4 | DISCUSSION:
Although there aren’t any studies in the literature evaluating the anxiety and depression in the relatives of the patients during the pandemic, it has been reported before the pandemic that being a relative of a hospitalized patient in the intensive care unit due to a life-threatening disease is an important stress factor and may cause anxiety and depression.11 Anxiety and depression rates of relatives of patients in the ICU were evaluated by studies conducted in different countries before the pandemic some of which are as follows: 69.1% and 35.4% in a multicenter trial in France, 71.8% and 53.8% in a trial reported from Brazil, 60% and 54% in another trial from Brazil, 35% and 66% in a trial from India, 35.9% and 71.8% in a trial from Turkey respectively.11,12,13,14,15 As a result of these trials preceding the pandemic, the anxiety levels in our country is lower than France and Brazil, similar to India while depression levels are higher than France, Brazil and India. When we compare the rates of anxiety and depression in relatives of the patients before the pandemic (35.9% and 71.8% respectively) by Köse et al. with our study, we can roughly tell that anxiety levels rised (45.8-46.7%) while depression levels decreased (62.5-67.5%) during the pandemic.15
Some of the studies showing the rates of anxiety and depression on the general population during the pandemic are as follows: 29.83% and 16.76% in Russia, 35% and 22% in Austria, 28.8% and 16.5% in China, and 45.1% and 23.6% in Turkey respectively.16,17,18,19 In our country, the anxiety rates in the general population were lower than Russia and Austria but higher than China while depression rates were higher than the rest. Apart from cultural differences, the differences in health care between countries and the onset of the trials as the beginning or mid-pandemic period or the level of awareness may be responsible for the results. One of the reasons why the anxiety and depression rates in our study were higher than China may be because in China, the study was carried out by WHO as soon as the pandemic was declared while our study 3-6th months of the pandemic in our country. The official onset of the pandemic was different between countries as well.18 This later onset of COVID-19 pandemic in our country may be cause of higher rates of anxiety and depression because of the awareness of transmission routes and speed as well as the mortality rates. National and social media shares updated information about number of patients, deaths in the country and the world which inclines day by day may also be responsible for the anxiety and depression rates. Özdin et al also conducted a study concerning the anxiety and depression among healthy volunteers during the pandemic.19 Depression rates of our study was higher probably because of the population we chose.
In the literature, there is no similar study conducted with relatives of patients hospitalized in ICU during pandemic. Our trial was started at the beginning of the pandemic and all patients were admitted to ICU with suspicion of COVID-19. The diagnosis was confirmed with PCR in addition to clinical and radiological findings. The higher rates of anxiety and depression in the relatives of patients with positive PCR test can be explained by the serious concerns about the disease. A positive PCR also eliminates the possibility of not having the disease and can incline anxiety and depression.
In our study we found that symptoms of anxiety and depression are more common in women during the pandemic, consistent with the studies prior to pandemic showing female susceptibility to anxiety and depression.20, 21 Studies from different countries conducted in the general population since the beginning of the pandemic also show tendency to anxiety and depression in female gender.6,17,23,24 During the pandemic, female gender was emphasized with regard to anxiety and depression in our country as well.19 Hormonal changes during the menstrual cycle can cause mood changes, which can cause women’s reactions to events to be more exaggerated or negative than men.25Considering that women have more posttraumatic stress symptoms such as negative alteration of cognition and mood, re-experiencing and hyperarousal than men in the COVID-19 epidemic, they are expected to have more anxiety and depression symptoms due to both the pandemic and the anxiety they feel for the wellbeing of their patients.23 Another factor affecting depression is the role that societies attribute to genders depending on cultural differences.22 Although the study is carried out in the capital of our country, the cultural mosaic in the city can reflect almost every region of our country since it is a city that continues to receive immigrants from all over the country. In some societies, the under-reacting of women to the events is regarded as abnormal, while in some regions, the overreaction of men is abnormal. Due to the place of men in society and the role assigned to them, men can show their emotions less than women. The characteristics of the regions where people come from, where they grow up, family and economic structure may be factors that make the reactions of women and men different from each other. Cultural characteristics and the acceptance that the female gender may be emotionally reactive in life may explain the higher frequency of anxiety and depression among females.
Another factor in which anxiety and depression rates were significantly higher in our study was if the participant was the spouse of the patient. After the spouses, the children, relatives, and siblings of the patients followed the frequency of symptoms of anxiety and depression among the relatives. The result of our study was consistent with previous studies.15,27 Because the spouses share a house, a life, and values, one’s illness of affects the surviving spouse both emotionally and socioeconomically. Therefore, we believe that it is an expected result that the symptoms of anxiety and depression are more common in spouses compared to other relatives of the ICU patients.
People aged 65 and over are more likely to have COVID-19 disease and especially respiratory failure and the need for intensive care than younger patients. However younger patients may also need treatment in intensive care and death of these patients is more devastating for their relatives. In our study, although the age of the patient did not significantly affect the anxiety and depression levels of their relatives, the rates of high anxiety and depression was higher in the relatives of young patients than those of middle and elderly patients. In this aspect, it was consistent with the results of other studies.13,26 In the literature, there is no difference between the anxiety and depression levels of the relatives of ICU patients in terms of scores predicting mortality or the education level of the patients’ relatives.15,29,30 In our study, we observed that learning the severity of the disease (high APACHE-II score) by the relatives of the patients did not increase the anxiety level, but it increased the depression. The higher incidence of depression among the relatives of the patients in the ICU can be because their patients are hospitalized in intensive care with the diagnosis of COVID-19, knowing that their condition is more severe and possibly lethal. Most of the participants in the study were university graduates, and although the lowest anxiety and depression levels were found in this group, and there was no significant relationship between the education level of the participants and their anxiety or depression levels. This suggests that education may be effective in the perception process and acceptance of results, but still cannot fully control emotional responses. Our study associates anxiety with COVID-19 as an independent risk factor in accordance with to the answer given to the question “How concerning is your patient’s hospitalization in the ICU due to an epidemic?” by the participants. A relative hospitalized in the ICU due to an epidemic was found to be effective in the development of anxiety.
With the restrictions made to prevent transmission during the pandemic period and the prohibition of daily patient visits, patients’ relatives could not visit their patients in the intensive care environment. Therefore, we think that the lack of seeing, communicating and physical contact in the ICU increases the curiosity and anxiety of the relatives of the patients. Not being able to visit and see a patient was found to be an independent risk factor for the development of depression in the participants.
There may be many different factors that can cause anxiety and depression on people during the pandemic period. Since we had only 25 participants who answered the question about other causes of anxiety and depression, these answers were not evaluated statistically. From these answers, which we have also stated in the findings section, we think that 10 different reasons may cause anxiety in the relatives of the patient during the pandemic process. We believe that these reasons should be questioned in future studies investigating the causes of anxiety and depression.
In conclusion, during the pandemic period, the fact that a relative is in the intensive care unit due to COVID-19 is an independent risk factor for anxiety and the restriction of visits in the ICU is an independent risk factor for depression.
Limitations: Single center, the number of participants, taking the questionnaire by phone are the limitations of our study.