Anxiety, depression and perceived social support among covid-19 patients admitted to a Covid Care Centre in Uttarakhand, India

Background: Mental illnesses including depression and anxiety are very common across all age groups. Even individuals with minimal or undetectable COVID-19 symptoms have felt the effects of this burden, which the COVID-19 pandemic has intensi�ed. Methods: A cross-sectional study was conducted on 346 COVID-19 patients with asymptomatic or mild illness. Depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS), and perceived social support was measured using the Multidimensional Scale of Perceived Social Support (MSPSP). Version 16 of SPSS was utilised to analyse the data. We employed ANOVA, Pearson's rank correlation, independent t-tests, and multivariate linear regression. P values less than 0.05 were considered statistically signi�cant. Results: 13.8 percent patients had comorbid depression and 32 percent, anxiety. 35.2 percent patients did not have enough support. Signi�cant correlation between depression and anxiety, depression and social support, and anxiety and social support was observed. Regression analysis showed age, marital status, covid case in family, and hypertension had signi�cant association with both anxiety and depression. Association of diabetes mellitus with anxiety was also observed. Perceived social support was found to be signi�cantly associated with age, covid case in family, and presence of diabetes mellitus and hypertension. Conclusion:Signi�cant number of COVID-19 patients displayed signs of anxiety, depression and lack of social support. Clinico-social factors found associated with anxiety, depression and perceived social support should be better taken care of in a future crisis like COVID-19.


Introduction
Ever since COVID-19 swept the entire globe, more than 18 million cases and nearly 4 million deaths were reported globally till June 2021 1 .India also contributed with signi cant numbers, both in number of cases and related deaths, which puts us at the second position worldwide, right next to the United States 1 .
Apart from the shocking data of the population which succumbed to the novel disease, researchers also showed that mental health of the population affected severely, due to the undetermined nature of COVID-19 infectivity and its high level of transmissibility in different populations 2 .Other than that, economic losses, interrupted daily routine, the inability to get engaged in the social events happening around and fear of being in isolation/quarantine also contributed to the psychiatric issues among the affected ones.
Studies during the previous epidemics 3 , have shown that a majority of the infected inpatients experienced various mental problems, including anxiety and depression 4 .In this pandemic too, patients with COVID-19 reported to have symptoms of anxiety [5][6][7][8] & depression 5,6,9 , in several surveys and even in patients with no previous psychiatric history, a diagnosis of COVID-19 was found to be associated with increased incidence of a rst psychiatric disorder 10 .
2][13] However, during initial studies, healthcare workers, 14,15 and general public 11 were studied primarily to know the psychological impact of COVID-19 and mental health of the hospitalized patients 16 , especially isolated ones with mild to moderate disease remained under the shadow.
As a result of the anti-pandemic measures, social connections were largely disrupted which increases the risk of having psychological di culties, and also has been coupled with early mortality 17 .So, considering social support and its protective role in relation to mental disorders should be looked upon for COVID-19 patients in different settings.As perceived, social support, concerns the subjective evaluation of how individuals, perceive friends and family members, as available to provide much needed support during di cult times, so it's measures are designed to assess individual perceptions concerning the general availability and adequacy of support provided 18 .
Several recent studies have concluded that higher ratings of perceived social support allays the effects of social isolation and social distancing measures (Zhang & Ma, 2020), and have an inverse association with levels of depression 19,20 , anxiety and other mental disorders 20 .However, it's really unfortunate that the role of perceived social support and its predictors pertaining to mental health, has not been highlighted enough during the current pandemic.
To best of our knowledge, not many studies, especially from India, assessed the mental state and social support in hospitalized patients with COVID-19.This study not only took a note of the anxiety, depression and perceived social support, COVID-19 patients had, but also, documented the correlation between them as well as their predicting factors during the COVID-19 outbreak.This study may serve as a reference to health care providers to offer comprehensive care to each individual patient, to minimize anxiety, depression and related complications and to nd out an early solution to it.It may also serve as a reference for future studies and can contribute towards development of future plans and policies.

Study population
Study included con rmed COVID-19 patients of 18 years and above, admitted at the covid care centre during the study period, willing to participate and were available at the time of interview.All patients were diagnosed with COVID-19 according to the advisory issued by the Indian government. 21,22All the admitted patients were either asymptomatic or had mild symptoms of the disease.All individuals suffering from any pre-existing mental disorders, and those who didn't give consent, were excluded from the study.

Study design
Interview was conducted on 2nd day of admission after informed consent was provided by the subjects before study commencement.The questionnaire was translated to the patients to get the response, maintaining social distancing norms.The nature of the study and its consequences were explained to the patients before commencing the interview.The ethical clearance was obtained from Institutional Ethics Committee, Govt.Medical College, Haldwani.Strict con dentiality was assured for the data related to identity.All the patients who reported mental health problems were provided help and were referred for further evaluation by psychiatrists if desired, apart from the routine counselling sessions at the respective centre.Total 346 patients completed the questionnaire during the study period.

Hospital Anxiety and Depression Scale (HADS)
Zigmond and Snaith developed the Hospital Anxiety and Depression Scale (HADS) 23 to identify possible or probable anxiety and depression in patients in non-psychiatric clinical settings.Since its inception, the instrument has been widely used worldwide and has been validated in various settings, both outside [24][25][26] and in India. 27The Hospital anxiety and depression scale is a 4 -point likert scale ranging from 0 to 3 and comprises of 7 questions each of depression and anxiety.The score ranges from 0-21 which was interpreted as 0-7 -normal, 8-10 -borderline abnormal, and 11 or more-"case" of psychiatric comorbidity. 23

Multidimensional Scale of Perceived Social Support (MSPSP)
The Multidimensional Scale of Perceived Social Support (MSPSS) is a brief research tool designed to measure perceptions of support from 3 sources: Family, Friends, and a Signi cant Other.The scale is comprised of a total of 12 items, with 4 items for each subscale.It has shown good internal and test-retest reliability, good validity, and a fairly stable factorial structure when translated and used into many languages. 28The Multidimensional Scale of Perceived Social Support has 12 questions and each is 1-7 point likert scale.In this scale, total score was divided by 12 to calculate mean score.In this approach any mean scale score ranging from 1 to 2.9 could be considered low support; a score of 3 to 5 could be considered moderate support; a score from 5.1 to 7 could be considered high support. 29

Statistical analysis Data
Data were analysed on SPSS version 16 version.Quantitative variables were expressed as mean and standard deviation and qualitative variables as percentage.Continuous variables were analysed using nonpaired Student t test or one-way analysis of variance (ANOVA) with post hoc.Multivariate linear regression analysis was done to nd out the predictors of depression, anxiety and social support while Pearson correlation was applied to see report the association between the dependent variables of the study.

Study population pro le
Mean age of the study participants came out to be 35.70 ± 12.17 years with 39.3 percent of the individuals were under 30 years of age, followed by 30.1 percent in 31-40 year age group.Majority of the participants were males, married, received education of up to intermediate and above.By occupation, 30.6 percent found to be indulged in skilled work followed by professional occupation but a good proportion, 27.7 percent, was found to be unemployed at the time of the study.Also, 39.9 percent study participants, do have other members in the family, contracted covid-19 during the period.Diabetes and hypertension, respectively, was found only in 2.9 and 4.3 percent of the study participants (Table 1).2. In this study, 13.8 percent covid positive individuals were found to be having depressive symptoms while 32 percent found to be having anxiety (Fig. 1).As far as social support is concerned, 35.2 percent patients found it di cult to have enough support from near and dear ones, with either low or moderate level of social support but the majority of patients had enough of it during the tough time (Fig. 1).Also, signi cant positive correlation was reported between depression and anxiety but a signi cant negative correlation of social support was observed with depression and anxiety.Depression vs anxiety (r = 0.634, p < 0.001), depression vs social support (r= -0.624, p < 0.001), anxiety vs social support (r= -0.583, p < 0.001) (Fig. 2).

Factors associated with depression, anxiety and perceived social support
Depression score was found to be signi cantly higher among females, married individuals, patients having pre-existing diabetes and hypertension and among patients who had other covid case in the family.Post hoc analysis was done for age, education and occupation, which sums up signi cantly higher depression score, along successive age groups, among patients with primary level of education and retired elderly (Table 3).
As with depression, anxiety score was also found to be signi cantly more among married individuals, patients having preexisting diabetes and hypertension and among patients who had other covid case in the family.Also, signi cantly higher score, for > 50 year old patients, retired elderly and individuals with primary level of education, was observed with post hoc analysis (Table 3).
Perceived social support seemed to be faded away during the pandemic for admitted patients as females, married individuals, patients with existing diabetes mellitus and hypertension and for those, who had another covid case in family.Post hoc analysis showed that social support, was comparatively not adequate for > 50 year old patients, patients with primary level of education and for non-working retired elderly patients (Table 3).diabetes mellitus and hypertension were more likely to be depressive (Table 4).Moreover, social support also seemed to have been predicted by age (β =-0.5, p<0.001), covid case in family (β = 0.241, p<0.001), presence of diabetes mellitus (β = 0.150, p<0.001) and hypertension (β = 0.165, p<0.001), so an elderly with chronic disease and having infection in other family members will be getting inadequate social support during the di cult time of covid-19 (Table 4).

Discussion
This study was aimed to know the prevalence of depression and anxiety among COVID-19 patients, admitted in the covid care centre, and also to nd out the social support available to them.Although, in recent past, a number of analyses have intertwined the depression and anxiety in patients with different disease 30,31 , but in this study, we nd out the burden of anxiety and depression among COVID-19 patients, social support they had, as well as the correlation between anxiety, depression and social support, and also reported their determinants.
In this study, 13.8 percent covid positive individuals had depression while 32 percent found to be having anxiety.Contrary to our study, higher prevalence of depression was reported by many other researchers, 32- 38 but a similar prevalence was also reported in a shelter hospital setting in china. 3939 As it is evident that social isolation and loneliness were found to be linked with unfavourable mental health outcomes, 40 and numerous studies have surfaced out the fact that in the case of illness, patient's surge for social support increases immensely to cope with di culty, which includes physical as well as psychological assistance provided by their near and dear ones along with medical workers.41 We also assessed the level of social support and found that majority of the patients, had high social support while only 15 and 20 percent had low to moderate support respectively.

Correlation between depression, anxiety, social support
As is the rule with almost all psychiatric disorders, anxiety and depression go hand in hand along with their symptoms. 42As far as life-time comorbidity of anxiety disorders with depression is concerned, it can range 20-70% for patients with social anxiety disorder 43 , and 50% for patients with panic disorder 43 .Correlational analysis in our study, exhibited a signi cant positive correlation between depression and anxiety.Similar association of depression and anxiety was also reported by other studies as well in the recent past. 34 37[46][47][48] Predictors of depression, anxiety and perceived social support Regression analysis showed that old patients higher chances to land up in depression and anxiety, and also to have poor social support.Other studies also found old age to be a signi cant contributing factor for anxiety and depression. 34,37,38rried status of the study participants did contributed towards having more anxiety and depression but contrary to that, research from Kuwait, nds marriage to be the predictor for allaying depressive symptoms while nding no such association with anxiety. 49whereas study done by khademian et al., reported no variation of mental stress for married individuals. 50As married patients, admitted to the covid care center, didn't had the space for home isolation along with having dependents in the family, could possibly explain the observed association.
This study also revealed that having family members diagnosed with COVID-19 was an independent predictor of both higher depression and anxiety score.This was very much on the cards as deep concern about infected family members and lack of family care may lead to hopelessness and doubt over the illness, which also found to be evident in many other studies done in different settings. 33,34,392][53] Being aware of that, even mild covid patients can feel the exaggerated anxiety or can show up with depressive symptoms which can rightly be the case in this study as well, where signi cantly higher depression and anxiety score was reported among hypertensives.
However, we found a signi cant association of diabetes only with higher anxiety score.
In the ongoing pandemic, almost everyone has been exposed to misinformation and it's a well-known fact that education level is vital in how people assimilate and assess information.A recently published study revealed that vulnerable populations with less education more likely to believe, share misinformation, 54 that can foster psychological distress including anxiety. 55This might explain why, in this study, lower education background predicted the higher level of anxiety among infected patients, which is in line with the nding of other researchers. 34Interestingly, in contrast with our ndings, others have found people with higher levels of education had greater levels of anxiety, depression, and stress, 56,57 because of high selfawareness in relation to their own health. 56wever, it is of interest that low social support also seemed to have been predicted by old age (β =-0.5, p<0.001), covid case in family (β = 0.241, p<0.001), pre-existing diabetes and hypertension.As far as age and social support is concerned, ndings from previous literature con rmed that the oldest people are more isolated and less socially supported. 58,59ring the pandemic, people have witnessed themselves to fall for the urge to practice stigmatization rather to live in mutual association.This study showed that support was hard to come by for patients who had infection in other family members.People fear of ending into something unfamiliar and ambiguous, the reason why they take guidance from the illustrious saying "better safe than sorry", 60 which can explain the discriminatory attitude towards the infected or suspected individuals as well as the ones considered responsible for spread of the disease.
In this study also, low social support for covid patients was found to be predicted by presence of chronic diseases like diabetes and hypertension.Family's life can be easily disrupt due to any chronic illness especially in case of low socioeconomic scenario.On one hand where chronically ill person may feel guilty about the demands his or her illness makes on the family, family's response to chronic illness varies based on the age and developmental stage of the ill individual, the strength and coping mechanisms of the family, and the family life-cycle stage, 61 that can create an environment of low social support for the affected ones.

Conclusion
Signi cant number of COVID-19 patients, admitted to the facility, had features of anxiety and depression.
Factors like age, marital status, covid case in family, and hypertension were found to have a signi cant association with anxiety and depression.Additionally, presence of anxiety also signi cantly associated with having diabetes mellitus.Also, age, covid case in family, and presence of diabetes mellitus and hypertension reported to be having a signi cant association with perceived social support.These factors found in the present study may help setting mental health of COVID-19 patients at priority along with other essential measures for the comprehensive care and much needed timely intervention for the patients during this crisis.

Limitation
Like any other study, our study has its limitations too.Firstly, it is di cult to comment upon the temporality, due to the cross sectional nature of the study and limited stay of the patients at the facility, and also due to gaps in meticulous observation of the mental health symptoms among the subjects.Also, the data was collected on the next day after admission, thus, any inferential investigation could not be elicited about any changes that may have occurred during the stay.And since, this study was conducted in a single COVID care centre, so the results cannot be generalised for the entire population, which strains for a multicentre study with a larger number of participants to support current study.Despite these limitations, this study provides an perceptiveness towards anxiety and depression among COVID-

Table 1
Socio-demographic and clinical pro le of the study population

Table 2
Mean score of depression, anxiety and social support of the study population.

Table 3
Association of socio-demographic factors with depression anxiety and social support.

Table 4
Multivariate regression analysis of factors associated with depression anxiety and social support.
19patients, in relation to the novel disease.
ReferencesFiguresFigure1proportion of study population suffering from depression and anxiety, with level of social support