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BRIEF REPORT
Ahead of print publication  

Psychological impact of coronavirus disease 2019 pandemic on patients with rheumatological disorders: A web-based cross-sectional multicentric survey


1 Department of Rheumatology, Manipal Hospital Whitefield, Bengaluru, Karnataka, India
2 Department of Rheumatology, Manipal hospitals, Old Airport Road, Bengaluru, Karnataka, India
3 Department of Rheumatology, Apollo BGS Hospitals, Mysuru, Karnataka, India
4 Department of Rheumatology, Columbia Asia Referral Hospital, Bengaluru, Karnataka, India
5 Department of Rheumatology and Immunology, JSS Academy of Higher Education and research, JSS Medical College, Mysuru, Karnataka, India
6 Department of Rheumatology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India
7 Department of Rheumatology, Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India
8 Department of Clinical Psychology, Manipal hospitals Old Airport Road, Bengaluru, Karnataka, India

Date of Submission04-Jul-2020
Date of Acceptance21-Jul-2020

Correspondence Address:
GC Yathish,
Department of Rheumatology, Manipal Hospital Whitefield, KR Puram Hobli, Bengaluru - 560 066, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_175_20

  Abstract 


Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in uncertainty and negative psychological outcomes for patients with autoimmune rheumatic diseases for several reasons. It is essential to understand the level of anxiety among rheumatic disease patients at the current situation of COVID-19.
Objectives and Methods: A web-based cross-sectional multicenter survey was done across 5 rheumatology centers in India. The study duration was between 9th May and May 16, 2020. The questionnaire included consent, demographic details, medication history, opinion about tele rheumatology services, and anxiety score measured by Beck Anxiety Inventory.
Results: The survey was sent to 2987 patients, there were 933 responses, and 581 were complete (male = 175). Complete responses were considered for data analysis. Rheumatoid arthritis was the most frequent (50.6%) diagnosis followed by other conditions. Most of the patients (43%) were on combination disease-modifying anti-rheumatic drug therapy, 12.7% of patients were on biological drugs, and 23.9% of patients were on glucocorticoids (GCs). Statistically significant higher anxiety scores were observed in females (8.79 ± 9.3), fibromyalgia patients (19.78 ± 14.8), patients on GCs (9.26 ± 8.8), and biological agents (10.65 ± 10.6). Difficulty in meeting rheumatologists and getting medications was expressed by 327 (56.2%) and 73 (29.7%) respondents, respectively.
Conclusion: The findings of the study revealed that anxiety is a major concern in patients with autoimmune rheumatic diseases. Fibromyalgia patients and those who were on GC and biological drugs were found to have more anxiety levels compared to other groups of patients. There is a need to intensify the awareness and address the mental health issues.

Keywords: Anxiety, autoimmune rheumatic diseases, biological drugs, COVID-19, glucocorticoids



How to cite this URL:
Yathish G C, Singh YP, Prasad S, Srinivasulu N, Kumar S, Subramanian R, Chebbi P, Jain V, Jain N, Kumar S. Psychological impact of coronavirus disease 2019 pandemic on patients with rheumatological disorders: A web-based cross-sectional multicentric survey. Indian J Rheumatol [Epub ahead of print] [cited 2020 Dec 4]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=299895




  Introduction Top


The coronavirus disease 2019 (COVID-19) pandemic may be considered “the illness that has changed the 21st century” and has become one of the central health crises of a generation. The pandemic has adversely affected all nations, races, continents, and their socioeconomic status. This has led to quarantining of entire communities, the closing of schools, social distancing, and sheltering place orders and has abruptly changed daily life.[1]

The COVID-19 outbreak has resulted in uncertainty and negative psychological outcomes for patients with rheumatic diseases for several reasons.[2] Negative psychological outcomes during contagious disease outbreaks may include loneliness, depression, anxiety, and fear.[3],[4],[5] This anxiety is predominantly acute for those with the indistinct underlying conditions that render them more vulnerable to the infection or severe complications.[6] People with rheumatic disease are expected to fall into this group because they are often immune-compromised because of their underlying diseases and the therapy used to treat them.[6]

Beyond the routine challenges of self-managing rheumatic disease, disease management has become notably more difficult with the imposition of social distancing including restricting nonessential health-care visits, impacts on treatment, and access to care. This has led to confusion about how patients with rheumatic diseases should balance managing their disease and reducing their risk of infection.[7],[8] Patients were found to be worried about being infected and developing COVID-19, whether they would survive an infection, how their medications would affect their risk, and the impact of the pandemic on access to medications and health care.[9]

It is essential to understand the level of anxiety among the rheumatic disease patients at the current situation of COVID-19.


  Objectives and Methods Top


The objectives of the study were to study the levels of anxiety in patients with rheumatological conditions and to assess the difference in anxiety score (mean/average score) among following groups: underlying rheumatic disease, age, gender, marital status, educational status, employment status, medications, those who are on glucocorticoids (GC's)/not, those who are biologicals/not.

A web-based cross-sectional multicentered study conducted from 9th May to 16th May 2020. Rheumatic disease patients across India were invited to participate in a self-administered questionnaire which was developed on an online cloud-based website (Survey Monkey®). The questionnaire included consent, demographic details, medical history, medication history, and access to rheumatologists and medication details were asked in the survey. The anxiety level was measured using the Beck Anxiety Inventory (BAI). BAI is a 21-questioned multiple-choice self-report inventory and is commonly used in psychometric tests to determine the severity of anxiety. According to the mentioned questionnaire, the level of anxiety can be divided into three levels of low, moderate, and severe.[10] The study questionnaire which includes BAI has been uploaded as supplementary file with the main article. Intellectual property checks were done to avoid duplicated responses from a single respondent. Two rheumatology consultants reviewed the questions and confirmed them to be representative of the content validity of the survey.

The survey was designed in English language and was circulated over E-mail and WhatsApp® to all participants. The study was approved by the institutional ethics committee (IEC-ECR/34/Inst/KA/2013/RR-19). The data were analyzed using SPSS version 22.0 (IBM Corp) (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp). Descriptive analyses such as mean values and numbers (percentages) were used to calculate the continuous variables and categorical variables. We utilized one-way analysis of variance for parametric data, and Kruskal–Wallis and Mann–Whitney U tests were utilized for nonparametric data as appropriate to determine statistical differences. The level of significance was set at α = 0.05.


  Results Top


The survey was sent to 2987 patients, there were 933 responses, and 581 were complete (Male = 175). Complete responses were considered for data analysis and evaluation. Most of the patients (32.9%) were at the age group of 30–40 years and 44.4% had Bachelor's degree education.

Among the respondents, rheumatoid arthritis was the most frequent diagnosis (50.6%) and other diagnoses included systemic lupus erythematosus/connective tissue disease (20.8%), spondyloarthropathy (17.6%), fibromyalgia (4.0%), and vasculitis (7.1%) [Table 1]. In medication, most of the patients (43%) were on combination disease-modifying antirheumatic drug therapy. 12.7% of patients were on biological drugs and 23.9% of patients were on GC.
Table 1: Demographics, anxiety score measurements in subgroups

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Most had mild anxiety and was seen in 522 (89.8%) respondents. Moderate and potentially concerning levels of anxiety were seen in 46 (7.9%) and 13 (2.2%) respondents, respectively. Statistically significant higher anxiety scores were observed in females, fibromyalgia, patients on GCs, and biological agents [Table 1] and [Figure 1]. There was no difference in the anxiety with regard to age, educational status, and employment status [Table 1].
Figure 1: Mean anxiety scores in various rheumatic conditions

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Difficulty in meeting treating rheumatologists and getting medications was expressed by 327 (56.2%) 73 (29.7%) respondents, respectively. Anxiety scores were found to be significantly higher (11.56 ± 10.6 vs. 6.87 ± 8.2) in those patients who had difficulty in getting medications as compared to those who had access to medications [Table 1]. Majority of respondents strongly agreed (49.4%) or agreed (37.2%) regarding use of telemedicine to access health care during the crisis.


  Discussion Top


In our study, fibromyalgia patients were observed with a high anxiety score. Although fibromyalgia does not fall into the immunosuppressed category, they had significantly higher anxiety levels. The pandemic appears to have adversely affected fibromyalgia patients as they are already known to have underlying psychological distress, including anxiety and depression.[11] The pandemic appears to have adversely affected fibromyalgia patients resulting in this increased level of anxiety.

The COVID-19 outbreak has resulted in unease in patients with rheumatic diseases due to several reasons. Having rheumatic disease itself is not known to be associated with an increased risk for developing COVID-19 or an adverse outcome from the infection. Patients with various rheumatic diseases, however, have a higher prevalence of several comorbidities such as advanced age, chronic pulmonary and kidney disease, heart disease, hypertension, obesity, and diabetes, which, in turn, are risk factors for severe illness with COVID-19.[12]

Recent data show that most individuals with rheumatic diseases or those on Immunosuppressive medications recover from COVID 19 infection. However, usage of moderate to high dose GC (>Prednisolone 10 mg/day) was associated with a higher risk of hospitalization for COVID-19.[13] In our study, patients on GCs and biological agents had significantly higher anxiety levels. The reason for higher anxiety could be due to worrying about being infected and developing COVID-19; whether they would survive an infection, and how their medications would adversely affect their outcome. Latest data, however, show that usage of biologic therapies, nonsteroidal anti-inflammatory drugs, and antimalarial drugs such as hydroxychloroquine were not associated with a higher risk of hospitalization for COVID-19.[13]

Other factors that may contribute to anxiety include fear of going to hospitals and inability to access health care during this period. In such periods of public health crises, telemedicine is a great tool for patients to access healthcare without fear of going to hospital. Switching to teleconsultation has been found to be feasible and well accepted in Indian population.[14],[15]

Although the present study has following limitations – selection bias – as patients who were only education and who could use internet were included, no matched controls, no data about patients' prior level of anxiety, and no data on underlying comorbid conditions, it clearly shows that anxiety is a major concern in patients with rheumatic diseases.


  Conclusion Top


COVID-19 outbreak has resulted in high anxiety levels in rheumatic diseases. Fibromyalgia patients and patients on GC and biological drugs were found to have higher anxiety levels. There is a need to intensify the awareness and address the mental health issues of rheumatology patients during this COVID-19 pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.  Back to cited text no. 1
    
2.
Pope J.E. What Does the COVID-19 Pandemic Mean for Rheumatology Patients?. Curr Treat Options in Rheum 2020;6: 71–74.  Back to cited text no. 2
    
3.
Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.  Back to cited text no. 3
    
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Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. Lancet Psychiatry 2020;7:300-2.  Back to cited text no. 4
    
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Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health 2020;17:E1729.  Back to cited text no. 5
    
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The Lancet Rheumatology. Unity amidst uncertainty: COVID-19 pandemic fosters collaboration in rheumatology community. Lancet Rheumatol 2020 ;2:e245.  Back to cited text no. 6
    
7.
Ferro F, Elefante E, Baldini C, Bartoloni E, Puxeddu I, Talarico R, et al. COVID-19: The new challenge for rheumatologists. Clin Exp Rheumatol. 2020;38:175-80.  Back to cited text no. 7
    
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Pires da Rosa G, Ferreira E. Therapies used in rheumatology with relevance to coronavirus disease 2019. Clin Exp Rheumatol 2020;38:370.  Back to cited text no. 8
    
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Michaud K, Wipfler K, Shaw Y, Simon TA, Cornish A, England BR, et al. Experiences of patients with rheumatic diseases in the US during early days of the COVID-19 Pandemic. ACR Open Rheumatology 2020 ;2:335-43.  Back to cited text no. 9
    
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Oh H, Park K, Yoon S, Kim Y, Lee SH, Choi YY, et al. Clinical Utility of Beck Anxiety Inventory in Clinical and Nonclinical Korean Samples. Front Psychiatry 2018;9:666.  Back to cited text no. 10
    
11.
Gormsen L, Rosenberg R, Bach FW, Jensen TS. Depression, anxiety, health-related quality of life and pain in patients with chronic fibromyalgia and neuropathic pain. Eur J Pain 2010;14:127.e1-8.  Back to cited text no. 11
    
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Nurmohamed M, Heslinga M, Kitas G. Cardiovascular comorbidity in rheumatic diseases. Nat Rev Rheumatol 2015;11:693-704.  Back to cited text no. 12
    
13.
Gianfrancesco M, Hyrich KL, Al-Adely S On behalf of the COVID-Global Rheumatology Alliance, et al. Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: Data from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis 2020;79:859-66.  Back to cited text no. 13
    
14.
Shenoy P, Ahmed S, Paul A, Skaria TG, Joby J, Alias B. Switching to teleconsultation for rheumatology in the wake of the COVID-19 pandemic: Feasibility and patient response in India. Clin Rheumatol 2020 ;39:2757-62.  Back to cited text no. 14
    
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Gupta L, Misra DP, Agarwal V, Balan S, Agarwal V. Response to: Telerheumatology in COVID-19 era: A study from a psoriatic arthritis cohort' by costa et al. Ann Rheum Dis 2020 ;0:1-2.  Back to cited text no. 15
    


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