Mental health outcomes following COVID-19 infection: impacts of post-COVID impairments and fatigue on depression, anxiety, and insomnia

Abstract

Background

The negative impact of the COVID-19 pandemic on the mental health is now clearly established. However, information on the levels of mental ill health of people infected with COVID-19 and potential correlates of poor mental health is still limited. Therefore, the current study aimed to study indicative of potential mental health problems in individuals with a history of probable or confirmed SARS CoV-2 infection/infections and address the impacts of post-COVID impairments and fatigue following COVID-19 infection/infections on depression, anxiety, and insomnia.

Methods

A web-survey including demographics, questions related to COVID-19 status and post-COVID impairments, and standardized measures of depression, anxiety, insomnia, and fatigue was completed by 507 individuals with a history of probable or confirmed SARS CoV-2 infection/infections.

Results

We found significant rates of significant depression, anxiety, and insomnia in our sample, with more than 70% experiencing levels above the clinical cut offs for at least one psychological health problems. Higher levels of depression, anxiety, and insomnia were associated with the severity of COVID-19 infection in the acute phase, hospitalization because of COVID-19, and higher levels of post-COVID impairments and fatigue. Reduced motivation emerged as the strongest predictor for mental ill health.

Conclusions

These findings highlight that individuals infected with COVID-19, especially those who still have experienced post-COVID impairments, are more likely to suffer from mental ill-health and may be more vulnerable for poor mental health outcomes. Therefore, more effective actions are needed to take in order to promote and protect mental health of individuals with a history of COVID-19 infection.

Background

Since the beginning of the COVID-19 pandemic, the study of mental health has been the focus for many investigations around the world. Early studies focused mainly on the psychosocial response to the COVID-19 pandemic and impacts of pandemic-related strategies, such as quarantine, lockdown, closing schools/universities, movement and travel restrictions, on mental health outcomes in the general population [1, 2, 3, 4, 5, 6]. Findings from studies in different countries showed that the prevalence of mental health problems increased significantly in the general population during the COVID-19 pandemic [7, 8, 9, 10, 11]. In Sweden, studies of mental health in the early phase of the COVID-19 pandemic showed elevated rates of depression, anxiety, and insomnia in the general population compared with before the pandemic, the same as in other counties [12, 13].

With increasing number of COVID-19 cases and hospitalization due to COVID-19 in the different countries, a possible bidirectional association between COVID-19 and mental health problems was attracting the attention of researchers [14, 15, 16]. On the one hand, pre-existing mental health problems could increase the risk to get COVID infection, or make the outcomes of the infection worse [17, 18, 19, 20, 21]. On the other hand, a significant proportion of patients with and survivors of COVID-19 reported numbers of psychological issues, such as post-traumatic stress disorder (PTSD), depression, anxiety, insomnia, and obsessive-compulsive symptoms [22, 23, 24, 25, 26].

Follow-up studies on COVID-19 survivors after discharge from hospital or/and recover from COVID-19 reported an unexpected result called post COVID-19 condition [27, 28, 29]. This condition affects individuals infected with COVID-19 and is characterized by a wide range of persistent symptoms even after months of the onset of disease or hospitalization [28, 30, 31, 32, 33, 34, 35]. The post COVID-19 condition has also been widely reported by individuals with the mild-to-moderate symptoms in the acute phase of SARS-CoV-2 disease, mostly recovered without requiring special treatment or/and hospitalization [36]. A recent meta-analysis, including data from fifty studies, shows that the global prevalence of post-COVID condition was 0.43 (95% confidence interval [CI], 0.39–0.46). In other words, nearly half of the people with a history of probable or confirmed SARS CoV-2 infection experienced mid- and long-term symptoms after recovery from COVID-19 [37]. Long-term impacts of COVID‐19 infection can be multi-systemic problems and disabilities, and fatigue in general was the most commonly reported symptom in previous studies [37, 38, 39, 40, 41, 42].

A collaborative cross-sectional study in Japan and Sweden examining associations between mental health and post-COVID conditions showed that rates of clinically significant depression and anxiety were significantly higher in groups with post-COVID conditions, compared to noninfected groups and infected group without post-COVID conditions. In addition, post-COVID conditions was demonstrated to be a risk for developing mental health illness [43]. Another study, conducted in Sweden reexamined the prevalence of depression, anxiety, and insomnia in the general population and the impact of COVID-19-related persistent symptoms on these psychiatric symptoms two years after the first appearance of COVID-19. Findings showed that the level of depression did not change significantly, the level of anxiety decreased, and the level of insomnia had increased compared with the early phase of the pandemic in Sweden. COVID-19-related persistent symptoms were found as an important vulnerability factor for mental ill-health [44]. However, research on the mental health of people infected with COVID-19 is still limited, and it is not clear how post-COVID impairments and fatigue, as the most common persistent symptom, might interrelate with mental health outcomes. The first purpose of the current study was to determine indicative of potential mental health problems in individuals with a history of probable or confirmed SARS CoV-2 infection/infections. To further enhance the knowledge, the second aim of the study was to address the impacts of post-COVID impairments and fatigue on mental health outcomes following COVID-19 infection/infections.

Methods

Measures

Procedure

The study was approved by the Swedish national ethical board (dnr 2021-06617-01) and informed consent was obtained from all participants. Participants answered the survey in the online platform, Research Electronic Data Capture (REDCap), hosted locally at Karolinska institute [67, 68]. Data were collected between the 23th of February and the 5th of April 2022.

Results

Correlational Analyses

Table 5 presents correlations between the outcome variables with participant background, COVID-19-related factors, post-COVID impairments, and fatigue dimensions. Notably, the background variables failed to significantly correlate with the mental health outcomes. More serious condition in the acute phase of COVID-19 infection was significantly related with all three outcome variables. Hospitalization because of COVID-19 achieved significant but small correlation with insomnia. Post-COVID impairments and fatigue variables significantly positively correlated with depression, anxiety, and insomnia.

Regression Analyses

Table 6 presents the final results of the hierarchical regression models for depression, anxiety, and insomnia. In a three-block model, COVID-19-related factors including severity of COVID-19 infection in the acute phase and hospitalization for COVID-19 were entered into the first block, followed by post-COVID impairments including impairments in mental functions, sensory functions and pain, body system functions, and activities and participation, entered in block 2, and fatigue factors including general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue, entered in block 3. All three blocks reached statistical significance for each of the outcome variables. For depression, fatigue accounted for the largest part of the variance, with \(\varDelta\)R² accounting for 23% of the variance. For anxiety, both fatigue factors and post-COVID impairments accounted similar variance in the equations, with \(\varDelta\)R² accounting for 12% of the variance. For insomnia, COVID-19-related factors accounted for the largest part of the variance. Interestingly, out of all variables, reduced motivation came out as the most important predictor for all three mental health outcomes.

Discussion

The first aim of the current study was to examine levels of mental health problems following COVID-19 infection/infections. The second aim was to study associations between COVID-19-related factors, post-COVID impairments as well as fatigue and mental health problems in individuals with a history of probable or confirmed SARS CoV-2 infection/infections. Results showed significant rates of significant depression (55%), anxiety (20.5%), and insomnia (60.9%) in our sample. The correlational analyses show that severity of COVID-19 infection in the acute phase and hospitalization due to COVID-19 were significantly correlated with mental health outcomes. All post-COVID impairments and fatigue dimensions were significantly associated with depression, anxiety, and insomnia. In multivariate models, generally, severity of COVID-19 infection in the acute phase explained a portion of the variance in depression and insomnia and impairments in mental functions explained variance in depression and anxiety. However, reduced motivation emerged as the most consistent predictor of all three mental health outcomes.

In our study, rates of mental health problems were clearly higher than previous studies using the same measures and cut-off levels, noticeably in depression and insomnia. There are a number of likely explanations. The first possible explanation for these findings lies in our sample and inclusion criteria. In the previous studies, the participants were recruited from social media and age ≥ 18 was a main inclusion criterion [12, 43, 44], whereas we used convenience sampling targeting individuals with a history of probable or confirmed COVID-19 infection. As a result, in studies by Matsumoto et al [43] and Brocki et al [44], 13% and 51.2% of the participants reported that they have been infected with the COVID-19, respectively, whereas in our study, 85% of the participants reported confirmed COVID-19 infection/infections supported by positive tests for COVID-19 virus (PCR) and/or positive rapid antigen test, including one time, 61.9%, two times, 20.7%, and more than two times, 2.4%. The second possible explanation of these results is that diagnosis of COVID-19 is likely to be associated with increased rates of mental health problems and subsequent psychiatric diagnoses. In that, psychiatric illness and mental health problems such as depression, anxiety, insomnia, post-traumatic stress disorder, obsessive-compulsive symptoms, and substance use disorders are highly prevalent in patients diagnosed with COVID-19 [16, 21, 22, 23, 24, 25, 26, 70, 71]. The third possible explanation is that a major proportion of participants in the current study had experienced the post-COVID impairments, such as impairments in mental function, sensory functions and pain, and body system functions. These findings are in line with a previous study that showed that incidence of clinically significant mental health problems was higher in COVID-19-infected participants, and it was more prominent in those with post-COVID conditions [43]. Furthermore, there are a number of previous studies indicating co-occurrence between pain, physical health problems and mental health illness [72, 73, 74]. The final possible explanation is the timing of data collection. Data for the current study was collected after the peak of the Omicron variant in Sweden, January 2022, which increased COVID-19 cases dramatically and tightened the restrictions. As a result, the rate of reinfection increased. In our sample, 19% (n = 99) of the participants reported that they had been infected for a second time and even a third time in January/February 2022. Considering possible explanations, we can safely say that individuals infected with COVID-19, especially those experiencing post-COVID impairments, are more likely to suffer from mental ill-health and may be more vulnerable for poor mental health outcomes.

Looking at potential predictors, prior severity of COVID-19 infection, post-COVID impairments and fatigue dimensions were associated with poor mental health outcomes and hospitalization because of COVID-19 was positively correlated with insomnia (see Table 4). These results are in line with previous studies showing high levels of mental health problems months after COVID-19 recovery, and a more serious COVID-19 infection in acute phase might be a risk factor for developing mental health illness [75, 76]. In more detail, individuals infected with COVID-19 showed the higher levels of mental health symptoms in the form of depression, generalized anxiety, and post-traumatic stress [43]. In more recent studies, post-COVID condition is clearly linked to mental ill-health [43, 76, 77].

Multivariate analyses were used to estimate the unique variance accounted for in depression, anxiety, and insomnia scores. The block of COVID-19-related variables explained unique variance in depression and insomnia and severity of COVID-19 infection appeared to contribute unique variance in depression and insomnia. The block of post-COVID impairments explained unique variance in depression and anxiety. The results are consistent with previous study reporting higher levels of mental health problems in individuals with post-COVID conditions compared with individuals who had developed COVID-19 without post-COVID conditions [43]. Looking at the importance of the separate variables within the set, impairments in mental functions appeared to contribute unique variance in depression and anxiety even we adjusted this variable to exclude depression, anxiety, stress, or sleep problems. It seems that impairments in mental functions such as impaired orientation, brain fatigue, concentration and attention difficulties, memory problem, and impaired organization and planning might be a risk factor for poor mental health outcomes. The block of fatigue variables, including general fatigue, physical fatigue, reduced activity reduced motivation, and mental fatigue, contributed unique variance in all three mental health outcomes. We further found that reduced motivation was interestingly the strongest predictors of risk for poor outcomes in depression, anxiety and insomnia. In other words, lower levels of motivation were associated with an increased risk of depression, anxiety, and insomnia symptoms. One possible explanation relies in that constancy in the face of difficulties as occurred during the COVID-19 pandemic is an important factor for lower wellbeing [78]. Life has been changed during the pandemic and a wide range of difficulties has been constantly experienced by many people such as financial difficulty, loneliness, fear of illness with COVID-19, loss of work, difficulties acquiring medication, difficulties accessing food, threats to personal safety, and difficulties in social functioning [9, 79, 80]. Therefore, reduced motivation could be a result of mental health issues or/and the pandemic period. Another possible explanation is that to stay motivated seems to play a key role for mental health outcomes in individuals infected with COVID-19. It has been nearly two years and a half since the COVID-19 pandemic started. People are tired to cope with pandemic and its consequences and demotivated to struggle with their post-COVID condition and improve their well-being beside the negative impacts on their life. So, we can assume that interventions targeting this group could use techniques like motivational interviewing in order to encourage patients to seek help and provide the initial motivation for treatment and changes [81, 82, 83, 84].

Conclusion

In conclusion, the current study outlines that individuals with a history of probable or confirmed SARS CoV-2 infection/infections are more likely to suffer from mental health problems. Therefore, it needs to have policies to promote and protect mental health in the individuals infected with COVID-19 especially those who still have experienced post-COVID impairments.

Limitations And Future Directions

There are several important limitations in the current study. First, using the cross-sectional design in this study did not enable us to interpret the findings as implying causality. Longitudinal studies are needed to identify how mental health outcomes change over time and the causal factors of changes. Second, we conducted this study on a convenience sample, which limits the generalizability of findings. Further studies are warranted to examine the mental health using more representative samples. Third, we gathered self-report data in this study. Self-report biases and poor recall should therefore be considered when interpreting the findings. The findings that reduced motivation and impaired mental functions were the strong predictor of poor mental health outcomes in the current study raise the chicken-and-the-egg dilemma. Further studies are vital to address the bidirectional associations between motivation as well as cognitive functions and mental health outcomes in individuals infected with COVID-19 especially those with post-COVID conditions.

Declarations

Ethical approval and consent to participate

The study was approved by the Swedish national ethical board (dnr 2021-06617-01) and informed consent was obtained from all participants. All procedures utilized in collecting data for the current paper follow the ethical standards of the Helsinki Declaration of 1964 and subsequent amendments.

Consent for publication

Not applicable.

Data availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors report no conflicts of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors’ contributions

Conceptualization, F.B, T.L, and M.J.F.; data curation, F.B.; formal analysis, F.B.; methodology, F.B, T.L, and M.J.F.; investigation, F.B, T.L, and M.J.F.; project administration, F.B.; writing – original draft, F.B.; writing – review & editing, F.B, T.L, and M.J.F. All authors have read and approved the manuscript.

Acknowledgements

We would like to thank all athletes that took part in this study.

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