Evaluation of Psychopathological Conditions, Corona Anxiety, Death Anxiety and Suicide Risk in Hemodialysis Patients During the COVID-19 Pandemic

Background Hemodialysis (HD) patients have serious psychopathological symptoms due to COVID-19 pandemic. Therefore, this study aimed to identify the psychopathological conditions among HD patients during the current pandemic and also to provide a theoretical basis for the implementation of effective preventions and psychological interventions. Methods This cross-sectional study was conducted with 114 HD patients who were undergoing treatment in the Dialysis Centers of two state hospitals between July and October 2021. Brief symptom inventory, Death anxiety scale, Suicide probability scale and Corona anxiety scale were applied to the participants for the assessment.


Introduction
The new Coronavirus disease 2019 (COVID- 19), which rstly emerged in China and spread quickly around the world. World Health Organization declared COVID-19 as a pandemic on March 2020 [1]. The virus that causes (17.4%) and peritoneal dialysis (5.3%). The prevalence was calculated as 935 per million population and the incidence as 147 per million population [3]. As in many other chronic diseases, serious physiological and psychological problems are seen in HD patients. It has been demonstrated that the incidence of psychiatric psychopathology is higher in HD patients than in the general population [4].
COVID-19 threatens the lives of people, especially those with chronic diseases (diabetes mellitus, hypertension, chronic renal failure, etc.) [5,6]. Additionally, mortality rates in dialysis patients infected with SARS-CoV-2 during the COVID-19 outbreak were found to be higher than in the normal population [7,8]. In addition to having a chronic disease in HD patients, the risk of getting infected with SARS-CoV-2 increases stress and anxiety. Serious psychopathological problems may occur due to high levels of anxiety such as death anxiety, corona anxiety, generalized anxiety, phobic anxiety. In a study which conducted with HD patients during the COVID-19, it was found that anxiety and depression symptoms increased [9].
It has been found that among HD patients, suicide is the most serious consequence of mental disorder, and these patients are more likely to suicide than the general population [10]. In accordance with this, a high incidence of suicide threats and attempts has been demonstrated among HD patients [11].
In the literature, there are limited studies focusing on the psychopathological conditions of HD patients during the COVID-19 pandemic. It is necessary to investigate the effects of the COVID-19 pandemic on the mental problems of HD patients from a comprehensive perspective. Therefore, this study aims to identify the psychopathological conditions among HD patients during the current pandemic and also to provide a theoretical basis for the implementation of effective preventions and psychological intervention.

Methods
This cross-sectional study was conducted with 114 HD patients who have been under treatment in the Dialysis Centers of two state hospitals in Antalya, in Turkey, between July-October 2021.
Participants were randomly selected. Sociodemographic data form was lled for each participant. In accordance with the purpose of the study; Brief symptom inventory, Death anxiety scale, Suicide probability scale and Corona anxiety scale were administered to the participants. Criteria for inclusion were as following; willing to participate in the study, above 18 years old, undergoing HD replacement therapy for at least 1 year, capable to read or understand the contents of the scales and able to communicate. Criteria for exclusion were as following; have psychiatric treatment in the last 3 months, have another chronical illness, have serious mental problem that will impair the cognition (e.g. dementia, mental retardation, epilepsy, alcohol/substance abuse or addiction, psychosis). Informed consent form was obtained from all participants for the study. This study was conducted according to the Declaration of Helsinki. The local ethics committee approved. Approval was obtained from the Ethics Committee of the Antalya Training and Research Hospital for the study (Approval number: 2021-167).

Psychometric assessment
Brief symptom inventory (BSI) The BSI performed to evaluate psychopathological and psychological symptoms [12]. The BSI is a 53-item self-report, 5-point Likert scale, ranging from 0 ("not at all") to 4 ("extremely"). The BSI contains nine symptom subscales, namely; somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. Subscales are determined by dividing the total score of the items by the number of items. The global severity index (GSI) is a summary index of psychological distress, was used as the primary BSI outcome measure. GSI is determined by the total score of all items divided by total item number. High scores are characteristic of participants with greater psychological distress [13,14]. The validity and reliability study of the Turkish version was performed [15].

Turkish Death Anxiety Scale
The concurrent validity of the TDAS was studied by its relationships with the Revised-DAS (RDAS) which developed by Thorson&Powell [16]. The scale includes 20 items scored on a 5-point Likert ranging from 0 (never) to 4 (always). The total scale scores may range from 0 to 80 and the higher scores indicate the higher levels of death anxiety. Cut-off scores for the total TDAS to be 0-7 (very low level anxiety); 8-25 (low level anxiety); 26-44 (medium level anxiety); 45-63 (high level anxiety); and 64-80 (very high level anxiety). ) The validity and reliability study of the Turkish version was performed [17].

Suicide Probability Scale (SPS)
The scale was developed to evaluate the suicide risk [18]. It is a four-point Likert-type ranging from 1 (never) to 4 (always) and self-assessment scale with 36 items. The aim of the scale is to assess suicide risk. The higher overall score indicates the higher risk of suicide. Validity and reliability of the Turkish version of the scale was conducted by Atli et al. [19].

Coronavirus Anxiety Scale (CAS)
CAS developed to identify possible causes of dysfunctional anxiety associated with the COVID-19 pandemic [20]. The scale is 5-point Likert-type scale ranging from 0 (not at all) to 4 (nearly every day) and includes 5 items. The optimized cut-off score of CAS was found as point of ≥5 [21]. The Turkish validity and reliability study of the scale was conducted by Biçer et al. [22].

Statistical analysis
Number and percentage distribution, mean and standard deviation values were used for the analysis of the patients'socio-demographic characteristics. Independent sample t-test was used to determine the differences between groups. Chi-square analysis was used to test the homogeneity of the groups and the relationships of categorical variables. ANOVA test was used to compare the between group differences. Tukey HSD test was used to determine the source of differentiation. Pearson's correlation analysis was used to evaluate the relationship between variables. The value of statistical signi cance was accepted as p<0.05 in all tests.
Statistical analysis was performed using the 21.0 version of SPSS Windows program.

Results
The study sample was composed of 114 patients who were undergoing HD therapy. The mean age of the participants was 60.61±15.10 (between age of 22-90). Of them, 14% were below the age of 50, 66.7% were between the age of 50-75 and 72.3% were above the age of 75. Of the participants 52.6% were men and 47.4% were women. Of the participants 71.9% were married, 35.1% graduated from a university, 81.5% were living with their family, 28.9% had history of a pyschiatric disease, 28.1% were needing of self-care or social support. The sociodemographic characteristics of the participants are shown in Table 1. The mean HD therapy period of the patients was found to be 13.6 years (min:1.3, max:28). On the other hand, 2.6% (n=3) of the participants declared that they were con rmed with COVID-19.
The mean total score of the TDAS was found to be 26.47 ± 20.2 (min:1, max:71). According to the severity level of death anxiety, the results were as following; 23.7% (n=27) very low , 24.6% (n=28) low, 33.3% (n=38) medium, 10.5% (n=12) high, 7.9% (n=9) very high. As seen in Table 2, death anxiety was statistically higher among the HD patients who were female, were above the age of 75, were married, were living with their family and were needing of self-care or social support (p < 0.05). The mean total score of the SPS was found to be 65.86 ± 9.72 (min:46, max:95). The probability of suicide was statistically higher among the HD patients who were above the age of 75, were needing of self-care or social support, had a history of psychiatric disease and had history of suicidal ideation (p < 0.05). ( Table 2). The mean total score of CAS in HD patients was 3.31 ± 2.86 (min:0, max:12). Of the participants 30.7% had corona anxiety (CAS score of ≥5). Corona anxiety was statistically higher among the participants who were female (p < 0.05) ( Table 2).

Conclusions
COVID-19 continues to be a serious threat to mental and physical health of individuals. The morbidity and mortality rates due to COVID-19 are increasing gradually. The current number of COVID-19 cases worldwide is about 253 million and the number of deaths is about 5.1 million [23]. Due to the inability to control the pandemic, these numbers are increasing even more. In addition, number of cases indicate the fatality and severity of the pandemic as a global health problem. Moreover, COVID-19 causes various mental health problems or increases existing symptoms such as stress, anxiety, depression, insomnia, phobia, death anxiety, obsession and fear [24,25,26]. On the other hand, as a result of many studies, HD patients have common psychopathological symptoms due to the negative effects of their chronical illness [27,28,29,30].
In addition, in a study which conducted during the COVID-19 pandemic found that, HD patients are highly susceptible to COVID-19 [7]. Also HD patients should be considered as a group at higher risk of mental health problems during the COVID-19. Regarding to current literature, this is one of the limited studies evaluating mental health conditions comprehensively in HD patients during the COVID-19 pandemic. In the limited studies conducted during COVID-19 found an increased incidence of anxiety and depression symptoms and increased psychosocial distress in HD patients [9,31].
In this study, it was determined that HD patients were seriously negatively affected by the emotional impact of pandemic. Psychopathological symptoms such as somatization, obsession, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid thought, and psychoticism were found to be high.
Additionally, psychological distress (GSI is a summary index of psychological distress) was found to be high. Due to the lack of study during COVID-19 which using similar assessment tools in HD patients, comparison could not possible. Therefore, the results of this study compared with the norms of adults nonpatients and compared with the results of a study which included HD patients, before COVID-19 [14,32]. A series of mental health problems have been triggered by multifactorial effect of various psychosocial conditions during the pandemic. That factors may caused an increase in psychopathological symptoms in HD patients such as limitation of physical activity due to quarantine, susceptibility to emotional problems, uncertainty about pandemic, fear of get infected with virus, hopelessness, di culties accessing psychosocial support. Additionally, it was determined that HD patients are at higher risk who who were female, were above age of 75, were married, had not graduated from university, were needing of self-care or social support and had a history of psychiatric disease.
HD patients, who are totally dependent on a machine for survival, have decreased quality of life, have reduced life expectancy and this may lead to death anxiety [33,34]. According to a study, the accessibility of deathrelated thoughts increases during virus pandemics [35] Another study which conducted during COVID-19, it was demonstrated that death anxiety was increased among the patients of HD [36]. In the present study, it was found that the death anxiety of the participants was at medium levels. Additionally, it was determined that 33.3% (n=38) of the patients had medium level death anxiety, 10.5% (n=12) had high level death anxiety and 7.9% (n=9) had very high level death anxiety. Furthermore, HD patients are at higher risk who were female, were above the age of 75, were married, were living with their family and were needing of self-care or social support. In the context of COVID-19, the high risk of death from the virus in HD patients has been considered as prominent factor that increases death anxiety. Other reasons may be that HD patients had problems such as accessing healthcare facilities during quarantine, having mobility constrains such as routine check-up for dialysis sessions and travel.
HD patients generally have to cope with various psychosocial di culties in course of their treatment, such as dependency to dialysis and medication regimens, dietary and liquid limitations, limitations in physical activities, time limitations, sexual dysfunctions and anxiety of death. Such as these psychological and physiological problems can lead to suicidal ideation [37]. Corroborative evidence has indicated that the suicide rate among HD patients is higher than general population [11,38]. In a study conducted in the general population during COVID-19, it was found that suicide rates increased [39]. To the best of our knowledge, this is the rst study to focus suicide risk on patients undergoing HD during COVID-19. In the present study, it was found that the suicide probability of the participants was at moderate levels [19]. Notably, HD patients are at higher risk who were above the age of 75, were needing of self-care or social support, had a history of psychiatric disease and had history of suicidal ideation. Of the HD patients 11.5% declared had suicidal ideation in a time of their lives and none of the participants have suicidal ideation during the interview. Additionally, none of them had attempted suicide. Psychosocial problems such as depression, psychological distress, stressful events, uncertainty about the pandemic, death anxiety, decrease in life expectancy, feeling helpless may be the reasons for this result.
Coronavirus anxiety de nes to the dysfunctional anxiety associated with the COVID-19 pandemic [20]. In a study conducted in normal population, the rate of coronavirus anxiety (CAS score of ≥5) was found to be 54.8% and in a study conducted with a group of healthcare workers consisting of nurses, it was found to be 37.8% [40,41] However, no study was found with HD patients in the literature. In present study, the rate of coronavirus anxiety was found to be 30.7%, which lower rate according to other studies mentioned. This may be because the majority of participants had not diagnosed with COVID-19 (only 3 HD patients con rmed with COVID-19).
The study results con rmed that psychological distress positively correlated with suicide probability, corona anxiety and death anxiety. This result clearly indicates that death anxiety, corona anxiety and suicide probability are directly affected by psychological distress. On the other hand, there was a positive correlation between corona anxiety and death anxiety. This result can be considered as a re ection of the increased anxiety levels in HD patients.
Notably, in the study, it is remarkable that the risk of psychological distress, death anxiety and suicide probability increases common in patients with age of above 75 and need of self-care or social support. In accordance with this results, it was found that elderly patients experienced severe death anxiety during COVID-19 [42,43]. Furthermore, it has been declared by the WHO and Turkish Statistical Institute that the suicide rate is highest above the age of 75 [44,45]. In another study, it was found that a functional family and social support reduced the risk of suicide in patients [46]. So, it was evaluated that these patients were more susceptible to mental health problems. Therefore, these patients should have priority in psychosocial support.
HD patients, who suffer from a chronical illness, experienced various psychological problems during the COVID-19 pandemic. The ndings of this study indicated the considerable psychopathological problems experienced by HD patients such as depression, anxiety somatization, obsession, interpersonal sensitivity, hostility, phobic anxiety, paranoid ideation, psychoticism, psychological distress, corona anxiety and death anxiety. In the context of COVID-19, factors such as uncertainty about the course of the pandemic, lack of curative treatment, overload of information, limited social and physical activities may be causal or precipitating factors for these psychiatric symptoms in HD patients.
Notably, the risk of suicide and death anxiety are more important issues to be evaluated in HD patients, may negatively affect the course of treatment and even cause them to stop treatment [34,37]. The results of the study also indicated that death anxiety and the probability of suicide are the issues that should be assessed carefully in these patients. Factors such as the highly transmission of the SARS-CoV-2, the fatal course of COVID-19, being more susceptible to COVID-19, may caused or increased these symptoms in HD patients.
This study has limitations. First, because of the cross-sectional design, the results indicated the psychological conditions within a certain period of pandemic. Thus there is a need for longer term studies to investigate changes over time. Second, this study was single-center and the generalizability of the results is limited as the study sample cannot be representative of all HD patients. Therefore, multicenter studies with larger samples are needed. Third, due to the design of the study, the temporal variation of psychosocial effects could not be evaluated. Studies in prospective or case-control design will more useful results. Lastly, when compared to other chronical diseases, there are much less comprehensive studies on the psychological conditions of HD patients during COVID-19. Because of no highly similar studies in the literature were found, comparison with the results of the study was not possible. Therefore, comparisons were made with the results of studies conducted before COVID-19. Despite these limitations, present study contains results that can be useful and guiding for future studies.
As a result, it was concluded that HD patients experienced serious psychopathological problems during the COVID-19 pandemic. The emerging mental health issues related to this global event may disrupt their course of treatment and develop into long-term health problems. Psychosocial support and interventions need to be planned by the healthcare system and healthcare providers to help HD patients in managing their disease and related mental health conditions as soon as. Psychoeducation should be given to patients and caregivers by mental health providers (e.g. psychologist, psychiatrist) on issues such as coping with negative psychological consequences, gaining problem-solving skills, and gaining mental health-promoting behaviors. In addition, the risk of suicide in HD patients should be identi ed early and appropriate treatment should be offered. Early detection of suicide risk may be possible with regular psychological screening and a high awareness of healthcare providers (e.g. nurse, doctor) about risk-related factors. Finally, due to the limited number of studies, more studies are needed to con rm the ndings of this study in a larger sample and comprehensively to evaluate the psychopathological effect of the pandemic on HD patients.  Table 2. Comparisons of the mean total scores of TDAS, SPS, CAS (score of ≥5) and GSI between th sociodemographic characteristics