The author’s current affiliation is Department of Psychiatry, Chungnam National University Sejong Hospital, Sejong, Republic of Korea.
Following the coronavirus disease-2019 (COVID-19) outbreak, the importance of addressing acute stress induced by psychological burdens of diseases became apparent. This study attempted to evaluate the effectiveness of a new mode of psychiatric intervention designed to target similar psychological crises.
Participants included 32 out of 114 COVID inpatients at a hospital in Daegu, Korea, who were assessed between March 30 and April 7, 2020. Multiple scales for screening psychological difficulties such as depressed mood, anxiety, insomnia, acute stress, and suicidality were done. Psychological problem evaluations and interventions were conducted in the form of consultations to alleviate participants’ psychological challenges via telepsychiatry. The interventions’ effects, as well as clinical improvements before and after the intervention, were analyzed.
As a result of screening, 21 patients were experiencing psychological difficulties beyond clinical thresholds after COVID-19 infection (screening positive group). The remaining 11 were screening negative groups. The two groups differed significantly in past psychiatric histories (p=0.034), with the former having a higher number of diagnoses. The effect of the intervention was analyzed, and clinical improvement before and after the intervention was observed. Our intervention was found to be effective in reducing the overall emotional difficulties.
This study highlighted the usefulness of new interventions required in the context of healthcare following the COVID-19 pandemic.
Korea had reported several confirmed coronavirus disease-2019 (COVID-19) cases before the World Health Organization declared the pandemic [
Emotional responses can persist as aftereffects even after the disaster situation has passed. A prior study showed that the prevalence of post-traumatic stress disorder (PTSD) increased in survivors of infectious diseases [
Patients admitted in the COVID-19 inpatient ward of the Catholic University Hospital, Daegu, between March 10 and April 7, 2020, were enrolled in the study. The quarantine ward can accommodate over 100 patients and is designed to meet the community’s medical needs (
To provide psychological support in the form of a psychiatric consultation program, two trained psychiatrists shared and standardized consulting methods and content, and provided telephone counseling. Assuming that all participants were experiencing acute stress, we included all patients except those who were unconscious, severely ill, or reluctant to participate.
The program consisted of a first interview, a psychological evaluation, and following psychiatric interviews. A psychiatrist conducted the first telephonic interview, during which future psychiatric interventions were explained to participants. Psychological evaluation was conducted through online surveys via participants’ mobile phones, to assess their condition safely and efficiently. For participants who had difficulty using mobile devices, the researchers read the survey questions over the phone and noted their answers. The basic assessment items were depression, anxiety, post-traumatic stress symptoms, insomnia, and suicidal ideation, chosen based on the common symptoms reported by those who experienced psychological disasters [
Data were collected on the following variables: age, sex, marital status, cohabitation family status, religion, education level, occupation, and type of insurance.
Data were collected on the following variables: quarantine type, quarantine period, infection route, past medical history, past psychiatric history, medication history, infectious disease level (National Early Warning Score [NEWS], presence of pneumonia on chest radiography, and oxygen supply).
Determining the degree of illness guides critical care intervention. The NEWS is based on a simple aggregate scoring system in which scores are allocated to physiological measurements and recorded in routine practice. Six simple physiological parameters form the basis of the scoring system: respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion, and temperature [
The CGI is a brief clinician-rated instrument that consists of three different global measures [
The Korean version of the PHQ-9 was used to screen depression. PHQ-9 evaluates the severity of the symptoms by summing all items’ scores [
Anxiety was measured using the GAD-7 [
PC-PTSD is used for trauma assessment in psychological disaster situations owing to its high level of diagnostic accuracy and clinical utility [
To measure sleep conditions, we used the AIS developed by Soldatos et al. [
P4 Suicidality Screener is a simple screening tool for assessing suicide risk [
SCL-90-R is a widely used questionnaire to determine several psychological symptoms [
Independent-samples t-test or the Mann-Whitney U-test were used to compare sociodemographic or clinical characteristics depending on whether the subjects were screened positive. Paired samples t-test for parametric data or the Wilcoxon signed-rank test for non-parametric data were performed to compare changes within participants before and after the program. We used IBM SPSS version 25.0 for data analyses (IBM Corp., Armonk, NY, USA). Statistical significance was defined as p<0.05.
During the intervention period, 114 (39 men, 75 women, and 58.82±19.66 years old) patients were admitted to the COVID-19 inpatient ward. Among them, 73 subjects were excluded; the exclusion criteria included cases with serious physical or neurological conditions at the time of treatment (n=62), brain damage or concussion accompanied by unconsciousness (n=10), and difficulty in understanding psychological interventions due to apparent deterioration of cognitive ability at the time of care (n=1). Cases where additional interviews were denied post the initial one, or appropriate data were not obtained due to insincere responses or unexpected early discharges, were also excluded (n=9). Finally, 32 subjects were included in the analyses (
The overall sociodemographic data of the participants are presented in
In the SP group (n=21) (5 men, 16 women, and 55.43±16.52 years old), most participants were in their 40s or older (n=18, 86%), the proportion of women (n=16, 76%) was similar to that in the total subjects, and the proportion of elderly patients in their 60s and above was higher. Sociodemographic factors, quarantine type, and medical conditions also showed similar tendencies. However, more than half (n=11, 52%) had past psychiatric histories. In the SN group (n=11) (7 men, 4 women, and 41.27±15.84 years old), most participants were in their 20s (n=4, 36%), with twice as many men as women. In terms of religion, New Heaven and Earth (n=4, 36%) had the highest number of followers, but had either mild medical histories or no medical or psychiatric histories.
Intervention effects were analyzed by comparing the sum of the pre- and post-tests, the number of tests corresponding to screening positives, CGI, and SCL-90-R results (
The novelty and contribution of this study lie in its socioenvironmental context: it focused on an intervention delivered directly by psychiatrists in a hospital setting in an area with a large-scale community outbreak of COVID-19. Based on the results, patients in the COVID-19 ward mostly comprised women in their 60s and older. Among them, many who received psychological support had mild medical conditions; for instance, even if pneumonia was detected, supportive oxygen was rarely needed. This was due to the exclusion of patients with severe physical or neurological conditions. The SP group included older women, whereas the SN group comprised a relatively younger male population. However, no statistically significant differences were found among the two groups in terms of sociodemographic variables, quarantine histories, and severity of medical conditions. However, the SP group had a higher frequency for psychiatric histories (p= 0.034). A review of the results of additional questions was conducted to assess the possibility of deterioration of underlying symptoms due to decreased access to psychiatric treatment during quarantine. A total of 12 participants reported previous psychiatric history, which largely comprised depression (n=5, 16.1%) and anxiety (n=3, 9.7%), while others had sleep disorders, alcohol use disorders, and other mental disorders. Approximately 50% were on medication for psychiatric treatment immediately before the COVID-19 outbreak; but all of them had maintained themselves during quarantine. In the COVID-19 era, it is assumed that individuals with psychiatric histories may be more vulnerable to emotional stress, as opposed to the deterioration of psychiatric symptoms due to limited therapeutic accessibility. This trend has also been shown in several relevant studies: patients with a severe mental illness had only slightly higher risks for severe clinical outcomes of COVID-19, than patients without psychiatric histories [
In terms of the effect of the psychiatric intervention, all participants from the SP group showed significant clinical improvements, but none from the SN group demonstrated any significant changes. However, all participants reported statistically significant reductions in the sum of the PC-PTSD-5; the SP group showed a significant reduction in positive scores and scores from the SCL-90-R in GSI, PSDI, and depression scale. The CGI-S pre- and post-assessment scores for all participants ranged from 2.25 to 1.53, meaning that, on average, participants went from “borderline mentally ill” to “normal, not at all ill.” The mean CGI-I value was 3.25, which is equivalent to “minimally improved.” The pre- and post- CGI-S value in the SP group was 2.71 and 1.76, respectively, indicating that, on average, there was a decrease to “mildly ill” from “borderline mentally ill.” The mean CGI-I value in the SP group was 3.00, corresponding to “minimally improved.” For the SN group, the pre- and post- CGI-S values were 1.36 and 1.09, respectively, which did not differ significantly.
Overall, the PC-PTSD-5 decline is believed to be based on the adaptations needed to reduce immediate acute stress. The program was effective in improving participants’ normal adaptation response to acute stress and preventing them from experiencing chronic aftereffects. An example of this acute intervention is psychological first aid (PFA) [
For the SP group, which displayed high levels of psychological difficulties, there was a clinical need to target relatively diverse illnesses such as depression, anxiety, and insomnia; however, the number of screening positives decreased after the intervention. This means that experiences of more severe symptoms of certain illnesses were reduced, which is also supported by the GSI reduction in SCL-90-R. Essentially, this primary intervention reduced the severity of clinical problems, while simultaneously reducing stress (as implied by the change in SCL-90-R PSDI value). The PSDI is a measure of participants’ response styles, reflecting overestimation or underestimation of symptoms [
This study has some limitations. Firstly, interviews and evaluations with psychiatrists were largely conducted without face-to-face contact to prevent the risk of infection. This limits the practice of using tools that allow doctors to observe and evaluate patients directly. Further, the effectivity of nonpersonal/non-contact interviews for forming therapeutic alliances (as compared to conventional interview techniques) is yet to be determined [
Secondly, there may be a possibility of selection bias, as the study was conducted with inpatient ward patients of the hospital. Not all confirmed cases are admitted to hospitals, and in the case of usual or minor symptoms, many self-quarantine in their homes or community centers. According to data released in April 2020 by the Korean government, the confirmed cases were 69.6% of the total in their 20s to 50s. In particular, 27.4% in their 20s showed a higher percentage than other age groups [
The data that support the findings of this study are available from Daegu Catholic University Hospital but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available.
The authors have no potential conflicts of interest to disclose.
Conceptualization: Geun Hui Won, Tae Young Choi. Data curation: Hye Jeong Lee, Jong Hun Lee, Hyo-Lim Hong, Chi Young Jung. Formal analysis: Geun Hui Won, Hye Jeong Lee. Funding acquisition: Tae Young Choi. Investigation: Jong Hun Lee, Hyo-Lim Hong, Chi Young Jung. Methodology: Geun Hui Won, Jong Hun Lee, Tae Young Choi. Supervision: Jong Hun Lee, Tae Young Choi. Writing—original draft: Geun Hui Won, Hye Jeong Lee. Writing—review & editing: Geun Hui Won, Tae Young Choi, Hyo-Lim Hong, Chi Young Jung.
This study was funded by a research grant from Daegu Medical Association COVID-19 scientific committee.
COVID-19 inpatient ward diagram. COVID-19, coronavirus disease-2019.
Process of the psychiatric consultation program. CGI, Clinical Global Impression; PHQ-9, Patient Health Questionnaire-9; GAD-7, 7-item Generalized Anxiety Disorder Scale; PC-PTSD-5, Primary Care PTSD Screen for DSM-5; AIS, Athens Insomnia Scale; SCL-90-R, Symptom Checklist-90-Revised; SP, screening positive.
Flow diagram of the psychiatric consultation program for the COVID-19 inpatient ward. COVID-19, coronavirus disease-2019.
Sociodemographic and clinical characteristics of the participants
Total (N=32) | SP group (N=21) | SN group (N=11) | p | ||
---|---|---|---|---|---|
Age | 0.061 | ||||
20–29 yr | 7 (22) | 3 (14) | 4 (36) | ||
30–39 yr | 2 (6) | 0 (0) | 2 (18) | ||
40–49 yr | 6 (19) | 5 (24) | 1 (9) | ||
50–59 yr | 5 (16) | 3 (14) | 2 (18) | ||
≥60 yr | 12 (38) | 10 (48) | 2 (18) | ||
Sex | 0.067 | ||||
Men | 12 (38) | 5 (24) | 7 (64) | ||
Women | 20 (62) | 16 (76) | 4 (36) | ||
Marital status | 0.969 | ||||
Married | 19 (59) | 13 (62) | 6 (55) | ||
Unmarried | 9 (28) | 4 (19) | 5 (45) | ||
Divorced | 3 (9) | 3 (14) | 0 (0) | ||
Separated | 1 (3) | 1 (5) | 0 (0) | ||
Religion | 0.938 | ||||
Christianity | 9 (28) | 6 (29) | 3 (27) | ||
Catholicism | 6 (19) | 4 (19) | 2 (18) | ||
Buddhism | 4 (13) | 3 (14) | 1 (9) | ||
New Heaven and Earth | 9 (28) | 5 (24) | 4 (36) | ||
No religion | 4 (13) | 3 (14%) | 1 (9%) | ||
Education | 0.531 | ||||
No | 1 (3) | 1 (5) | 0 (0) | ||
≤9 yr | 7 (22) | 6 (29) | 1 (9) | ||
≤12 yr | 12 (37) | 6 (29) | 6 (55) | ||
>12 yr | 12 (38) | 8 (38) | 4 (36) | ||
Occupation | 0.938 | ||||
Yes | 24 (75) | 17 (81) | 7 (64) | ||
No | 8 (25) | 4 (19) | 4 (36) | ||
Insurance | 0.907 | ||||
Health insurance | 21 (66) | 14 (67) | 7 (64) | ||
Medical benefit | 11 (34) | 7 (33) | 4 (36) | ||
Quarantine space | 0.696 | ||||
Single room | 4 (13) | 2 (10) | 2 (18) | ||
Shared room | 28 (87) | 19 (90) | 9 (82) | ||
Quarantine period | 0.639 | ||||
≤7 days | 2 (6) | 1 (5) | 1 (9) | ||
8–14 days | 17 (53) | 11 (52) | 6 (55) | ||
15–27 days | 12 (38) | 8 (38) | 4 (36) | ||
≥28 days | 1 (3) | 1 (5) | 0 (0) | ||
Infection route | |||||
Family | 5 (16) | 3 (14) | 2 (18) | 0.815 | |
Neighborhood | 3 (9) | 2 (10) | 1 (9) | ||
Workplace | 2 (6) | 2 (10) | 0 (0) | ||
Medical institution | 3 (9) | 2 (10) | 1 (9) | ||
Religious activities | 6 (19) | 4 (19) | 2 (18) | ||
Unknown | 13 (41) | 8 (38) | 5 (46) | ||
Past medical history | 0.168 | ||||
Yes | 18 (56) | 14 (67) | 4 (36) | ||
No | 14 (44) | 7 (33) | 7 (64) | ||
Past psychiatric history | 0.034 |
||||
Yes | 12 (37) | 11 (52) | 1 (9) | ||
No | 20 (63) | 10 (48) | 10 (91) | ||
NEWS | 0.389 | ||||
Mild | 28 (88) | 17 (81) | 11 (100) | ||
Moderate | 3 (9) | 3 (14) | 0 (0) | ||
Severe | 1 (3) | 1 (5) | 0 (0) | ||
Pneumonia | 0.506 | ||||
Yes | 24 (75) | 17 (81) | 7 (64) | ||
No | 8 (25) | 4 (19) | 4 (36) | ||
Oxygen supply | 0.815 | ||||
Yes | 4 (13) | 3 (14) | 1 (9) | ||
No | 28 (87) | 18 (86) | 10 (91) | ||
Medication for COVID | |||||
Yes | 32 (100) | 21 (100) | 11 (100) | ||
No | 0 (0) | 0 (0) | 0 (0) |
Values are presented as number (%).
p<0.05.
NEWS, National Early Warning Score; SP, Screening positive; SN, Screening negative; COVID-19, coronavirus disease-2019
Psychopathological scale scores of the participants before and after the program
Pre | Post | p | |||
---|---|---|---|---|---|
Total participants | |||||
PHQ-9 | 6.38 (5.80) | 3.37 (3.59) | 0.187 | ||
GAD-7 | 4.38 (5.46) | 1.42 (1.87) | 0.590 | ||
PC-PTSD-5 | 1.22 (1.66) | 0.21 (0.54) | 0.041 |
||
AIS | 7.06 (5.69) | 4.68 (4.81) | 0.080 | ||
P4 screener | 0.22 (0.42) | 0.00 (0.00) | 0.083 | ||
Number of scale (+) | 1.05 (1.13) | 0.68 (1.06) | 0.069 | ||
CGI | |||||
CGI-S | 2.25 (1.24) | 1.53 (0.88) | <0.001 |
||
CGI-I | 3.25 (0.92) | ||||
SP group | |||||
PHQ-9 | 8.86 (5.66) | 5.30 (3.86) | 0.437 | ||
GAD-7 | 6.43 (5.72) | 2.20 (2.10) | 0.458 | ||
PC-PTSD-5 | 1.76 (1.81) | 0.30 (0.67) | 0.066 | ||
AIS | 9.95 (4.87) | 7.10 (4.70) | 0.106 | ||
P4 screener | 0.33 (0.48) | 0.47 (0.51) | 0.083 | ||
Number of scale (+) | 2.71 (1.35) | 1.20 (1.23) | 0.022 |
||
CGI | |||||
CGI-S | 2.71 (1.27) | 1.76 (1.00) | 0.001 |
||
CGI-I | 3.00 (1.00) | ||||
SCL-90-R | |||||
GSI | 48.88 (10.44) | 44.00 (3.85) | 0.026 |
||
PST | 46.50 (10.60) | 42.67 (2.94) | 0.197 | ||
PSDI | 55.13 (10.74) | 51.17 (5.95) | 0.046 |
||
Somatization | 47.88 (9.62) | 46.50 (6.69) | 0.317 | ||
OC | 48.88 (7.38) | 44.50 (3.99) | 0.176 | ||
IS | 46.63 (11.28) | 39.67 (8.64) | 0.500 | ||
DEP | 50.38 (12.95) | 41.00 (5.83) | 0.042 |
||
ANX | 48.94 (10.70) | 43.33 (7.03) | 0.144 | ||
HOS | 43.19 (10.06) | 37.50 (4.97) | 0.357 | ||
PHOB | 47.50 (9.32) | 47.33 (4.23) | 0.893 | ||
PAR | 47.25 (9.83) | 44.00 (4.10) | >0.999 | ||
PSY | 49.50 (6.95) | 44.17 (5.42) | 0.223 | ||
ADD | 55.88 (10.70) | 51.50 (8.17) | 0.080 | ||
SN group | |||||
PHQ-9 | 1.64 (1.57) | 1.22 (1.56) | 0.242 | ||
GAD-7 | 0.45 (1.04) | 0.56 (1.13) | >0.999 | ||
PC-PTSD-5 | 0.18 (0.40) | 0.11 (0.33) | 0.317 | ||
AIS | 1.55 (1.37) | 2.00 (3.43) | 0.439 | ||
P4 screener | 0.00 (0.00) | 0.10 (0.32) | >0.999 | ||
Number of scale (+) | 0.00 (0.00) | 0.11 (0.33) | 0.317 | ||
CGI | |||||
CGI-S | 1.36 (0.50) | 1.09 (0.30) | 0.083 | ||
CGI-I | 3.73 (0.47) |
Values are presented as mean (standard deviation).
p<0.05;
p<0.001.
PHQ-9, Patient Health Questionnaire-9; GAD-7, 7-item Generalized Anxiety Disorder Scale; PC-PTSD-5, Primary Care PTSD Screen for DSM-5; AIS, Athens Insomnia Scale; CGI, Clinical Global Impression; CGI-S, CGI severity; CGI-I, CGI improvement; SCL-90-R, Symptom Checklist-90-Revised; SP, screening positive; SN, screening negative; GSI, Global Severity Index; PST, positive symptom total; PSDI, Positive Symptom Distress Index; OC, obsessive-compulsive; IS, interpersonal sensitivity; DEP, depression; ANX, anxiety; HOS, hostility; PHOB, phobic anxiety; PAR, paranoid ideation; PSY, psychoticism; ADD, additional symptoms