San Diego, California , USA).
Postdata collection, psychological assistance was offered to all participants and provided to those who sought the same. Information of a psychological assistance helpline was also provided to all participants in case they needed assistance in the future.
| Results|| |
Our sample consisted of 541 consenting individuals who were registered as immediate relatives of patients diagnosed with COVID-19 and admitted in the COVID wing of a tertiary care hospital. A majority of the population was male (85.39%), between the ages of 30–60 years (58.04%), married (86.32%), belonged to Hindu religion (84.28%), and lived in nuclear families (60.07%). Nearly 40.67% of the population had had relatives who had been admitted for <5 days, 59.33% had relatives admitted for ≥5 days [Table 1].
The population was divided into two groups based on the GHQ-28 total score – one group with GHQ-28 <4 and the other with GHQ-28 ≥4.
Of the sample size of 541, 28 individuals (5.17%) had a GHQ 28 total score of ≥4 [Table 2].
|Table 2: Division of sample based on total General Health Questionnaire-28 score|
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On observing responses to individual items of the GHQ-28, we found that fatigue (18.85%), stress (6.09%), sleep disturbances (4.43%), and anxiety (4.43%) were the most commonly reported symptoms among the 541 participants [Table 3].
|Table 3: Responses to individual items on the General Health Questionnaire-28|
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In the group with GHQ 28 total ≥4, the most commonly reported symptoms were stress (89.28%) followed by sleep disturbances (85.71%), anxiety (82.14%), and fatigue (50%) [Table 4].
|Table 4: Responses to individual items on the General Health Questionnaire-28 in individuals with General Health Questionnaire-28 total score ≥4|
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The sample consisted of a total of 220 (40.67%) individuals whose relatives were admitted for <5 days. Out of these, 11 (5%) had a GHQ total of ≥4. While out of 321 (59.33%) individuals whose relatives were admitted for ≥5 days, 17 (5.29%) had a GHQ total of ≥4.
The difference between groups was not statistically significant, with a P > 0.99.[Table 5].
|Table 5: Association of duration of hospital stay of COVID patients with total General Health Questionnaire score|
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Association of gender with total General Health Questionnaire-28 score
The sample consisted of a total of 462 (85.39%) males and 79 females (14.60%). Out of these, 20 males and 8 females had a GHQ total of ≥4. The difference between groups was statistically significant, with a P = 0.0487.
Association of age with total General Health Questionnaire-28 score
The sample had a variable age distribution, with 203 individuals between 18 and 30 years of age, 314 between 30 and 60 and 24 individuals >60 years of age. 2.4% of the individuals aged between 18 and 30 years, 6.3% of the individuals aged between 30 and 60, and 12.5% of individuals aged over 60 years had a GHQ total score of ≥4. Chi-square test for trend showed a statistically significant difference between the groups, with a P = 0.011.
There was no statistically significant difference between groups with respect to variables such as religion, marital status, family type, history of past/preexisting psychiatric illness, and family history of psychiatric illness.
| Discussion|| |
This cross-sectional study consisted of 541 participants, of which 28 (5.17%) reported GHQ-28 scores of ≥4 indicative of “psychiatric morbidity.” Our study further indicated that males (3.69%) had a higher risk of psychiatric morbidity than females. Although contrary to studies reporting an equal impact of COVID-19 and previous epidemics such as severe acute respiratory syndrome (SARS) on both male and female contacts of patients,, the increased prevalence in males in our study may be due to a larger number of male respondents which may be explained by situations specifically faced by males in our culture like being the primary decision-makers when someone is admitted in a hospital, and being the primary responders when the hospital needs to contact a relative regarding a patient's care, and also being responsible to bear the economic cost of illness, which may consequently increase the psychological burden.
An increasing trend in age was also significantly correlated with more risk, with 12.5% of individuals aged over 60 years having a GHQ-28 total score of ≥4 compared to 2.4% in the 18–30-year age group and 6.3% in the 30–60 age group. The impact of COVID-19 on the mental health of elderly is already known, with factors such as social isolation, easy access to a near-constant stream of information about the pandemic, and advancing age itself highlighted as key to vulnerabilities in this population. Bearing the additional burden of a close relative suffering from COVID-19 will add to the mental health burden, given the possible risks of close contact, and given that “illness is a family affair.”
The most common symptom reported in our study population was fatigue (19.22%), but only 50% of individuals in the group with GHQ-28 ≥4 reported it. Fatigue can be psychological, physical, or both; it is correlated with negative states such as anxiety, depression and stress, and external factors such as climate, and is a nonspecific symptom of COVID itself. Fatigue was found to be correlated significantly with isolation and people who had come in close contact with COVID. It appears that although fatigue was the most common symptom in general, it was not similarly preponderant in patients with GHQ caseness. This could mean that stress and anxiety might not be correlated with fatigue.
Next to fatigue, the 2nd most common symptom was stress in 4.62% of participants overall, and 89.28% of the group with GHQ-28 total ≥4. Inadequate and/or confusing information regarding relative's illness and management, not knowing where their relative was admitted and being unable to contact them, fear of contracting infection or of losing a member of the family, the requirement of isolation, stigma, economic difficulties, and the states of anxiety and depression are all factors which are likely to have contributed to stress in our study population. Studies done in previous pandemics such as H1N1 have revealed elevated levels in terms of stress perceived by family members compared to normative population data.
Sleep disturbance was seen in 4.43% overall, and in 85.21% individuals in the group with GHQ-28 total ≥4. Summer heat, worry about family members being infected, lack of confidence in health infrastructure, daily life being interfered due to COVID-19, having stress, anxiety, and depression; all were found to correlate with worsened sleep quality, as studied by Yu et al. Similar to Chinese culture, Indian culture places a strong value on traditions and family relationships, and worry about family members correlating with deterioration in sleep is a feature common to this study as well.
Anxiety was reported by 4.43% of the study population and by 82.18% of participants in the group with GHQ-28 total score of ≥4. Fear of contracting the disease, fear of family members dying from the disease, inability to help loved ones, bereavement, high intolerance of uncertainty, and a constant COVID-19 related stream of news may contribute to anxiety. Mertens et al. found the risk to loved ones to correlate strongly with fear and anxiety of COVID-19.
Symptoms of irritability were seen in 2.95% of our population and 46.42% of the group with GHQ-28 total score of ≥4. Lack of information from hospital it authorities, dissatisfaction with treatment, lack of governmental support, impending socioeconomic difficulties, the states of fear, anxiety, and stress, all are factors of irritability. This has been studied previously in the context of the SARS epidemic, with “being easily irritable” seen as a major psychosomatic symptom of those with affected family members.
Out of 541, 5 individuals in our sample reported death wishes and/or suicidal ideation, with only one individual in the group with GHQ-28 total ≥4, and the other four in the group with GHQ-28 total score <4. The subject who reported death wishes in the GHQ positive group was the wife of a COVID patient. Reports of suicidal ideation/attempts/completed suicides in apparently mentally healthy individuals are mostly isolated, and these findings are consistent with our study. Symptoms such as problems in decision making too were uncommon, reported in six individuals with all six of them belonging to the group with GHQ-28 total ≥4.
| Conclusions|| |
Nearly 5.17% of the study population had a GHQ-28 total score of ≥4 indicative of “psychiatric morbidity.” The most common symptoms were fatigue, stress, sleep disturbance, and anxiety. Male gender and advanced age were statistically significantly more likely to have a GHQ-28 total score ≥ 4. Hopelessness, problems in decision-making, and death wishes/suicidal ideation were rare in our sample.
The scope of the study is limited since the sample is entirely from one institution. The symptoms were assessed using a screening questionnaire, and diagnostic thresholds were not applied. Although the Gujarati version of GHQ has been used in multiple studies so far, no data regarding its validation could be found. As the relatives were not staying with the patients many of them were not aware of the exact health status of the patients and so severity of COVID infection could not be ascertained. It was a cross-sectional study, and a follow-up may help in tracking any changes in mental health status in the study population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Asmundson GJ, Taylor S. Coronaphobia: Fear and the 2019-nCoV outbreak. J Anxiety Disord 2020;70:102196.
Grover S, Dua D, Sahoo S, Mehra A, Nehra R, Chakrabarti S. Why all COVID-19 hospitals should have mental health professionals: The importance of mental health in a worldwide crisis! Asian J Psychiatr 2020;51:102147.
Poreddi V, Kathyayani BV, Hatti NM, Reddemma K, Narayana Manjunatha NK, Math SB. NIMHANS-Telenursing Practice Guidelines. NIMHANS, Bangalore; 2020.
Goldberg D. Manual of the General Health Questionnaire. GL Assessment Limited, London: Nfer Nelson; 1978.
Jackson C. The general health questionnaire. Occup Med (Lond) 2007;57:79.
Robinson RG, Price TR. Post-stroke depressive disorders: A follow-up study of 103 patients. Stroke 1982;13:635-41.
Failde I, Ramos I. Validity and reliability of the SF-36 Health Survey Questionnaire in patients with coronary artery disease. J Clin Epidemiol 2000;53:359-65.
Jani CT, Desai T, Parikh S, Shah AA, Katara S. Correlation between types of diabetic retinopathy and its psychosocial impact. PeerJ PrePrints 2015;3:e981v1.
Tanoue Y, Nomura S, Yoneoka D, Kawashima T, Eguchi A, Shi S, et al.
Mental health of family, friends, and co-workers of COVID-19 patients in Japan. Psychiatry Res 2020;291:113067.
Hawryluck L, Gold WL, Robinson S, Pogorski S, Galea S, Styra R. SARS control and psychological effects of quarantine, Toronto, Canada. Emerg Infect Dis 2004;10:1206-12.
Mihashi M, Otsubo Y, Yinjuan X, Nagatomi K, Hoshiko M, Ishitake T. Predictive factors of psychological disorder development during recovery following SARS outbreak. Health Psychol 2009;28:91-100.
Philip J, Cherian V. Impact of COVID-19 on mental health of the elderly. Int J Community Med Public Health 2020;7:2435-6.
Bell JM, Wright LM. The Illness Beliefs Model: Advancing practice knowledge about illness beliefs, family healing, and family interventions. J Fam Nurs 2015;21:179-85.
Morgul E, Bener A, Atak M, Akyel S, Aktaş S, Bhugra D, Ventriglio A, Jordan TR. COVID-19 pandemic and psychological fatigue in Turkey. Int J Soc Psychiatry. 2021;67:128-35.
Elizarrarás-Rivas J, Vargas-Mendoza JE, Mayoral-García M, Matadamas-Zarate C, Elizarrarás-Cruz A, Taylor M, et al.
Psychological response of family members of patients hospitalised for influenza A/H1N1 in Oaxaca, Mexico. BMC Psychiatry 2010;10:1-9.
Yu BY, Yeung WF, Lam JC, Yuen SC, Lam SC, Chung VC, et al.
Prevalence of sleep disturbances during COVID-19 outbreak in an urban Chinese population: A cross-sectional study. Sleep Med 2020;74:18-24.
Verdery AM, Smith-Greenaway E, Margolis R, Daw J. Tracking the reach of COVID-19 kin loss with a bereavement multiplier applied to the United States. Proc Natl Acad Sci U S A 2020;117:17695-701.
Mertens G, Gerritsen L, Duijndam S, Salemink E, Engelhard IM. Fear of the coronavirus (COVID-19): Predictors in an online study conducted in March 2020. J Anxiety Disord 2020;74:102258.
Lee S, Chan LY, Chau AM, Kwok KP, Kleinman A. The experience of SARS-related stigma at Amoy Gardens. Soc Sci Med 2005;61:2038-46.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]