The results of the present study objectified that patients with a low socio-economic level during the first and delta waves, who had not complied with quarantine during the first wave, and those who had a suspect case in the immediate family or a positive or suspect case in their immediate neighbourhood during the delta and Omicron waves were the most vulnerable group during the COVID-19 pandemic. Similarly, the severity of the disorder and associated comorbidities covaried with the duration of the pandemic. Patients felt better and better during successive waves, and much better in the Omicron wave than in the first wave of the COVID-19 pandemic.
This study revealed no significant association between the age of our patients and the panic disorder severity score. The literature reports mixed results for this variable, with some authors suggesting that greater anxiety among younger people may be due to greater access to information via social media during the pandemic, which can easily trigger stress. Others have indicated that the psychological impact of the pandemic was greater for younger adults and the elderly, considering advanced age (> 50 years) can be a predictor of severity [45–47].
Similarly, the gender difference was not significant in the face of high panic disorder severity in this population sample, despite the fact that several studies have concluded that women develop more emotional manifestations than men, whether stress, anxiety or depression [47].
On the other hand, these results showed a statistically significant association between low socio-economic status and severe panic disorder during the first and delta waves of the pandemic. In this context, a study of the COVID-19 crisis in Senegal highlighted some alarming figures: 86.8% of the sample studied reported loss of income, 77.5% were worried or very worried about being infected, and this worry related more to the health consequences (56.1%) than to the economic consequences (39%) [48]. This can be explained by the uncertainty of a disrupted working life due to confinement [4] since the economic impact of the pandemic, according to several studies, cannot be neglected and low-income families feared losing their jobs and homes during the pandemic [15].
With regard to certain risk factors linked to COVID-19, this study indicated a statistically significant association between increased panic disorder severity and non-compliance with quarantine during the initial recruitment period, the presence of a suspect case in the immediate family and the presence of a positive or suspect case in the immediate neighbourhood during the Delta and Omicron waves. As a result, non-compliance with containment and the presence of a suspect or confirmed case in the immediate vicinity may be associated with hypervigilance to interoceptive somatic signals for fear of infection, which increases the risk of new clinically significant panic symptoms in vulnerable individuals [49].
However, other studies suggest that the consequences of quarantine and social isolation can be negative and increase the risk of mental health problems [50, 51].
On the other hand, the results of the present study suggest a high rate of panic disorder severity during the first assessment, followed by a statistically significant improvement over two successive study periods. Comparison of our findings with data from the literature brings contradictory results, with some showing deterioration [52, 53] and others reporting no change or even improvement in symptoms during the COVID-19 pandemic [20].
Indeed, a study conducted early in the pandemic among patients with panic disorder objectified higher levels of overall COVID stress in this category compared to people with mood disorders and those without mental health problems, this result was more consistent during the first waves of the pandemic, suggesting that COVID stress responses may have stabilized in people with anxiety-related disorders as the pandemic progressed [22]. Similarly, an epidemiological study found some subjective improvement during the pandemic in the order of 7–17% in people with pre-existing psychiatric disorders suggesting that some pandemic-related conditions may have exerted temporary favourable effects on mental health [12].
What's more, in a longitudinal study of three psychiatric case-control cohorts in the Netherlands involving 1,517 patients, the COVID-19 pandemic did not appear to exacerbate the severity of pre-existing symptoms in people with severe pre-pandemic mental health problems [6], which the researchers speculate could be explained by stay-at-home orders enabling more structured and consistent daily routines [6, 54]. According to another study by Watkins-Martin et al, pre-existing severe symptoms in the mental health status of young people did not deteriorate but rather improved, perhaps reflecting a natural improvement in mental illness over time following a reduction in social stressors during periods of confinement [20].
In contrast, a study of the consequences of the COVID-19 pandemic in 1,210 people in China showed that certain physical symptoms such as sore throat, cough and breathing difficulties were significantly associated with higher scores on the anxiety and depression subscales of the DASS-21 [55], suggesting an accentuation of catastrophic interpretations focused on respiratory disorders and worsening of panic attacks in patients with panic disorder following hypervigilance on respiratory symptoms [56].
Similarly, and in cases of agoraphobia comorbid with panic disorder, an initial improvement in panic symptoms during confinement may have occurred, according to Caldirola et al, followed by an exacerbation of symptoms when the confinement measures became less rigorous, which could be related to the negative reinforcement associated with confinement as part of operant conditioning, hindering habituation and desensitization to feared situations or sensations, as well as consolidation of fear extinction [12]. This mechanism may partly explain why 6.2% and 21.7% of people, according to Caldirola et al, identifying themselves as panic disorder and agoraphobia sufferers, respectively, reported considerable or slight improvement in their perception during the first confinement in Germany [11, 12].
Suicidal risk and post-traumatic stress symptoms during the COVID-19 pandemic :
The consequences of significant deterioration in post-traumatic stress symptoms, suicidal ideation and behavior compared to pre-pandemic assessments were particularly higher in people with pre-existing psychiatric diagnoses [57].
Indeed, a Chinese study published in July 2020 of a psychiatric population prior to the onset of the pandemic reported a significant increase in post-traumatic stress states (30%), sleep disorders (25%) and the presence of very frequent suicidal ideation [58, 59].
In the same context, a comparative study between psychiatric patients and healthy controls conducted during the COVID-19 pandemic objectified a significant difference with higher levels of PTSD, anxiety, depression, stress and insomnia [1, 58].
In our study, there was a significant decrease in the mean Event Impact Scale scores between the first and second assessments. The difference between the delta and omicron waves was statistically significant (p < 0.001). In addition, with regard to suicidal risk, the participants in our study felt better and better during the successive waves of the pandemic, and much better in the omicron wave than in the first wave.
Anxiety and depression comorbidities during the COVID-19 pandemic :
Several studies have shown that anxiety-depressive disorders are frequently encountered in a variety of chronic conditions, and have indicated that patients with psychiatric disorders may have difficulty controlling these symptoms and experience impaired quality of life [60].
In addition, scores related to anxiety-depressive symptoms tended to be highest in panic disorder sufferers, which is not surprising given that health anxiety (i.e. fear of dying during panic attacks) is a cardinal feature of this disorder [22]. Participants in our study reported lower levels of anxiety symptoms during the delta (T2) and omicron (T3) waves than in the first wave, the differences between (T2) and (T3) were not significant. Similarly, depressive symptoms decreased significantly over time, from one wave to the next.
The literature review provides additional results by comparing pre-pandemic assessments of depression and anxiety symptoms in the psychiatric population. A study by Wang et al found that anxiety fluctuated dynamically with the evolution of the COVID-19 pandemic, and more specifically, COVID-19 pandemic anxiety peaked at T1 and dropped sharply at T2 and T3 [61]. Another study suggests that participants had higher scores on the stress, anxiety and depression subscale, which is in line with previous studies published during the MERS epidemic in Saudi Arabia and studies conducted during the COVID-19 pandemic in Singapore and India [15, 62–65].
These results are consistent with the findings of a meta-analysis indicating that mental health deteriorated early in the pandemic before returning to baseline levels by mid-2020 [19, 20] and to a prospective UK longitudinal study of anxiety and depression during the first 20 weeks of containment (March 23-August 9, 2020), which found a significant reduction in depressive and anxiety symptoms during both the strict and relaxed containment periods [20, 66].
Contrary to previous research, the result of a study conducted in patients with severe depression and anxiety before the pandemic [20] did not observe a worsening of depression and anxiety symptoms during the pandemic. These results are also in line with a meta-analysis of 65 longitudinal cohort studies by Robinson and colleagues, who found that unlike anxiety symptoms, increases in depressive symptoms tended to be greater and to remain elevated beyond the first few months of the pandemic [19], suggesting that the mental health consequences of the pandemic may differ according to symptom type [20].
Overall, the results of this particular study are consistent with the systematic review of longitudinal studies by Robinson and colleagues, who found that the overall increase in mental health symptoms between before and during the pandemic was most pronounced during the early stages of pandemic assessment before returning to pre-pandemic levels in the following months [19].
The contradictory data concerning the divergence of results can be attributed to several factors [67] linked to resilience, social inclusion and coping styles, the dynamic nature of the pandemic in each country and restriction policies, the type of pre-existing symptoms and associated comorbidities, the socio-economic consequences of quarantine, the types of reinforcement associated with confinement, the natural improvement of mental illness over time following a reduction in social stressors, and other pandemic-related conditions that may exert temporary effects on mental health [68–85]. It should be noted that, during the initial recruitment phase, the sample size was limited to patients with pre-existing panic disorder, with no comorbid anxiety, depression or symptoms of post-traumatic stress or suicidal risk, thus considerably reducing the sample size, but benefiting from a more homogeneous sample.
This study had several limitations, firstly a small sample size, as we restricted ourselves to patients who had met the inclusion criteria and came for consultation during the first period of the pandemic. In addition, telephone self-assessments in T2 and T3 could introduce a systematic bias, and telephone interviews during the delta and omicron waves may reduce the accuracy of assessments and give different rates compared with measures based on the initial face-to-face assessment in T1. This should not detract from the strengths of this study; namely, the longitudinal design, the use of standardized measures, the two-year duration of the study and the timing of assessments corresponding to the peaks of the three waves of the pandemic in Morocco. The results of the present study therefore contribute to filling gaps in knowledge about individual changes in the mental health of panic disorder patients during this pandemic.
Finally, the results of the present study cannot be interpreted as causal links, but much more as correlations. Nevertheless, this study is one of the first to focus on assessing the mental health of this vulnerable population in Morocco in a COVID-19 pandemic context.