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.