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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 62-68

“Psychological consequences and coping strategies of patients undergoing treatment for COVID-19 at a tertiary care hospital”: A qualitative study


Department of Psychiatry, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India

Date of Submission18-Jan-2021
Date of Decision01-Mar-2021
Date of Acceptance07-Mar-2021
Date of Web Publication28-May-2021

Correspondence Address:
Manjiri Chaitanya Datar
Bharati Vidyapeeth Medical College, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/shb.shb_5_21

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  Abstract 


Introduction: Coronavirus disease-2019 (COVID-19) pandemic is a global threat and has affected physical as well as mental health adversely. There had been an exponential rise in COVID-19 cases in India from May to October 2020. Isolation, hospitalization, and stigmatization were significant issues in COVID-19 crisis. The literature is sparse on the mental health effects on hospitalized COVID-19 patients. This study aimed to describe the psychological consequences and coping strategies of COVID-19 patients admitted to tertiary health-care hospital. The objectives were (1) to assess the psychological consequences in COVID-19 patients admitted to our hospital, (2) to assess the coping strategies in these COVID-19 patients, and (3) to find correlations of sociodemographic characteristics, psychological consequences, and coping strategies of these COVID-19 patients. Methods: In this cross-sectional qualitative study, 100 patients hospitalized for COVID-19 infection participated. In-depth interviews were conducted using semi-structured questionnaire. The narratives were coded into themes and correlations of variables generated were done using Chi-square test. Results: The most common themes about the psychological state of patients were loneliness and isolation (56%), adjustment issues in the hospital (54%), and concerns about family members (32%). Patients who had family members also suffering from COVID-19 illness (24%) had more concerns about their health (Chi-square 25.209, P = 0.00) and had worries of their future (Chi-square 7.023, P = 0.008). Females had more worries about family members (Chi-square 16.295, P = 0.00) and had more concerns about their own health (Chi-square 5.71, P = 0.01). The most common coping strategies used by patients were digital communication with family members (82%), distraction (58%), and communicating with other co-patients (30%) to deal with their psychological distress. Conclusion: COVID-19 infection leads to psychological distress due to multiple factors. Timely interventions with support for effective coping mechanisms can help in alleviating the distress.

Keywords: Coping, coronavirus disease 2019 patients, psychological consequences


How to cite this article:
Patil ST, Datar MC, Shetty JV, Naphade NM. “Psychological consequences and coping strategies of patients undergoing treatment for COVID-19 at a tertiary care hospital”: A qualitative study. Asian J Soc Health Behav 2021;4:62-8

How to cite this URL:
Patil ST, Datar MC, Shetty JV, Naphade NM. “Psychological consequences and coping strategies of patients undergoing treatment for COVID-19 at a tertiary care hospital”: A qualitative study. Asian J Soc Health Behav [serial online] 2021 [cited 2021 Jul 27];4:62-8. Available from: http://www.healthandbehavior.com/text.asp?2021/4/2/62/317106




  Introduction Top


Pandemics of various infectious diseases with millions dying have been recorded in history for the past several centuries.[1] The novel coronavirus disease-2019 (COVID-19) outbreak was declared a public health emergency of international concern by the World Health Organization (WHO) on January 30, 2020. Believed to have originated from a seafood wholesale market in the city of Wuhan of Hubei Province in late December 2019, the number of cases increased exponentially within and beyond Wuhan, spreading widely across the world.[2] Globally, as of November 15, 2020, 53.7 million confirmed cases and 1.3 million deaths have been reported to the WHO.[3] COVID-19 is considered as one of the highly virulent illnesses. COVID-19 symptoms range from mild flu symptoms to severe pneumonia, acute respiratory distress syndrome, and death.[4] It has shaken the entire world and created global panic and has significant and variable psychological impacts in each country.

The psychological problems include fear of getting COVID-19 infection in the general population to frank anxiety and depressive symptoms.[5] The emerging mental health issues related to the COVID-19 pandemic may develop into long-lasting health problems, isolation, and stigma.[6] The stressors of COVID-19 patients noted were the disease itself, the treatment regimens in quarantine, and concerns regarding family health, resulting in changes in mood, diet, sleep, and behavior.[7] The emotional experience of patients during the early stages of the disease included anger, anxiety, and concern. Quarantine also led to loneliness, anxiety, helplessness, and depression, consistent with previous reports of other epidemic diseases.[8] On the contrary, some studies also demonstrate the positive experience and growth brought by the collective anti-epidemic efforts.[9]

A mixed-method study by Guo et al. evaluated and compared the mental status and inflammatory markers among 103 patients who tested positive with COVID-19 and recruited 103 matched controls who were COVID-19 negative. This study revealed that COVID-19 patients had higher levels of depression (P < 0.001), anxiety (P < 0.001), and posttraumatic stress symptoms (P < 0.001) compared to non-COVID-19 controls.[10]

In India, cases soared up after lockdown was lifted after May 2020. Maharashtra state in India alone recorded 19,063 cases till May 9, 2020, which was highest among all the states in India. From March 14, 2020, to July 31, 2020, out of 736 districts, six metropolitan cities (Pune, Mumbai, Chennai, Thane, Bengaluru, and Hyderabad) emerged as the major hotspots in India, containing around 30% of confirmed total COVID-19 cases in the country.[11]

In a study by Sahoo et al. in India on patients admitted to hospital with COVID-19 infection, when asked about their initial emotional reaction to the information about their COVID-19-positive status, a majority reported going through multiple negative emotional states, with the most common emotional states being that of shock (72%), along with feelings of sadness (60%), panic/anxiety (68%), and disbelief (54.0%). The authors reported that high levels of anxiety could be due to various factors such as staying alone, fear of death, feeling of not been cared for, adjustment to a new environment, fear, and apprehension about health and deterioration of physical health, following the news update with respect to the COVID-19, worries related to the development of infection in family members and friends, fear of the unknown, fear of death, coming to known about the health status of other family members, and seeing other patients being shifted to the ICU.[12]

Pune district located in central Maharashtra, India, has been worst affected across the country with a rapid surge in active cases. From July 2020 to October 2020 the active cases in the district increased from 56,416 to 3, 20, 112 and death toll increased from 1442 to 7733.[13],[14] The public and private sectors were roped into the emergency situation due to the urgent requirement of outpatient and inpatient hospital services to rapidly surging number of patients with spread of infection after the lockdown.

Our hospital is a private charitable hospital in Pune city, India. It was declared a dedicated COVID-19 hospital by the city corporation and witnessed a high turnover of patients from as well as outside Pune district. All health-care workers including multispecialty doctors, nurses, and supporting professionals were allotted duties for efficient management of COVID-19 patients.

Considering the vulnerability of COVID-19-diagnosed patients admitted in the hospital to psychological symptoms, a psychological support system network was developed in our hospital for detection of any mental distress or other psychological symptoms for immediate delivery of any interventions as required. The team included physicians, intensivists, pulmonologists, psychiatrists, psychologists, and social workers. The current study was planned as a part of detection and assessment of any psychological distress and to note the psychological reactions in all patients admitted with COVID-19 during the mentioned study duration.

Considering the fact that COVID-19 illness is not only an individual medical illness but has multiple psychosocial hazards due to infectivity, involvement of family members, isolation, and stigma, it is essential to study the psychological consequences as well as disease-specific coping techniques in patients suffering from COVID-19. The literature is sparse on the psychological consequences of COVID-19, as it is a newly emergent epidemic in 2020. Hence, a qualitative approach was chosen to explore various psychological consequences and coping techniques of patients wherein open-ended interviewing technique was used using phenomenology design. The study findings can help in developing various specific quantitative psychological assessments of COVID-19 patients in future.

The aim of the study was to describe the psychological consequences and coping strategies of patients undergoing treatment for COVID-19 at a tertiary care hospital. The objectives were (1) to assess the psychological consequences in COVID-19 patients admitted to our hospital, (2) to assess the coping strategies in these COVID-19 patients, and (3) to find correlations of sociodemographic characteristics, psychological consequences, and coping strategies of these COVID-19 patients.


  Methods Top


Design

This was a qualitative study. The qualitative study design was phenomenology based on Polit and Beck model in which subjective experience of individuals is explored.[15]

Study setting and participants

Our hospital investigated patients with clinical symptoms and their contacts with RT-PCR test. The patients who had clinical symptoms and COVID-19 antigen was detected on RT-PCR test (COVID-19 positive) were admitted for management. The patients depending on the severity of illness, oxygen requirement, and comorbidities were admitted in general wards, high-dependency unit, and intensive care unit (ICU). There would be on an average 15–20 admissions per day in COVID-19 sections, with bed occupancy of approximately 250–300 beds per month from July to October 2020 when the city witnessed a peak of COVID-19 cases.

Participants were selected from general wards, high-dependency units, and ICUs. The inclusion criteria were (1) COVID-19-positive patients above 18 years of age, who were admitted in our hospital, during the course of COVID-19 duties of the author, (2) who were medically stable as evaluated by their primary physicians, and (3) consenting for in-depth interviews. Patients were initially asked about prior history of psychiatric illness or treatment. The patients with a past history of psychiatric illness and who were not cooperative for the interview were excluded.

Sampling

The sampling technique was convenient sampling during the COVID-19 unit duties of the first author. The patients fulfilling the inclusion criteria and admitted during the period of July–October 2020 in the hospital units were selected. The recruitment of patients was stopped after interviews of 100 patients when there was sample saturation and no additional themes were generated.

Data collection

The first author in the course of COVID-19 hospital unit duties conducted the interviews of patients. Adequate personal protective equipment and distancing were maintained as per the guidelines in the hospital. The phenomenological qualitative study design was followed.[16] In-depth interviews were conducted using a semistructured open-ended questionnaire which was used as an interview guide. The semi-structured questions were developed by expert opinion and consensus of the authors who are specialized and experienced in the field of psychological medicine.

The questionnaire included patient's sociodemographic details, severity of COVID-19 illness, family structure, and presence of COVID-19 illness in the family which were asked to patients and their primary treating physicians. The following semi-structured open-ended questions were asked:

  • What was your psychological state and perception about COVID-19 before you becamepositive?
  • What were your immediate psychological reactions after admission?
  • What is your current psychological state?
  • How are you coping with the psychological distress and your stay in hospital?


The interviews were conducted in a quiet setting where privacy and confidentiality were ensured. It was also ensured that rapport was well established with patients and they were interviewed with an empathetic and nonjudgmental approach. The interviews were conducted for an approximate period of 30–45 min. The patients were interviewed only once. All the interviews were transcribed.

Data analysis of qualitative data

The transcribed narratives of each patient were analyzed by all authors and common themes were generated with consensus from all authors. The format of thematic analysis of the transcript was followed. The data was familiarized, themes were derived and reviewed. Data triangulation was done with interpretation individually and then in group by all authors till common themes were generated.[17],[18] The themes were then coded for the analysis.

Trustworthiness of data

We adopted strategies of credibility, transferability, dependability, and confirmability to ensure the trustworthiness of data.[19] We followed the COREQ checklist for conducting and reporting qualitative research.[20]

Ethical consideration

The study was approved by the institutional ethics committee prior to the initiation of the study (Ref–BVDUMC/IEC/18 dated June 24, 2020). The participants were explained about the nature of the study and informed consent was obtained from all participants before initiation of data collection. They were explained that they were free to suspend or withdraw from the interview if they were uncomfortable or it was negatively affecting their emotional state.

Statistical analysis

Frequency and percentages were calculated for quantitative variables. Qualitative data were analyzed using Chi-square test for comparison of coded variables.


  Results Top


[Table 1] shows the sociodemographic structure of the sample of patients included in the study and the nature and severity of COVID-19 illness and treatment given to patients. About 74% of the patients had mild illness, 22% of the patients needed oxygen support, and 4% of the patients needed intensive care monitoring with oxygen support.
Table 1: Sociodemographic and coronavirus disease-2019 clinical details (n=100)

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The patients were initially asked about their psychological state and perception of COVID-19 before the diagnosis. Nearly 35% were concerned about family members' health. This was evident, especially about the elderly and children. About 24% were worried about their age and comorbidity as a risk factor for causing COVID-19 infection. About 34% were apprehensive of contracting COVID-19 sometime. Nearly 49% reported that they had adequate knowledge of the precautions to be taken and were following them. Nearly 7% were not completely aware of the precautions to be taken and did not consider COVID-19 to be a major illness.

The patients were then asked about their psychological reactions on being diagnosed and advised admission. Almost 77% reported that they were anxious, apprehensive, and worried after being diagnosed with COVID-19. About 47% were concerned about family members and 18% were distressed due to sudden changes in their schedule, roles, and responsibilities. A 36-year-old software engineer reported, “I can't believe I have COVID-19 as I was taking all precautions and not going out of the house. I am shocked and feeling worried and tensed. I am worried of how my wife will manage home and kid when I am in hospital now. I don't know how I will be able to complete my job commitments.”

The patients were then asked to narrate the current psychological state which they are experiencing during their hospital stay. [Table 2] depicts the prominent themes in the narratives of patients.
Table 2: Themes about psychological state of Covid patients

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Concern about family members

About 32% of the patients reported worries about their family members. The theme was statistically significant in female patients (17 [60%] as compared to male patients (15 [20%] Chi-square: 16.295, P = 0.000).

A 32-year-old female, homemaker, with all family members suffering from COVID-19 reported, “I am not much worried about myself. But my father in law and mother in law are old and admitted in another hospital and I don't know about their health condition and I am worried a lot about any deterioration in their health. I am concerned about my husband in home quarantine about how he could be managing and monitoring them and home activities as well.”

Concern about one's own health

The theme was significantly found in patients who had moderate-to-severe illness and needed oxygen support (76%) as compared to mild illness (19.4%) (Chi-square value: 44.437, P = 0.00). About 44% of the females were concerned about their own health as compared to 26% of males (Chi-square value: 5.710, P = 0.017). About 67% of the patients' whose family members were COVID-19 negative 34% had acceptance toward the disease (P = 0.017, Chi-square: 5.748a) [Table 3].
Table 3: Correlation of patient psychological state with coronavirus disease-2019 status of family members

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A 72-year-old male, diabetic and hypertensive, admitted in the ICU reported, “Will I be okay and get discharged, I want to go home and stay with my family members. It is very frightening because of my age and health issues, I am feeling tensed about my health, this is new and scary. Every day I get thoughts that will I ever become okay and recover completely.”

A 67-year-old male admitted in the high-dependency unit on oxygen support reported, “I'm old and not very educated; I don't understand what treatment is going on. I don't think I'm getting better; I still feel very weak and breathless. Whenever they try to stop oxygen my condition becomes worse and now, I'm very much concerned if I can manage without oxygen in future.”

A 59-year-old female narrated, “Already my family members are positive, some are admitted, and some are home quarantined, now even I'm positive, I am not sure when will I get better again. Since yesterday my sugars are also high. This COVID-19 is taking a toll on my health. What if my sugars will continue to remain high even in future? How and when will I get better?”

Adjustment issues with the hospital

About 54% of the patients had adjustment problems in the hospital. These included distresses due to not being able to be with family members, problems about eating hospital food, doubts in treatment, being confined in the space, and inability to do daily chores were prominent among them.

Loneliness and isolation

About 56% of the patients felt lonely and isolated. The theme was significantly seen in patients above 40 years of age (46 patients – 64%) as compared to younger patients (10 patients – 34%) (Chi-square value: 7.675, P = 0.006). A 54-year-old male reported, “I feel so alone and low, there is no one to talk to. I am surrounded by all patients who are occupied with their own problems; it is lonely and sad here. I wish to go home as soon as possible.”

Calm and composed

Nearly 29% of the patients had acceptance about the disease and had a positive outlook, of which 35% were male patients and 11% were female patients. The patients' whose family members were COVID-19 negative 34% had acceptance toward the disease (P = 0.017, Chi-square: 5.748a) [Table 3].

A 58-year-old male in the ward on oxygen support reported, “I own a shop that comes under essential services, so I had to work all through lockdown. As the case numbers started increasing, somewhere I also started feeling that everyone is going to be positive and anyway most of the people are recovering well. Even after taking all precautions I became positive but I'm confident I'll be recovering soon.”

Worries about future

The theme was reported by 19% of the patients. It was significantly found in patients whose family members were also suffering from COVID-19 (P = 0.0008, Chi-square 7.023) [Table 3]. A 34-year-old patient admitted in the ward reported, “I lost my job in lockdown. We 4 family members are ill. Now I am worried how I will manage finances and whether I will get any work in future as I have COVID-19.”

[Table 4] depicts the coping strategies used by the patients during their hospital admission stay coded into themes from their narratives.
Table 4: Themes about coping strategies of Covid patients

Click here to view


Communication with family/friends

Almost 82% of the total patients were coping by talking to their friends and family telephonically and through exchange of messages.

A 30-year-old male admitted in the ward reported that “I feel very lonely and sad here, sometimes I get scared too. But I talk to my family and friends every time I feel so and feel better and relieved. They assure me that everything will be okay and I will be better soon.”

A 42-year-old female admitted in the ward reported, “I thank technology every day because even after being alone here I can talk to my family and children every time. I feel connected to home even if I am here.”

Spirituality

Nearly 24% of patients indulged in chores of praying, listening to devotional songs, and chanting. This was significant in older age group patients. Out of these, 40% were female patients and 18% were male patients (Chi-square value: 5.683 P = 0.017).

A 64-year-old male patient on oxygen support reported, “I'm old now, I know I have to die one day, but I don't want to die in a hospital that is why I pray every day. I believe in Ganapati Bappa, he will make everything okay, and I will go home and meet my family members. Anyway, those who are good to others, God always does good to them.”

Distractions

About 58% of the patients were coping by distracting themselves, out of which 40% were female and 64% were male (Chi-square value: 4.523, P = 0.033). They would watch movies through the phone, listening to music, play games, and watch TV etc.

A 25-year-old male who was a student reported, “I feel bored and do not have anything to do. I feel sad and irritable. I try to divert my attention by watching movies on my phone or watch TV. I pass my day engaging in these activities and don't think about my illness and isolation.”

Sharing with co-patients

About 30% of patients were spending their time by talking to other patients in the ward, of which 55% were female and 20% were male (Chi-square value: 11.5038, P = 0.001).

A 38-year-old female, teacher, admitted to the ward reported, “The first 2 days I was very alone, I did not know how things were working and I would be constantly worried the entire day. But afterwards, I made friends with other patients here and now most of the time is spent talking to them and I feel much better knowing they are in the same situation as me.”

Venting out

Venting out anger and frustration was seen in 12% of the patients, of these 12% and 14% were female and 10.9% were male (Chi-square value: 0.278, P = 0.598). They reported feeling irritable for being confined to the hospital or reported unhappiness about treatment.

Correlations of psychological status with the coping techniques used

The patients who were calm and composed and who were frequently worried about future significantly used the coping technique of communication with the family members. The patients who reported themes of worries about family members, concerns about their own health, and reported loneliness coped by spirituality. Distraction techniques were significantly used by patients, who had worries about their health and future and also by patients who reported to be calm with acceptance of illness. Those patients who reported worries about family members and loneliness coped significantly by sharing with co-patients. The patients who coped with venting anger and frustration significantly had more adjustment problems with the hospital and worries about future [Table 5].
Table 5: Correlation of coping themes with psychological state of Covid patients

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  Discussion Top


COVID-19 pandemic evoked a wide range of psychological reactions in admitted patients. The initial reactions were related to anxiety and panic with acute stress reactions on knowing the diagnosis. The concern about their medical condition was evident in most of the patients, however, many patients reported worries about family members which was a common theme derived from their narratives. COVID-19 illness medical and psychological symptoms concur in family members as a unit. Worrying about loved ones in ill patients was most evident due to its infectivity and stigmatization and isolation consequences. Multiple family members having the illness added to worries about health and loneliness, as not all of them were admitted or quarantined in the same place. Admissions were mainly dependent on the availability of beds and severity of the patients' symptoms, thus resulting in all the family members at different places, not being able to communicate adequately and meet each other for at least a month. The findings concurred with the study by Sahoo et al., 2020.[12]

Adding to these were the financial constraints, unemployment due to lockdown, and additional expenditure on health which seemed to take a toll on patients' mental health as concurred by studies.[21] The restrictions of family members and support persons to physically be present with patients added to feelings of loneliness and isolation. Prolonged isolation and restriction of movements can affect the mental well-being, as reported by studies.[22],[23]

The use of coping strategies also affects individuals' psychological adjustment and resilience. A study on COVID-19 patients noted that perceived social support and use of adaptive coping strategies were found to be negatively associated with anxiety and depression symptoms.[24]

Coping with stress and managing one's own health in the hospital were the challenges as quarantine did not allow caretakers or visitors. Telephonic communication with family members, sharing with co-patients, and spiritual techniques were significantly used by patients to allay distress, although communicating through the digital medium posed a challenge for the elderly, as did staying alone and managing their chores, especially people with comorbidities. Similar findings were reported by Banerjee, 2020.[25]

It is important to encourage adaptive coping responses in patients such as self-care which includes adequate rest, spending time with loved ones, recreational activities within official advisory limits, or upskilling, which can be done online as recommended by a study.[26] Inculcating adaptive coping strategies training may allay the psychological distress to a major extent.[27] Relevantly, a variety of mental health supporting strategies are required in pandemic areas to facilitate lifestyle changes and re-adaptation activities required after the occurrence of invalidating outbreaks.[28]

Limitations

This was a qualitative study; hence, a formal diagnosis of psychological condition was not done. Data collection was done only during the course of COVID-19 duties of the authors which may lead to bias.


  Conclusion Top


COVID-19 patients admitted in the ward had psychological distress related to multiple factors. Communication by digital media, spirituality, and distraction techniques were majorly used by them to cope with their distress.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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