The anxiety response of patients with severe psychiatric disorders to the recent public health crisis

doi:10.21203/rs.3.rs-3574133/v1

Download PDF

Research Article

The anxiety response of patients with severe psychiatric disorders to the recent public health crisis

https://doi.org/10.21203/rs.3.rs-3574133/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 23 Apr, 2024

Read the published version in BMC Psychiatry →

You are reading this latest preprint version

Background

The recent public health crisis, COVID-19, has had devastating health, economic, and social consequences in many societies. These consequences harmed to the already vulnerable groups, particularly people with Sever Psychiatric Disorders (SPDs). The present study was conducted with the aim of investigating the anxiety response of patients with SPDs during COVID-19 pandemic.

Methods

This cross-sectional analytical study was conducted on 351 patients with SPDs [schizophrenia spectrum (SSD), bipolar (BD), major depressive (MDD), and obsessive-compulsive (OCD) disorders] and a control group in Guilan province. The anxiety response consisted of four concepts: COVID-19-related anxiety, general health anxiety, anxiety sensitivity, and safety behaviors. After conducting a clinical unstructured interview with all participants, the self-report measures, including the Corona Disease Anxiety Scale, the Anxiety Sensitivity Index – Revised, the Short Health Anxiety Inventory, and the Checklist of Safety Behaviors, were administered.

Results

ANOVA showed a significant difference between the groups of patients with SPDs and the control group in COVID-19-related anxiety (F = 6.92, p = 0.0001), health anxiety (F = 6.21, p = 0.0001), and safety behaviors (F = 2.52, p = 0.41). However, no significant difference was observed between them in anxiety sensitivity (F = 1.77, p = 0.134). The Games-Howell test showed that the control group obtained a higher mean than the groups of people with BD (p < 0.0001), SSD (p = 0.033), and OCD (p = 0.003) disorders in COVID-19-related anxiety. Also, the MDD (p = 0.014) and OCD (p = 0.01) patients had a higher mean than the control group in health anxiety. Tukey's test showed that the mean of safety behaviors of the control group was significantly higher than the OCD group (p = 0.21). No difference was observed between the groups of MDD, BD, SSD, and OCD in terms of COVID-19-related anxiety, health anxiety, and safety behaviors.

Conclusion

Anxiety response to health crisis is different in groups with SPDs and control group. These difference in responses shows that patients with SPDs may have special needs in the occurrence of health crises. It also warns that having a mental illness is not necessarily associated with maladaptive reactions in health crises.

Anxiety

Severe psychiatric disorders

COVID-19

The beginning of COVID-19 disease at the end of December 2019 in Wuhan, China, soon became a global pandemic and created numerous and vast crises in various areas of human life, such as the health, economic, and social [1]. Crises disproportionately affect poor and vulnerable populations, including people with mental disorders [2]. Crises like COVID-19 pandemic do not affect the whole society equally, and there is a profound inequality in their adverse consequences for human life. In such crises, people with mental disorders are susceptible to more harm and unfortunate aftereffects [3]. One reason is that screening for medical comorbidities is less common in people with mental disorders, and they have higher mortality and a poorer prognosis than ordinary people when diagnosed with a disease [4]. Specifically, public health crises can cause recurrence or exacerbation of existing psychiatric disorders and, or physical diseases if people have a strong stress response to those crises compared to the general population [5]. Variation in response to crises, particularly global health crises, is also observed among people with mental disorders. Many studies sought to answer the question of what effects COVID-19 pandemic, has on various psychiatric disorders. Although a large part of the literature examines the impact of COVID-19 on the illness and well-being of people with non-SPDs [6, 7], few studies address the vulnerability of people with SPDs to COVID-19. At the same time this group often deals with more harmful and adverse consequences in the face of environmental threats [2, 3].

People with SPDs typically experience many disparities in physical health [8]. It is estimated that their life expectancy is 15 years less than the general population, and the main reason for that is being at high risk for physical diseases [9]. Until now, in patients with SPDs, the main focus has been on illnesses such as cardiovascular and metabolic diseases. However, as a result of the spread of epidemics and pandemics in the last years, infectious diseases have also been addressed as one of the vulnerabilities of these patients [8]. Six large-scale studies from Sweden (N = 195,565), Denmark (N = 144,321), Israel (N = 125,273), the UK (N = 447,296), England (N = 34,446), and the US (N = 7,348) showed an increased risk of the COVID-19 infection, hospitalization, and mortality for patients with SPDs, with no increased risk for other psychiatric disorders such as anxiety disorders [3, 8, 10–13]. A South Korean cohort study found that the patients with SPDs had a slightly higher risk for severe clinical outcomes of COVID-19 than patients without psychiatric disorders [14]. The patients with schizophrenia spectrum disorder had a higher risk of mortality related to COVID-19. It is not known to what extent patients with BD and MDD are at increased risk for COVID-19-related mortality [15].

The pandemic such as COVID-19 are often perceived as a life-threatening danger and correspondingly evoke emotional (anxiety, distress, helplessness), physical (physiological reactions), and behavioral (avoidance, safety behaviors, reassurance) responses in order to protect the person exposed to it [16]. Feeling anxious about one's health, having increased physical arousal, and performing behaviors to eliminate or reduce the relevant danger are among the expected responses in such times, ranging on a continuum from adaptive to non-adaptive health anxiety [17]. After the outbreak of COVID-19, there were several reports of increased health anxiety (and one of its components, death anxiety) in the general population [18–20], and people with mental disorders [21].

Some findings led to the assumption that it is better to consider distinctions between general health anxiety and anxiety related to COVID-19. Sauer and colleagues [22] in a time-course analysis of 12 single cases with the diagnosis of pathological health anxiety found that COVID-19-related anxiety was significantly lower than anxiety related to other severe diseases (e.g., cancer), and was not significantly associated with anxiety related to other severe diseases or pre-COVID-19 health anxiety. Norbye and colleagues [23] in the study of 1012 participants with one or more measurements of health anxiety between 2015 and 2020 and, or during COVID-19 pandemic (from 2020 to 2022), found no significant changes in health anxiety scores during the pandemic compared to the first two years of the pandemic in Norwegian adults. This finding means that general health anxiety has remained stable over time, although anxiety specific to COVID-19 is reported to be significantly higher. For reasons like these, some have argued that anxiety caused by COVID-19 is different from classic health anxiety in some ways, and due to the high severity of symptoms and high contagiousness and mortality, the fear and caution of people may seem justified and cannot be considered simply pathological [24]. Others have found it necessary to use other terms, such as corona phobia, to name and describe anxiety related to COVID-19 [25].

In addition, research indicates that some general vulnerability and trans-diagnostic factors play a role in the level of anxiety, including health anxiety, in all types of psychiatric disorders and ordinary people. One well-studied factor is anxiety sensitivity [21]. Anxiety sensitivity is a multidimensional construct that consists of fears of physical, cognitive, and social aspects of anxiety. People with higher anxiety sensitivity believe their symptoms and physical arousal can have harmful and dangerous consequences [26]. It is assumed that anxiety sensitivity correlates with anxious reactions to life-threatening events, particularly pandemics [27]. Specifically, research has shown that this factor affects anxiety response to previous pandemic threats such as H1N1 and Ebola, although some findings have not shown such an association [21].

While people with SPDs appear more vulnerable to COVID-19 disease and its consequences, research on them is more limited [12, 28]. Mainly, the literature has not sufficiently addressed the possible distinction between general health anxiety and anxiety related to COVID-19 and the differences between diagnostic groups with SPDs in psychological responses to the recent public health crisis. To our knowledge, this is the first study distinguishes between general health anxiety and COVID-19-related anxiety responses. We examined anxiety sensitivity as a specific vulnerability factor of anxiety, and measured safety behaviors as one of the most common behavioral reactions in the face of a pandemic in people with SPDs. We compared variables as mentioned earlier among the four diagnostic groups and between patients with SPDs and control subjects. We hypothesized that the four diagnostic groups with SPDs would obtain higher scores than controls on self-report assessments of general health anxiety, COVID-19-related anxiety, anxiety sensitivity, and safety behaviors. We also hypothesized that the four diagnostic groups would not have significant differences in those variables.

Sample

This cross-sectional analytical study was conducted on patients aged 18 to 65 with psychiatric disorders (schizophrenia spectrum, bipolar, major depressive and, obsessive-compulsive disorders) who had been referred to the outpatient clinics of Shafa hospital and one private psychiatry clinic in Rasht in Guilan province (the second center of the outbreak of COVID-19 in Iran). The research sample was selected using convenience sampling and divided into four distinctive experimental groups and a control group: 43 patients with schizophrenia spectrum disorders (schizophrenia, schizoaffective, and schizophreniform), 51 patients with bipolar disorders (type 1 and type 2), 46 patients with major depressive disorder, 60 patients with obsessive-compulsive disorder and 151 participants without any psychiatric disorders. Control group participants were recruited from the normal relatives of the patients or by advertising the research project on online social networks.

The inclusion criteria were passing at least six months since the final diagnosis of the disorder, undergoing treatment for psychiatric disorders, having at least ninth-grade education, and the absence of any psychiatric disorders in the control group. Exclusion criteria were being in the intoxication phase of substance use or acute phase of the disorder. A clinical interview using the diagnostic criteria based on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders [29] was conducted by a faculty psychiatrist (the first author of the study) on all participants (patients and control participants) .Then the study tools regarding anxiety related to COVID-19 disease, general health anxiety, anxiety sensitivity, and safety behaviors were administered by two trained medical students on the participants in random order and following the safety precautions recommended by the World Health Organization. All patients were included in the study based on their primary diagnosis. After providing the necessary points to the participants’ written consent was obtained from them.

Measures

1. The Information Checklist:

This checklist contains information related to the clinical status of the patients, including current psychiatric diagnosis and COVID-19 disease, as well as information related to demographic variables such as age, gender, marital status, education, employment status, substance/drug use, history of COVID-19 infection in oneself or first and second-degree relatives.

2. The Corona Disease Anxiety Scale (CDAS):

This scale was developed and validated in Iran in 2019 by Alipour et al. to measure corona disease-related anxiety [30]. This scale consists of 18 items and two components (factors). Items 1 to 9 measure psychological symptoms, and items 10 to 18 measure physical symptoms of anxiety. Each of these items is scored on a 4-point Likert scale (never = 0, sometimes = 1, most of the time = 2, and always = 3). Therefore, the score that individuals get on this scale will be between 0 and 54, where higher scores indicate a higher level of anxiety. In Alipour and colleagues’ study [30], the reliability of CDAS using Cronbach's alpha was obtained for the first factor, the second factor, and the total scale of 0.88, 0.86, and 0.92, respectively. Also, the correlation of the CDAS with the total score of the 28-item General Health Questionnaire (GHQ-28) and the subscales of anxiety, physical symptoms, impairment in social functioning, and depression was found to be 0.48, 0.51, 0.42, 0.33, and 0.27, respectively (P < 0.01).

3. The Anxiety Sensitivity Index - Revised (ASI-R):

The ASI-R is a 36-item self-report scale that measures the fear of anxiety-related sensations based on beliefs about their harmful consequences, and has a four-factor structure: (1) fear of respiratory symptoms, (2) fear of publicly observable anxiety reactions, (3) fear of cardiovascular symptoms, and (4) fear of cognitive dyscontrol [31]. Respondents indicate their level of agreement with each item on a Likert scale that ranges from meager (score 0) to very high (score 4). Therefore, the range of scores is between 0 and 144, and higher scores indicate greater anxiety sensitivity. Taylor and Cox reported the internal consistency coefficient for factors 1 to 4, 0.91, 0.86, 0.88 and 0.89, respectively, and the correlation coefficient between the ASI-R and the anxiety sensitivity index was 0.94. Also, they reported the correlation of factors with each other in the range of 0.28 to 0.40 and with the total score of the ASI-R in the range of 0.66 to 0.77 [31]. In an Iranian study, the Cronbach's alpha coefficient of the ASI-R was 0.91 [32].

4. The Short Health Anxiety Inventory (SHAI):

This self-report inventory was developed and validated by Salkovskis et al. to assess worry about one's health, awareness of bodily sensations or changes, and fear of disease consequences [33]. The SHAI contains 18 items and each item has four choices and the respondents must choose one of the sentences that best describes her/his. Scoring for each item is from 0 to 3, and a high score indicates higher health anxiety. Its retest reliability is 0.90 and its Cronbach's alpha coefficient is reported from 0.70 to 0.82. Its test-retest reliability, internal consistency, and convergent validity were reported as 0.90, 0.70 to 0.82, and 0.72, respectively [33]. In an Iranian study, Cronbach's alpha coefficient of 0.87 was reported for the SHAI [34].

5. The Checklist of Safety Behaviors:

This checklist contains 23 safety behaviors related to COVID-19 disease and the respondents are asked to mark each of the behaviors in this checklist if they do it. The behaviors included in this checklist were extracted from the checklists that were examined in two studies by Musche and colleagues [35] and Olatunji and colleagues [36].

Statistical analysis

To analyze the data, after calculating the central and dispersion statistical indices, the skewness and kurtosis indices and the Shapiro-Wilk test were used to examine the normal distribution of the data. Levene's test was also used to examine the homogeneity of variances. Then, a one-way analysis of variances (ANOVA) was used to discover the difference between the study groups in the research variables. Finally, the variables that one-way ANOVA showed that there is a difference between the study groups, Tukey HSD and Games-Howell post hoc test were used to examine which group is different from which group. To examine those variables whose homogeneity of variance was confirmed by Levene's test, Tukey's test was used, and for those that were not confirmed, Games-Howell's test was used.

351 people formed the population of our study. Demographic data by patient and control groups are presented in Table 1. 27.9% of the participants had a history of COVID-19 infection; 7.1% of them had lived with people who were infected with COVID-19; and 59.8% of their relatives were infected with the COVID-19.

Table 1

Demographic characteristics of patient and control groups
	MDD	BD	SSD	OCD	Control	Total
N	46	51	43	60	151	351
Age [M (SD)]	51.5 (14.11)	43.94 (13.7)	43 (11.25)	39.6 (11.69)	39.83 (12.58)	42.31 (13.19
Gender [n (%)]
Male	12 (26.1)	16 (31.4)	23 (53.5)	21 (35)	37 (24.5)	109 (31.1)
Female	34 (73.9)	35 (68.6)	20 (46.5)	39 (65)	114 (75.5)	242 (68.9
Marital Status [n (%)]
Single	5 (10.9)	15 (29.4)	18 (41.9)	24 (40)	60 (39.7)	122 (34.8)
Married	41 (89.1)	30 (70.6)	25 (58.1)	30 (60)	91 (60.3)	229 (65.2)
Education [n (%)]
Under diploma degree	14 (30.4)	12 (23.5)	14 (32.6)	13 (21.7)	10 (6.6)	63 (17.9)
Diploma degree	20 (43.5)	17 (33.3)	8 (18.6)	22 (36.7)	29 (19.2)	96 (27.4)
Associates’ degree	3 (6.5)	4 (7.8)	7 (16.3)	4 (6.7)	10 (6.6)	28 (8)
Bachelor’s degree	9 (19.6)	16 (31.4)	10 (23.3)	15 (25)	61 (40.4)	111 (31.6)
Master’s degree	0 (0)	1 (2)	3 (7)	6 (10)	26 (17.2)	36 (10.3)
Doctoral degree	0 (0)	1 (2)	1 (2.3)	0 (0)	15 (9.9)	17 (4.8)
Employment Status [n (%)]
Employed	6 (13)	17 (33.3)	19 (44.2)	19 (31.7)	64 (42.2)	125 (35.6)
Unemployed	29 (63)	33 (45.1)	21 (48.8)	37 (61.7)	36 (23.8)	146 (41.6)
Student	2 (4.3)	4 (7.8)	1 (2.3)	3 (5)	29 (19.2)	39 (11.1)
Retired	9 (19.6)	7 (13.7)	2 (4.7)	1 (1.7)	22 (14.6)	41 (11.7)
Substance use [n (%)]
No	44 (95.7)	50 (98)	25 (58.1)	58 (96.7)	151 (100)	328 (93.4)
Yes	2 (4.3)	1 (2)	18 (41.9)	2 (3.3)	0 (0)	23 (6.6)
Corona infection
Owns	8 (17.4)	7 (13.7)	12 (27.9)	12 (20)	59 (39.1)	98 (27.9)
In family	2 (4.3)	6 (11.8)	2 (4.7)	3 (5)	12 (7.9)	25 (7.1)
In relatives	23 (50)	25 (49)	27 (62.8)	34 (56.7)	101 (66.9)	210 (59.8)
Note: MDD: major depressive disorder; BD; bipolar disorder; SSD: schizophrenia spectrum disorder; OCD: obsessive-compulsive disorder.

Shapiro-Wilk test (p < 0.01) and kurtosis and skewness indices showed that the distribution of scores follows the normal distribution. Also, Levene's test did not confirm the assumption of homogeneity of variances in COVID-19-related anxiety (p = 0.001) and health anxiety (p < 0.0001), however this assumption was confirmed in anxiety sensitivity (p = 0.056) and safety behaviors (p = 0.065) (Table 2). Therefore, the Games-Howell post hoc test was used to examine the differences in COVID-19-related anxiety and health anxiety and Tukey's test was used to examine the differences in anxiety sensitivity and safety behaviors.

Table 2

Normal distribution indices and homogeneity of variances test
	MDD	BD	SSD	OCD	Control
Measures of variability [(Statistic (SE)]
Skewness	1.12 (0.350)	0.869 (0.333)	1.802 (0.361)	2.218 (0.309)	1.126 (0.197)
Kurtosis	0.547 (0.688)	0.526 (0.656)	3.456 (0.759)	6.932 (0.608)	1.921 (0.392)
COVID-19-related anxiety [Sig.]
Shapiro-Wilk	0.000	0.004	0.000	0.000	0.000
Levene’s test	0.001
Health anxiety [Sig.]
Shapiro-Wilk	0.035	0.060	0.038	0.115	0.020
Levene’s test	0.000
Anxiety sensitivity [Sig.]
Shapiro-Wilk	0..112	0.099	0.241	0.299	0.055
Levene’s test	0.056
Safety behaviors [Sig.]
Shapiro-Wilk	0.099	0.006	0.015	0.001	0.020
Levene’s test	0.065
Note: MDD: major depressive disorder; BD; bipolar disorder; SSD: schizophrenia spectrum disorder; OCD: obsessive-compulsive disorder.

In Table 3, the mean and standard deviation of COVID-19-related anxiety, health anxiety, anxiety sensitivity, and the number of safety behaviors of different groups of participants are presented. ANOVA showed that there is a significant difference between the groups of patients with psychiatric disorders and the control group in terms of COVID-19-related anxiety (F = 6.92, p = 0.0001), health anxiety (F = 6.21, p = 0.0001), and safety behaviors (F = 2.52, p = 0.41). However, no significant difference was observed between them regarding anxiety sensitivity (F = 1.77, p = 0.134).

Table 3

Mean and standard deviation of participants' scores by patient and control groups and significance of difference between groups in scores (ANOVA)
	Groups [M (SD)]					F	Sig.
	MDD (n = 46)	BD (n = 51)	SSD (n = 43)	OCD (n = 60)	Control (n = 151)	F	Sig.
COVID-19-related anxiety	10.98 (8.97)	7.04 (5.62)	8.09 (9.58)	8.63 (7.11)	12.97 (9.31)	6.92	0.0001
Health anxiety	21.04(11.62)	16.59(7.46)	19.32(11.70)	19.5 (9.3)	15.09 (6.51)	6.21	0.0001
Safety behaviors	9 (6.14)	9.39 (6.7)	9.59 (6.4)	7.22 (5.14)	9.9 (5.39)	2.52	0.041
Anxiety sensitivity	57.09(31.67)	50.88(33.43)	49.84(29.56)	55.88(30.02)	46.79(24.98)	1.77	0.134
Note: MDD: major depressive disorder; BD; bipolar disorder; SSD: schizophrenia spectrum disorder; OCD: obsessive-compulsive disorder.

As shown in Table 4, the Games-Howell test showed a significant difference between the control group and the groups of people with BD (p < 0.0001), SSD (p = 0.033), and OCD (p = 0.003) in terms of COVID-19-related anxiety, so that the control group obtained a higher mean than them. Also, there was a significant difference between the control group and the MDD (p = 0.014) and OCD (p = 0.01) groups in terms of health anxiety, so that the control group had a lower mean than them. Tukey's test showed that the mean of safety behaviors of the control group was significantly higher than the OCD group (p = 0.21). It should be noted that no difference was observed between the groups of MDD, BD, SSD, and OCD in terms of the COVID-19-related anxiety, health anxiety, and safety behaviors.

Table 4

Significance of differences between the patient and control groups from each other (Games-Howell & Tukey)
	MDD	BD	SSD	OCD	Control
COVID-19-related anxiety
MDD	-	0.089	0.588	0.593	0.686
BD	0.089	-	0.969	0.681	0.000
SSD	0.588	0.969	-	0.998	0.033
OCD	0.593	0.681	0.998	-	0.003
Control	0.686	0.000	0.033	0.003	-
Health Anxiety
MDD	-	0.184	0.957	0.947	0.014
BD	0.184	-	0.678	0.362	0.706
SSD	0.957	0.678	-	1.000	0.171
OCD	0.947	0.362	1.000	-	0.010
Control	0.014	0.706	0.171	0.010	-
Safety Behaviors
MDD	-	0.997	0.937	0.516	0.887
BD	0.997	-	0.990	0.281	0.983
SSD	0.937	0.990	-	0.127	1.000
OCD	0.516	0.281	0.127	-	0.021
Control	0.887	0.983	1.000	0.021	-
Note: MDD: major depressive disorder; BD; bipolar disorder; SSD: schizophrenia spectrum disorder; OCD: obsessive-compulsive disorder.

The recent pandemic has had devastating health, economic, and social consequences in many societies. These consequences harmed to the already vulnerable groups, particularly people with SPDs [3]. In the present study, we examined the anxiety response of four groups of patients with SPDs in the face of the recent global health crisis compared to each other and people without psychiatric disorders. Our results showed that, except for anxiety sensitivity, there was a significant difference between patients with SPDs and the control group in COVID-19-related anxiety, health anxiety, and safety behaviors. Unexpectedly, the control group had significantly higher COVID-19-related anxiety than patients with BD, SSD, and OCD, while patients with MDD and OCD had significantly higher health anxiety than the control group. Also, the number of safety behaviors of the control group was more significant than OCD group, at the same time no difference was observed between the four diagnostic groups in the COVID-19-related anxiety, health anxiety, and safety behaviors.

Although many meta-analytic and systematic review studies have shown an increase in anxiety and depression in the general population in dealing with the recent pandemic [37–39], it was expected that patients with SPDs, considering their higher sensitivity to stress, would show more anxiety response when faced with the numerous health, economic, and social challenges of COVID-19. Our findings showed the opposite. Patients with SPDs, except for MDD, reported less COVID-19-related anxiety than control group, while regarding health anxiety, two groups of patients with SPDs (MDD and OCD) showed higher health anxiety. The COVID-19 pandemic has become a global threat to mental health due to its contagiousness and high mortality. The news coverage of the pandemic was worldwide, and many rumors were spread about it [21]. On the other hand, the World Health Organization and healthcare policymakers have equally required everyone to follow health and safety recommendations. All this caused the consequences of the pandemic to become universal, and its psychological reactions spread to many people without psychiatric disorders. Stressful factors such as fear of death, fear of losing loved ones, loss of social connection, and loss of employment may even cause serious psychological problems in formerly healthy people [40], so in some studies the anxiety and depression of healthy people exceeded that of people with SPDs [41]. What further strengthens this interpretation is that participants without psychiatric disorders performed more safety behaviors in response to the pandemic than patients with OCD, or did not differ from patients with SSD, BD, and MDD in this respect, at the same time there was no significant difference in anxiety sensitivity, as a general trans-diagnostic factor of vulnerability to experience anxiety [21], between them.

There are various reasons for the lower manifestation of COVID-19-related anxiety and safety behaviors in patients with SPDs. Some have suggested that the lives of patients with psychiatric disorders are already troubled by many challenges, and the outbreak of a sever global health crisis has had more adverse effects on the lives of non-disordered individuals [41, 42]. In other words, the most significant anxiety, interference, and restrictions caused by the pandemic have been created for those who had a less troublesome life before. For example, many people with mental disorders may have previously experienced isolation and lack of a suitable social network, as a result, the "social distancing" recommended by the healthcare system and the resulting psychological consequences do not seem problematic to them [42]. Another issue that we repeatedly saw in our patients' visits was that patients were struggling with their problems and symptoms, and many times, there was no correspondence between public concerns related to COVID-19 and their concerns. For example, the fear of being infected with a virus may not be important to a patient with OCD, because her/his fear was actually of being contaminated with toxic substances. Alternatively, a patient with BD may be more preoccupied with having an affair or tension with a partner than with health concerns. Some neuropsychological deficits and symptoms may also interfere with patients' understanding of health risk factors and cause inappropriate responses to them. Symptoms such as an exaggerated sense of well-being and self-confidence (euphoria), amotivation, and disorganized thinking [29] can cause such interferences in the lives of patients with BD, MDD, and SSD, respectively. As a result, amotivation in a patient with MDD can lead to neglecting self-protection or visiting a doctor if necessary, and disorganized thinking or delusional thinking in a patient with SSD can make her refuse to use a mask [43]. Also, since many patients with SPDs may have underlying cognitive impairments in information processing and proper planning and action [44], it has been suggested that cognitive deficits, along with other factors, such as low education level, cause a decrease in their health literacy and directly interfere with proper hygiene behaviors [14, 42].

Our results regarding the higher level of health anxiety in two groups of patients with SPDs (MDD and OCD) compared to control group may confirm the view of clinicians who believe that as long as the anxiety response to the threat of COVID-19 pandemic is possibly justified, it is better to distinguish between the pandemic-related anxiety and general or classic health anxiety. In other words, during a global pandemic, it may be reasonable for people to attribute their anxiety symptoms to the corona virus infection and show considerable reactions to it, in the end, this difference is of degree and not of nature [24]. In addition, a longitudinal study of the level of health anxiety from 2015 to 2022 in Norway based on several measurements suggests that health anxiety remains stable despite the recent global health crisis [23]. All this indicates that despite the increase in the anxiety response of the general population to COVID-19, the previous level of health anxiety in patients with disorders such as OCD and MDD continues to exist as before. This finding is inconsistent with the findings of other studies that report a positive association between health anxiety and anxiety specific to COVID-19 virus in the general population [45, 46].

Our study has several limitations. First, this study was carried out under epidemic conditions and quarantine rules. Health restrictions created difficulties for access to patients and research activities. Some patients did not want to participate in the research due to their health concerns. We reduced some of these limitations by using video interviews. Second, our sample was small in any four patients’ groups, and this may hinder both the clinical significance and the generalizability of the results. Third, there are ethnic communities in Guilan province. Some studies have shown that there is a considerable ethnic disparity in contracting COVID-19 disease or worsening its symptoms. African Americans with MDD, BD, and schizophrenia had a higher risk of contracting COVID-19 than Caucasians even after controlling for medical conditions, suggesting that social, behavioral, and lifestyle factors related to ethnicity also play a significant role in health inequalities [43]. Finally, due to the small sample, we did not consider subgroups of OCD. The washing-contamination subgroup is expected to experience greater fear of being infected through a virus [21]. The few existing studies indicate that patients with OCD had heterogeneous responses to problems caused by COVID-19 [41].

Public health crisis has global effects on various aspects of human life. Patients with severe psychiatric disorders may show a considerable anxiety response to such crisis due to their high vulnerability to stress. Although health anxiety persists in many of these patients during the pandemic, their anxiety response to the health crisis may be less than expected due to various factors such as pre-existing symptoms, low health literacy, and possible co-occurring cognitive impairment. It is reasonable to consider this level of anxiety response by patients with SPDs compared to individuals without psychiatric disorder. The response of people without psychiatric disorders to the pandemic has been so high and in some cases acute that it may justify considering the differences between health anxiety and anxiety related to corona virus.

Authors' Contribution: Study concept and design: All authors; Acquisition of data: MK, PZ and MM; Analysis and interpretation of data: MK and HF; Drafting of the manuscript: MK, HF and PK; Critical revision of the manuscript for important intellectual content: All authors; Statistical analysis: HF and SMKA.

Acknowledgments: The authors would like to express thanks to the personnel of Dr. Khalkhali’s and Shafa Hospital Outpatient Clinic, and the colleagues of Kavosh Research Center for their cooperation.

Competing Interests: The authors disclose that they have no competing interests.

Data Reproducibility: The dataset presented in the study is available on request from the corresponding author during submission or after publication.

Funding/Support: No funding.

Ethical approval and consent to participate: The present study was approved by the scientific and ethical committees of Guilan University of Medical Sciences (Code: IR.GUMS.REC.1400.334). All participants declared their written informed consent.

Author details

^1.Kavosh Cognitive Behavior Sciences and Addiction Research Center, Department of Psychiatry, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran.

Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. The lancet. 2020;395(10223):470-3.
Druss BG. Addressing the COVID-19 pandemic in populations with serious mental illness. JAMA psychiatry. 2020;77(9):891-2.
Wallin AS, Ohlis A, Dalman C, Ahlen J. Risk of severe COVID-19 infection in individuals with severe mental disorders, substance use disorders, and common mental disorders. General Hospital Psychiatry. 2022;75:75-82.
Erlangsen A, Andersen PK, Toender A, Laursen TM, Nordentoft M, Canudas-Romo V. Cause-specific life-years lost in people with mental disorders: a nationwide, register-based cohort study. The Lancet Psychiatry. 2017;4(12):937-45.
Pierce M, Hope H, Ford T, Hatch S, Hotopf M, John A, et al. Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. The Lancet Psychiatry. 2020;7(10):883-92.
Racine N, McArthur BA, Cooke JE, Eirich R, Zhu J, Madigan S. Global prevalence of depressive and anxiety symptoms in children and adolescents during COVID-19: a meta-analysis. JAMA pediatrics. 2021;175(11):1142-50.
Yan Y, Du X, Lai L, Ren Z, Li H. Prevalence of depressive and anxiety symptoms among Chinese older adults during the COVID-19 pandemic: A systematic review and meta-analysis. Journal of geriatric psychiatry and neurology. 2022;35(2):182-95.
Hassan L, Peek N, Lovell K, Carvalho AF, Solmi M, Stubbs B, et al. Disparities in COVID-19 infection, hospitalisation and death in people with schizophrenia, bipolar disorder, and major depressive disorder: a cohort study of the UK Biobank. Molecular psychiatry. 2022;27(2):1248-55.
Firth J, Siddiqi N, Koyanagi A, Siskind D, Rosenbaum S, Galletly C, et al. The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. The Lancet Psychiatry. 2019;6(8):675-712.
Barcella CA, Polcwiartek C, Mohr GH, Hodges G, Søndergaard K, Niels Bang C, et al. Severe mental illness is associated with increased mortality and severe course of COVID‐19. Acta Psychiatrica Scandinavica. 2021;144(1):82-91.
Goldberger N, Bergman-Levy T, Haklai Z, Yoffe R, Davidson M, Susser E, et al. COVID-19 and severe mental illness in Israel: testing, infection, hospitalization, mortality and vaccination rates in a countrywide study. Molecular psychiatry. 2022;27(7):3107-14.
Penington E, Lennox B, Geulayov G, Hawton K, Tsiachristas A. The early impact of the COVID-19 pandemic on patients with severe mental illness: An interrupted time-series study in South-East England. European Psychiatry. 2022;65(1):e31.
Nemani K, Li C, Olfson M, Blessing EM, Razavian N, Chen J, et al. Association of psychiatric disorders with mortality among patients with COVID-19. JAMA psychiatry. 2021;78(4):380-386.
Lee SW, Yang JM, Moon SY, Yoo IK, Ha EK, Kim SY, et al. Association between mental illness and COVID-19 susceptibility and clinical outcomes in South Korea: a nationwide cohort study. The Lancet Psychiatry. 2020;7(12):1025-31.
De Hert M, Mazereel V, Stroobants M, De Picker L, Van Assche K, Detraux J. COVID-19-related mortality risk in people with severe mental illness: a systematic and critical review. Frontiers in Psychiatry. 2022;12:798554.
Asmundson GJ, Taylor S. How health anxiety influences responses to viral outbreaks like COVID-19: What all decision-makers, health authorities, and health care professionals need to know. Journal of anxiety disorders. 2020;71:102211.
Asmundson GJ, Abramowitz JS, Richter AA, Whedon M. Health anxiety: current perspectives and future directions. Current psychiatry reports. 2010;12:306-12.
Luo J, Wang P, Li Z, Cao W, Liu H, Meng L, et al. Health Anxiety and Its Correlates in the General Chinese Population During the COVID-19 Epidemic. Frontiers in psychiatry. 2021;12:743409.
Özdin S, Bayrak Özdin Ş. Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: The importance of gender. International journal of social psychiatry. 2020; 66(5): 504-511.
Patra I, Muda I, Ketut Acwin Dwijendra N, Najm MA, Hamoud Alshahrani S, Sajad Kadhim S, et al. A systematic review and Meta-analysis on death anxiety during COVID-19 pandemic. OMEGA-Journal of Death and Dying. 2023:00302228221144791.
Dennis D, Radnitz C, Wheaton MG. A perfect storm? Health anxiety, contamination fears, and COVID-19: lessons learned from past pandemics and current challenges. International Journal of Cognitive Therapy. 2021;14:497-513.
Sauer KS, Schmidt A, Jungmann SM, Bailer J, Witthöft M. Do patients with pathological health anxiety fear COVID-19? A time-course analysis of 12 single cases during the “first wave” of the COVID-19 pandemic in Germany. Journal of psychosomatic research. 2022;152:110687.
Norbye AD, Farbu EH, Terjesen CL, Fleten N, Höper AC. The level of health anxiety before and during the COVID-19 pandemic. Plos one. 2023;18(5):e0285799.
Tyrer P. COVID‐19 health anxiety. World Psychiatry. 2020;19(3):307.
Asmundson GJ, Taylor S. Coronaphobia: Fear and the 2019-nCoV outbreak. Journal of anxiety disorders. 2020;70:102196.
Deacon B, Abramowitz J. Anxiety sensitivity and its dimensions across the anxiety disorders. Journal of anxiety disorders. 2006;20(7):837-57.
Schmidt NB, Morabito DM, Mathes BM, Martin A. Anxiety sensitivity prospectively predicts pandemic-related distress. Journal of Affective Disorders. 2021;292:660-6.
Hassan L, Sawyer C, Peek N, Lovell K, Carvalho AF, Solmi M, et al. Heightened COVID-19 mortality in people with severe mental illness persists after vaccination: a cohort study of greater manchester residents. Schizophrenia Bulletin. 2023;49(2):275-84.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: Author, 2013.
Alipour A, Ghadami A, Alipour Z, Abdollahzadeh H. Preliminary validation of the Corona Disease Anxiety Scale (CDAS) in the Iranian sample. Health Psychology. 2020;8(32):163-75.
Taylor S, Cox BJ. Anxiety sensitivity: Multiple dimensions and hierarchic structure. Behaviour research and therapy. 1998;36(1):37-51.
Moradymanesh F, MirJafari SA, Goudarzi MA, Muhammad N. Psychometric examination of the revised Anxiety Sensitivity Index (ASI-R). J Psychol. 2007; 44 (4): 426-446.
Salkovskis PM, Rimes KA, Warwick H, Clark D. The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychological medicine. 2002; 32(5): 843-853.
Davoudi I, Nargesi F, Mehrabizadeh Honarmand M, The Comparison of dysfunctional beliefs and Personality traits between teachers with and without health anxiety, Jentashapir Journal of Cellular and Molecular Biology, 2012; 3(4): 21-34.
Musche V, Bäuerle A, Steinbach J, Schweda A, Hetkamp M, Weismüller B, et al. COVID-19-related fear and health-related safety behavior in oncological patients. Frontiers in Psychology. 2020;11:1984.
Olatunji BO, Etzel EN, Tomarken AJ, Ciesielski BG, Deacon B. The effects of safety behaviors on health anxiety: An experimental investigation. Behaviour research and therapy. 2011;49(11):719-28.
Salari N, Hosseinian-Far A, Jalali R, Vaisi-Raygani A, Rasoulpoor S, Mohammadi M, et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Globalization and health. 2020;16(1):1-11.
Necho M, Tsehay M, Birkie M, Biset G, Tadesse E. Prevalence of anxiety, depression, and psychological distress among the general population during the COVID-19 pandemic: A systematic review and meta-analysis. International Journal of Social Psychiatry. 2021;67(7):892-906.
Mahmud S, Mohsin M, Dewan MN, Muyeed A. The global prevalence of depression, anxiety, stress, and insomnia among general population during COVID-19 pandemic: A systematic review and meta-analysis. Trends in Psychology. 2023;31(1):143-70.
Kavoor AR. COVID-19 in people with mental illness: challenges and vulnerabilities. Asian Journal of Psychiatry. 2020;51:102051.
D’Urso G, Magliacano A, Dell’Osso B, Lamberti H, Luciani A, Mariniello TS, et al. Effects of strict COVID-19 lockdown on patients with obsessive-compulsive disorder compared to a clinical and a nonclinical sample. European Psychiatry. 2023;66(1):e45.
Shinn AK, Viron M. Perspectives on the COVID-19 pandemic and individuals with serious mental illness. The Journal of Clinical Psychiatry. 2020;81(3):14205.
Wang Q, Xu R, Volkow ND. Increased risk of COVID‐19 infection and mortality in people with mental disorders: analysis from electronic health records in the United States. World Psychiatry. 2021;20(1):124-30.
Millan MJ, Agid Y, Brüne M, Bullmore ET, Carter CS, Clayton NS, et al. Cognitive dysfunction in psychiatric disorders: characteristics, causes and the quest for improved therapy. Nature reviews Drug discovery. 2012;11(2):141-68.
Sica C, Caudek C, Cerea S, Colpizzi I, Caruso M, Giulini P, et al. Health anxiety predicts the perceived dangerousness of covid-19 over and above intrusive illness-related thoughts, contamination symptoms, and state and trait negative affect. International Journal of Environmental Research and Public Health. 2021;18(4):1933.
Jungmann SM, Witthöft M. Health anxiety, cyberchondria, and coping in the current COVID-19 pandemic: Which factors are related to coronavirus anxiety? Journal of anxiety disorders. 2020;73:102239.

No competing interests reported.

Download PDF

Journal Publication

published 23 Apr, 2024

Read the published version in BMC Psychiatry →

Editorial decision: Revision requested
03 Jan, 2024
Reviews received at journal
03 Dec, 2023
Reviewers agreed at journal
02 Dec, 2023
Reviewers agreed at journal
22 Nov, 2023
Reviewers invited by journal
22 Nov, 2023
Editor assigned by journal
21 Nov, 2023
Editor invited by journal
07 Nov, 2023
Submission checks completed at journal
07 Nov, 2023
First submitted to journal
07 Nov, 2023

You are reading this latest preprint version

The anxiety response of patients with severe psychiatric disorders to the recent public health crisis

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusion

Introduction

Methods

Sample

Statistical analysis

Results

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1