ACHAIKI IATRIKI | 2022; 41(2):73–78
Original research article
Katerina Karaivazoglou1, Georgia Konstantopoulou1, Maria Kalogeropoulou1, Theoni Lourida2, Theodora Kafentzi2, Georgia Diamantopoulou2, Georgios Theocharis2, Konstantinos Assimakopoulos1, Konstantinos Thomopoulos2, Christos Triantos2
1Department of Psychiatry, University General Hospital of Patras, Rio, Patras, Greece
2Division of Gastroenterology, Department of Internal Medicine, University General Hospital of Patras, Rio, Patras, Greece
Received: 28 Apr 2022; Accepted: 07 Jun 2022
Corresponding author: Katerina Karaivazoglou, Department of Psychiatry, University General Hospital of Patras, Rio, Tel.: +30 6977711259 , E-mail: karaivaz@hotmail.com
Key words: IBD, psychological functioning, COVID-19 lockdown
Abstract
Background: The COVID-19 outburst and the following lockdown had a drastic effect on the Greek general population’s mental health and especially in chronic disease patients. The aim of the current study was to assess the psychological burden of inflammatory bowel disease (IBD) patients during the first COVID-19 lockdown in Greece.
Methods: IBD outpatients of the Division of Gastroenterology of the University General Hospital of Patras were enrolled to the study. Participants were administered the Hospital Anxiety and Depression Scale at two time points, before and during the lockdown, and the Impact of Event Scale-Revised and the Short-Form-36 Health Survey at one time point, during the lockdown.
Results: Twenty-two (22) patients entered the study, 15 (68.2%) females with a mean age of 43.2 years old (SD:12.5). Eleven (11) patients were diagnosed with ulcerative colitis and 11 with Crohn’s disease. During the lockdown, 30% of participants reported clinically significant anxiety symptoms, 50% reported clinically significant depression symptoms and 59.1% reported clinically significant post-traumatic stress symptoms. During the lockdown, we observed a significant rise in depression symptoms in the whole sample (p=0.038) and in female patients (p=0.006) compared to the pre-lockdown period.
Conclusion: During the first COVID-19 lockdown in Greece, we detected a significant percentage of post-traumatic stress disorder in IBD patients and a significant increase in depression levels compared to the pre-lockdown period, especially in females.
INTRODUCTION
The SARS-CoV-2 infection rapidly spread around the globe affecting all aspects of human living including economy, social relationships, lifestyle and people’s physical and mental health [1]. During the first pandemic wave, most administrations implemented strict lockdown measures in order to control viral transmission [2]. Several studies worldwide have shown that during lockdown measures people experienced increased psychosocial suffering, mostly anxiety, depression and post-traumatic stress and reported impaired quality of life [3-5]. COVID-19 quarantine measures seem to have exerted an even greater impact on chronic disease patients’ well-being, mainly because these populations reported greater fears regarding their health and experienced reduced access to standard medical care due to the allocation of healthcare resources to the management of the pandemic [6].
Inflammatory bowel disease (IBD) is a chronic auto-immune gastrointestinal disorder which is associated with increased levels of psychological distress, impaired quality of life and significant limitations in everyday functioning [7]. The majority of IBD patients receive immunosuppressive or immunomodulative treatment, thus being considered a high-risk group regarding the SARS-CoV-2 infection [6,8]. In addition, there is a growing body of research showing that IBD patients experienced intense feelings of fear and isolation and reported increased prevalence of anxiety, depression and stress symptoms following the outburst of the pandemic [2,6,9,10]. In this context, the aim of the current prospective study was to evaluate the impact of the first lockdown imposed throughout Greece in spring 2020 on IBD patients’ psychological functioning. To our knowledge, this is the first study focusing on this issue in Greek IBD patients.
MATERIALS AND METHODS
The current prospective study was performed at the Division of Gastroenterology of the Internal Medicine Department of the University Hospital of Patras in Greece with the collaboration of the Department of Psychiatry. The study was conducted from April 10th to May 4th 2020, a period during which the whole country was under strict lockdown measures in an attempt to control SARS-CoV-2 transmission. The study protocol conformed to the principles of the Helsinki Declaration and was approved by the Institutional Review Board of the University Hospital of Patras. IBD patients recruited from the IBD Outpatients Department of the University Hospital of Patras were initially approached by phone and were invited to enroll to the study after being thoroughly informed regarding its aim and methods. These participants were selected because they had been enrolled a few months prior to the COVID-19 pandemic to another research protocol and had completed the Hospital Anxiety and Depression Scale at that time. Two members of the research team (GK and MK) contacted by phone or video call those patients who consented to participate and administered the study questionnaires by interview.
Psychometric instruments
Post-traumatic stress (PTS) symptoms related to the COVID-19 epidemic were assessed with the use of the Impact of Event Scale-Revised (IES-R), which is a 22-item scale. Respondents were asked to indicate how much they were distressed or bothered during the past week by each “difficulty” listed in regards with the epidemic outbreak. Each item was rated on a 5-point scale ranging from 0 (“not at all”) to 4 (“extremely”). The IES-R yields a total score (ranging from 0 to 88) and subscale scores can also be calculated for the Intrusion, Avoidance, and Hyperarousal subscales. A cut-off score of 24 was used for the detection of clinically relevant post-traumatic stress symptoms [11].
Psychological functioning was evaluated with the use of the validated Greek version of the Hospital Anxiety and Depression Scale (HADS), which comprises seven items for anxiety and seven items for depression. Each item is rated on a 4-point scale (0-3) and each subscale is scored from 0 to 21. Higher scores indicate greater symptom severity. We used a cut-off score of 8 to detect clinically significant anxiety and depression symptoms according to the instructions of the initial validation study [12,13].
Health-related quality of life was assessed with the validated Greek version of the Short-Form-36 Health Survey (SF36), which is a self-reported, generic HRQOL validated instrument. It includes 8 multi-item scales (36 items) that evaluate the extent to which an individual’s health limits his or her physical, emotional, and social well-being. More specifically, it covers 8 domains of HRQOL, namely physical functioning, role limitations due to physical problems, bodily pain, general health perception, vitality, social functioning, role limitations due to emotional problems, and mental health. Scores on each subscale range from 0 to 100, with higher scores indicating a better HRQOL results [14]. The Greek version of the SF-36 provides population-based normative data which make possible the calculation of norm-based scores for each sub-scale. Norm-based scores below 50 indicate impaired functioning compared to the general population [15,16].
Statistical analysis
Statistical analysis was performed with the SPSS package for Windows (release 22.0). Numerical data were expressed as means and standard deviations (SD), and categorical data as counts and percentages. Due to the small sample size we used Mann-Whitney U-tests to perform between-group comparisons in HADS, SF36 and IES-R scores by gender and disease type. We also used repeated measures to compare anxiety and depression levels prior and during the lockdown for the whole sample and separately by gender and disease type.
RESULTS
Twenty-two (22) IBD patients, 15 (68.2%) females, were approached by phone and agreed to enter the study. 11 patients were diagnosed with ulcerative colitis (UC) and 11 patients were diagnosed with Crohn’s Disease (CD). Participants’ mean age was 42.3 years (SD: 12.5).
Figure 1. Clinically significant anxiety, depression and PTS symptoms.
During the COVID-19 lockdown, 30.0% of subjects reported clinically significant anxiety symptoms, 50.0% reported clinically significant depressive symptoms and 59.1% reported clinically significant COVID-19 related post-traumatic stress symptoms (Fig.1). As far as quality-of-life scores are concerned, participants scored below the Greek general population in all sub-scales of the SF36 with the exception of the Physical Functioning sub-scale. Figure 2 depicts comparisons between our sample’s SF36 subscale scores and the Greek general population’s scores.
Figure 2. Participants’ norm-based SF36 subscale scores vs Greek general population’s scores.
No significant differences were observed between males and females in anxiety (p=0.603), depression (p=0.936), total PTS (p= 0.121), intrusion (p=0.243) and avoidance (p=0.216) symptoms, however there was a significant difference in hypervigilance symptoms (p=0.048) reported during the COVID-19 lockdown. Likewise, no significant differences were observed between UC and CD patients in anxiety (p=0.848), depression (p=0.759), total PTS (p=0.411), intrusion (p=0.429), avoidance (p=0.767) and hypervigilance (p=0.391) symptoms reported during the COVID-19 lockdown. In a similar way, no difference was observed in any of the SF36 sub-scales between males and females and between UC and CD patients. Table 1 presents HADS, IES-R and SF36 scores during the COVID-19 lockdown by gender and disease group.
Figure 3. Changes in HADS-A and HADS-D scores for the whole sample pre- and post- lockdown measures.
Figure 4. Changes in HADS-A and HADS-D scores for female patients pre- and post- lockdown measures.
Comparing HADS scores prior to and during the lockdown measures, we observed a significant increase in depression symptoms (p=0.038), while no significant effect was observed in anxiety symptoms (p=0.259) (Fig. 3). We then proceeded to separate data analyses by gender. In females, there was a significant increase in depression scores (p=0.006) during the lockdown compared to the pre-quarantine period (Fig.4). No significant changes in anxiety (p>0.999) or depression (p=0.884) scores compared to the pre-lockdown period were observed in males.
DISCUSSION
Our study revealed that during the first lockdown period in Greece, IBD patients reported increased levels of depression and post-traumatic stress symptoms and experienced impairment in most sub-domains of quality of life. These findings corroborate recent studies originating from various countries, including the Netherlands, Japan, Australia, UK, Spain, USA [2,4,10, 17,18,19] suggesting that during the COVID-19 lockdowns IBD patients experienced intense stress, increased health-related worries and depressive and anxious symptomatology. The fact that our sample was already enrolled in another research protocol and had been evaluated for anxiety and depression symptoms prior to the lockdown measures, provided us with the unique opportunity to assess prospectively the impact of the quarantine. The current analysis revealed a significant increase in depression symptoms during the lockdown which represents solid evidence regarding the negative psychological effects of social distancing and isolation on this patient population. We also found an increase in anxiety scores, although it did not reach statistical significance, probably due to the small sample size.
According to most relevant research, female patients appeared more vulnerable to the negative mental health consequences of the quarantine [4,6,10,19]. In our study, no significant differences were detected in anxiety, depression, overall PTS symptoms and quality of life scores between males and females at time point T2, during the quarantine. However, we found that female patients experienced a significant worsening in depression symptoms after the pandemic outburst, suggesting a higher vulnerability towards the quarantine-related adverse psychological consequences. General population studies have shown that women experienced more intensely the psychosocial impact of the pandemic [5,20] and this vulnerability has been mainly attributed to increased childcare demands and greater occupational and financial difficulties during the lockdown period [21]. The current study’s design did not allow us to detect potential mediators of women’s psychological burden, however our results suggest that female IBD patients’ mental health needs require extra attention and care not only during the pandemic but also in the upcoming post-pandemic era.
A major limitation of this study was the small sample size which probably did not allow us to detect more significant associations between the studied parameters.
In conclusion, our study confirmed that IBD patients commonly experience increased psychological distress and poor quality of life and their mental health was adversely affected during the first COVID-19 lockdown period. Female patients appeared more vulnerable to the quarantine’s negative psychosocial consequences and their needs should be prioritized during the process of healthcare resources allocation, given that the upcoming post-pandemic period is anticipated to be characterized by a dramatic increase in psychosocial difficulties especially within high-risk populations.
Conflict of interest disclosure
None to declare
Declaration of funding sources
None to declare
Author contributions
KK conceived the idea, analyzed data and wrote the manuscript; GK and MK conducted the study and collected data; TL, TK, GD and GT recruited patients and collected data; KA and KT reviewed the manuscript and provided expert opinion; CT conceived the idea, reviewed and approved the final version of the manuscript
REFERENCES
1. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus outbreak of global health concern. Lancet. 2020; 395(10223):470-3.
2. Nishida Y, Hosomi S, Fujimoto K, Nakata R, Sugita N, Itani S, et al. Impact of the Lockdown Due to the COVID-19 Pandemic on Patients With Inflammatory Bowel Disease. Front Med (Lausanne). 2021; 8:649759.
3. 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(5):1729.
4. Planchuelo-Gómez Á, Odriozola-González P, Irurtia MJ, de Luis-García R. Longitudinal evaluation of the psychological impact of the COVID-19 crisis in Spain. J Affect Disord. 2020; 277:842-9.
5. Karaivazoglou K, Konstantopoulou G, Kalogeropoulou M, Iliou T, Vorvolakos T, Assimakopouloset K, al. Psychological distress in the Greek general population during the first COVID-19 lockdown. BJPsych Open. 2021;7(2):e59
6. Hernández Camba A, Ramos L, Madrid Álvarez MB, Pérez-Méndez L, Nos P, Hernández V, et al. Psychosocial impact of the COVID-19 pandemic on patients with inflammatory bowel disease in Spain. A post lockdown reflection. Gastroenterol Hepatol. 2021; S0210-5705(21): 00252-1.
7. Cao Q, Huang YH, Jiang M, Dai C. The prevalence and risk factors of psychological disorders, malnutrition and quality of life in IBD patients. Scand J Gastroenterol. 2019; 54(12):1458-66.
8. Mao R, Liang J, Shen J, et al. Chinese Society of IBD, Chinese Elite IBD Union; Chinese IBD Quality Care Evaluation Center Committee. Implications of COVID-19 for patients with pre-existing digestive diseases. Lancet Gastroenterol Hepatol. 2020; 5(5):425-7.
9. Cheema M, Mitrev N, Hall L, Tiongson M, Ahlenstiel G, Kariyawasam V. Depression, anxiety and stress among patients with inflammatory bowel disease during the COVID-19 pandemic: Australian national survey. BMJ Open Gastroenterol. 2021 ;8(1):e000581.
10. de Bock E, Filipe MD, Meij V, Oldenburg B, van Schaik FDM, Bastian OW, et al. Quality of life in patients with IBD during the COVID-19 pandemic in the Netherlands. BMJ Open Gastroenterol. 2021; 8(1):e000670.
11. Weiss DS, Marmar CR. The Impact of Event Scale – Revised. In Assessing Psychological Trauma and PTSD (eds Wilson JP, Keane TM): 399–411. Guilford Press, 1997.
12. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983; 67(6):361–70.
13. Michopoulos I, Douzenis A, Kalkavoura C, Christodoulou C, Michalopoulou P, Kalemi G, et al. Hospital Anxiety and Depression Scale (HADS): validation in a Greek general hospital sample. Ann Gen Psychiatry. 2008; 7:4.
14. Ware JE, Kosinski M and Gandek B (eds). SF-36 Health Survey manual and interpretation guide. Lincoln, RI: QualityMetric Incorporated, 2004. 15.
15. Pappa E, Kontodimopoulos N, Niakas D. Validating and norming of the Greek SF-36 Health Survey. Qual Life Res. 2005; 14(5):1433–8.
16. Anagnostopoulos F, Niakas D, Pappa E. Construct validation of the Greek SF-36 Health Survey. Qual Life Res. 2005;14(8):1959-65.
17. Harris RJ, Downey L, Smith TR, Cummings JRF, Felwick R, Gwiggner M. Life in lockdown: experiences of patients with IBD during COVID-19. BMJ Open Gastroenterol. 2020; 7(1):e000541.
18. Sempere L, Bernabeu P, Cameo J, Gutierrez A, Laveda R, García MF, et al. Evolution of the emotional impact in patients with early inflammatory bowel disease during and after Covid-19 lockdown. Gastroenterol Hepatol. 2022; 45(2):123-33.
19. El-Dallal M, Saroufim A, Systrom H, Ballou S, Farhoud A, Pasam RT, et al. Assessing the repercussions of COVID-19 pandemic on symptoms, disease management, and emotional well-being in patients with inflammatory bowel disease: a multi-site survey study. Scand J Gastroenterol. 2022;57(4):406-14.
20. Luo M, Guo L, Yu M, Jiang W, Wang H. The psychological and mental impact of coronavirus disease 2019 (COVID-19) on medical staff and general public – a systematic review and meta-analysis. Psychiatry Res. 2020; 291:113190.
21. Yerkes MA, André SCH, Besamusca JW, Kruyen PM, Remery CLHS, van der Zwan R, et al. ‘Intelligent’ lockdown, intelligent effects? Results from a survey on gender (in)equality in paid work, the division of childcare and household work, and quality of life among parents in the Netherlands during the Covid-19 lockdown. PLoS One. 2020; 15(11): e0242249.