This study indicated that one-third of participants present with mental distress even when China was recovering from the COVID-19 pandemic. In the earlier stage of this pandemic, several studies conducted to estimate the level of mental distress induced by COVID-19 were inconclusive. Some research revealed that the symptoms of psychiatric patients worsened1415. Besides, as a vulnerable group of the population, they showed significantly more mental distress than people without psychiatric illnesses16. However, one study showed no noteworthy difference in the distress level between patients with severe mental illness and the general population17. In another study, anxiety disorder patients did not exhibit with marked psychological impact secondary to COVID-1918. According to Gao et al., 43.2% of patients with emotional disorder were affected, similar to our finding13. One explanation we proposed would contribute to this result: negative news like the virus might strike again during the upcoming winter trigger a series of emotional stress responses including anxiety and fear since these stable patients could easily access the Internet and media. Patients with psychiatric diseases tended to hold less positive anticipation for a future epidemic prospect13, resulting in worries about their routine medical consultant and drug compliance, which are critical in their convalescence, would be disrupted again.
According to our study, unmarried status correlated with a higher SRQ score. This result contrasted with those obtained in pre-existing mental disorder patients19. Convalescent psychiatric patients who remained single might have worse personal and more trouble maintaining relationships at baseline, making them easier to be affected. A prior national survey indicated that those who were single or widowed or divorced were less likely to seek mental health service20. Without timely help-seeking behaviour, convalescent psychiatric patients, in particular, who are single, might struggle more to cope with the accumulating adverse emotional effects induced by COVID-19. However, we found the marital status had no statistically significant effect on patients' SRQ score with an additional analysis conducted, which may partially because some of our participants were students. Age, another influencing factor concerning anxiety caused by the pandemic8, had its role to play in increasing our patients' SRQ score. Compared with older age patients, younger patients had less experience and weaker psychological self-regulation ability when faced this health crisis might be the reason.
It is also showed that events that happened during this period affected patients' psychological distress level. In our study, we made no restriction on the types of the event, intending to focus on the psychological impact they might have on our participants. A large body of research had provided evidence that negative life events were partly responsible for the onset of mental disorder2122. Moreover, stressful life events and the first appearance of neuroses and depression revealed a strong association23. In contrast, positive life events have been thought to either directly protect patients from the distress feeling or buffer the adverse effect induced by negative events. During this particular period, negative events like death in the family or medical emergencies due to COVID-19 infection, and financial hardship secondary to the pandemic can act as exact stressors which impact patients' mental stability, while positive events might improve their quality of life. We observed patients who reported shorter sleeping duration and worse self-rated general condition had a higher SRQ score response. Emotional events easily caused sleep disturbance and vice versa24. One recent study suggested that participants reported lower posttraumatic stress symptoms during COVID-19 outbreak when they had a better sleep25. Literature indicated that subjects who had insomnia or short sleep duration presented higher odds of developing chronic mental health symptoms26. Our study was consistent with previous findings. Keeping up a daily routine is vital for dealing with the crisis. COVID-19 outbreak disrupted most people's daily life. They were encouraged to stay at home instead of gathering with families and friends, which people usually do during the Spring Festival, to prevent the virus from spreading. After the end of the holiday season, adults had to work from home while children had to have online teaching sections instead of going back to school. A national lockdown replaced the 7-days holiday with the uncertainty of when life will go back to normal. People were stressed, worrying about their jobs and their children's education while taking care of household chores. With increased interaction between work and private lives, people may have less time to sleep.
School children and adolescent, in particular, may feel more anxious because they had to learn in a completely different environment, which leads to sleep difficulties26. Moreover, now the companies and schools reopened, convalescent psychiatric patients may need more time for adaption. Besides, working patients might be anxious about their financial security with fears of a new recession following this pandemic. Times like this was prone to trigger negative emotion amongst patients who used to be in stable recovery, and their sleep duration could be affected. If the patients experienced symptoms fluctuation, naturally, their self-perceived condition would be worse.
One impressive result of our study was annual income remarkably associated with self-report psychological impacts. The higher socioeconomic status convalescent psychiatric patients were in, the less worried they felt. Base on the income survey published in 2020, the average earnings for citizens from Zhejiang Province, where most of our participants lived, was 60,000 RMB27. Therefore, we set this amount as the point by which we dived participants into two groups, the high-income one and the low-income one. The COVID-19 outbreak affected global economies and inevitably interfered every aspect of human life. Primary sectors, secondary sectors, and tertiary sectors all suffered from heavy losses because of the implement border shutdown, travel control and strict home confinement measures5.
From an economic perspective, people in the low-income group might lack resources to cope with external risks. Even when the COVID-19 pandemic seemed to get closer to an end, they may be concerned about the economic burden of the family and family members' well-being as well, which created significant challenges for their coping strategies. Their economic disadvantage, including decreased wages and job loss due to the post-pandemic effect, damaged the treatment continuance. Convalescent psychiatric patients from the low-income group might prefer to spend money on daily expenditure rather than medications if they had reduced personal disposable income. Also, they might not get sufficient protective equipment because of financial strain. Another reason would be that their unstable living conditions make them more susceptible to COVID-19 infection. Moreover, we found out that higher income was associated with longer sleep duration and more content feeling about the general condition in stable patients. Because sleep duration and general condition of the patients affected how they reacted to the pandemic, we rationally suggested that patients with higher income would report fewer problems on those two aspects and had a lower distress level.
This study has several limitations. First of all, since our research had a modest sample size of 136 participants and lacked a control group, caution is required in interpreting the results. Second, the way we used to collect data excluded convalescent psychiatric patients who have less access to digital technologies such as smartphones or the Internet and, therefore, our findings may not adequately reflect trends seen throughout the whole targeted population. Third, we adopted self-reported psychometric tools that have common drawbacks of such instruments. Finally, because the causal relationship indicated in our study was based on cross-sectional data, more research should be carried out to clarify the reason behind its existence.
To the best of our knowledge, this is one of the few studies that focused on convalescent psychiatric patients and whether COVID-19 pandemic still has psychological impacts on them.