Evaluation of the Psychological Impact of COVID-19 Pandemic on Chinese Patients with Common Mental Disorders in Primary Care: A Cross-Sectional Study

Purpose: Our study aimed to evaluate the psychological impact of COVID-19 pandemic on Chinese patients with common mental disorders in primary care in Hong Kong. Method: A cross-sectional study was conducted on 102 Chinese patients with common mental disorders and being followed up in two public integrated mental health clinics in Hong Kong from 1 st November 2020 to 31 st January 2021. Patients would be evaluated about the impact of COVID-19 pandemic on their mood and daily life by using a questionnaire which assessed social distancing effects, financial impact, relationship with family, anxiety and depressive symptoms. The Patient Health Questionnaire-9 (PHQ-9) and General Anxiety Disorder-7 Questionnaire (GAD-7) would also be used to assess patients’ mood symptoms. Factors which were related to COVID-19 pandemic and associated with anxiety or depressive symptoms would be analysed. Results: The mean age of the subjects was 58.0 years and more patients were female (77.5%). There were 84.3% and 72.5% of patients reported their anxiety and depressive symptoms being affected by COVID-19 pandemic respectively. It was found that 17.6% of patients had their income decreased or were unemployed. About one-third (30.4%) of patients indicated that their relationship with their family was worsened while 8.8% was improved. Social distancing was significantly associated with anxiety (p = 0.006) and depressive symptoms (p psychological impact of COVID-19 pandemic on their patients. Our findings shed light on mental health care planning and preventive measures during the COVID-19 pandemic and potential subsequent pandemics.


Introduction
Since the first outbreak reported in mainland China in December 2019, the novel coronavirus disease (COVID-19) had rapidly spread into a global pandemic.
To date (1 September 2020), over 25,000,000 confirmed cases and 800,000 deaths attributable to this disease had been reported [1]. In Hong Kong, COVID-19 had also been rapidly transmitted since late January 2020 with 4823 confirmed cases as of 1 September 2020 [2].
Reports already indicated that the COVID-19 pandemic would not only affect physical heath, but also mental health [3]. The pandemic and the related containment measures i.e. lockdown curfew, quarantine, social distancing and selfisolation could have a detrimental impact on mental health [4] [5]. In particular, the increased loneliness and reduced social interactions, were the main riskfactor for depression and anxiety [6]. Fear of unknown was found to raise anxiety levels in both healthy individuals as well as those with pre-existing mental health conditions [7] [8]. This emotional response might evolve into distress reactions (insomnia, anger, extreme fear of illness even in those not exposed), health risk behaviours (increased use of alcohol and tobacco, social isolation), mental disorders, lowered perceived health and suicidal ideation [9] [10].
The rapid transmission of the disease would increase the likelihood of mental distress and psychiatric morbidities in different sub-populations, not simply attributed to persistent quarantine and massive negative news portrayal, but also influenced by the growing number of confirmed and suspected cases [11]. Symptoms of anxiety and depression and self-reported stress were found to be common psychological reactions to the COVID-19 pandemic [12]. Moreover, downturn in the economy caused by COVID-19 would lead to unemployment, financial insecurity and poverty; and could thus induce mental health problems in previously healthy people and negative effects on those with pre-existing mental disorders [13]. Youngster, women and those living with children, especially preschool age children were particularly vulnerable [14] [15]. And people with mental health conditions could be more substantially influenced by the emotional responses brought on by the COVID-19 pandemic, resulting in relapses or worsening of an already existing mental health condition [16] [17].

Procedure
Collected variables including age, gender and diagnoses, were retrieved from computerized records. The impact of COVID-19 pandemic on patients' daily life and mood was evaluated by using a questionnaire (Appendix I) which assessed social distancing effects, financial impact, relationship with family, anxiety and depressive symptoms. The Patient Health Questionnaire-9 (PHQ-9) (Appendix II) and General Anxiety Disorder-7 questionnaire (GAD-7) (Appendix III) were used to assess patients' mood. PHQ-9 and GAD-7 are two validated questionnaires for identification and assessment of severity of depression and anxiety respectively [19] [20] [21]. The PHQ-9 consisted of 9 items whereas GAD-7 consisted of 7 items, both indicated on a 4-point Likert scale where "0" as not at all, "1" as several days, "2" as more than half the days and "3" as nearly every day.
PHQ-9 total score for the 9 items ranges from 0 to 27. Scores of 5, 10, 15, and 20 represent cut-points for mild, moderate, moderately severe and severe depression, respectively. For GAD-7, total score for the 7 items ranges from 0 to 21.
Scores of 5, 10, and 15 represent cut-points for mild, moderate, and severe an-Open Journal of Psychiatry xiety, respectively.
Patients were interviewed by a nurse or an occupational therapist of the mental health clinics to complete the 3 questionnaires before they were seen by the attending family physicians.
Subsequently, the PHQ-9 score and GAD-7 score of pre-and peri-COVID-19 pandemic were compared between patients who perceived their anxiety symptoms were not worsened by COVID-19 pandemic and patients who perceived their anxiety symptoms were worsened by COVID-19 pandemic. The PHQ-9 score and GAD-7 score of pre-and peri-COVID-19 pandemic were also compared between patients who perceived their depressive symptoms were not worsened by COVID-19 pandemic and patients who perceived their depressive symptoms were worsened by COVID-19 pandemic.

Outcome
The main outcome was to evaluate the psychological impact including increase in anxiety or depressive symptoms due to COVID-19 pandemic in Chinese patients with common mental disorders in primary care in Hong Kong.

Study Population
There were 129 patients fulfilled inclusion criteria during the study period with 102 patients participated in the study. There were 11 (8.5%) patients refused to participate and 16 (12.4%) patients defaulted follow-up. The mean age of the subjects was 58.0 years and more patients were female (77.5%). Mixed anxiety and depressive disorder was the most prevalent (25.5%) common mental disorder diagnosed among the study subjects, followed by generalised anxiety dis-  Table 1 and Table 2 respectively.
Univariate analysis results for the impact of COVID-19 pandemic on patients' anxiety symptoms were summarized in Table 3. The mean GAD-7 score (peri-COVID-19 pandemic) in patients who perceived their anxiety symptoms worsened by COVID-19 pandemic was statistical significantly higher than those who perceived their anxiety symptoms not affected by COVID-19 pandemic pandemic on patients' depressive symptoms and were summarized in Table 4.
The mean GAD-7 score (peri-COVID-19 pandemic) in patients who perceived their depressive symptoms worsened by COVID-19 pandemic was statistical    was obtained by backward method according to the likelihood ratio until variables had p value < 0.1) as in Table 5 and

Discussion
This was the first study on the psychological impact of the COVID-19 pandemic  In our study, the proportions of patients who rated their anxiety and depressive symptoms were affected by COVID-19 pandemic were 84.3% and 72.5% respectively which were much higher than those of the general population in Hong Kong [22]. This might be due to the reasons that our patients had underlying common mental disorders (CMD) and this study was conducted during the fourth wave of the pandemic with more local confirmed cases compared with the initial phase of the pandemic. Similarly, a large study in Dutch showed that the levels of depressive symptoms, anxiety, worry and loneliness increased modestly in people with less severe chronic mental health disorders compared with individuals without mental health disorders [16]. Our results provide further evidence that COVID-19 pandemic had significant psychological impact on patients who had CMD.
In addition, this study highlighted that social distancing contributed significantly to the worsen anxiety and depressive symptoms among patients with CMD.

Social Distancing
This study was unique in showing that social distancing was associated with worsen anxiety and depressive symptoms in patients with CMD in both univariate and multivariate analysis. In Hong Kong, the government had implemented various social distancing measures including restrictions of group gatherings and facility closures. Social distancing measures were one of the public health measures adopted by most countries, which contributed to loss of daily routines, reduction of social and physical contact with others, disruption of social rhythm, reduction of the availability of family and social supports and were shown to cause boredom, frustration and loneliness [7]. Social distancing measures were essential for the protection of individuals and to reduce the risk of infection through close contact with people infected with COVID-19, but at the same time, individuals might experience a high burden of mental health conditions [6] and patients with pre-existing mental health disorders were particularly at risk [13]. Reviews reported a high burden of mental health conditions among individuals who experienced isolation or quarantine. Among specific mental health outcomes, all reviews reported a high prevalence of anxiety among study participants in the US [25]. A small-scale Chinese study also showed that more anxiety and depression were experienced in psychiatric patients with strict lockdown measures [26].
In a Spain study, more frequent leisure activities during confinement includ-Open Journal of Psychiatry ing watching films, reading, talking to someone via phone or video calls, were associated with lower stress, anxiety and depression scores [15]. Therefore, maintaining social connections, reducing isolation by phone or video calls and maintaining physical activities could be promoted by general practitioners and mental health practitioners, and specific guidelines should be promulgated by policy makers for the public to follow so that they could take care of their mental health.

Financial Situation
The financial status of majority patients (82.4%) in our study was unaffected, 16.7% of patients had their income decreased and only 0.9% were unemployed.
Our results showed that the association between financial status and both anxiety and depressive symptoms was statistically insignificant. Econometric analysis of the world's economic growth rate showed that the COVID-19 pandemic had led to widespread economic damage. The highest unemployment rates were in Asia, Europe, and America [27]. In Hong Kong, Gross Domestic Product (GDP) growth was 9% in the first half of 2020 but narrowed to 3.5% in second half of 2020 and the unemployment rate had risen to 6.4% in Oct 2020 due to COVID-19 pandemic [28]. Subsequent analyses indicated that economic hardships led to much higher prevalence of expressing adverse mental health, including feelings of depression and health anxiety [29]. Adults experiencing household job loss during the COVID-19 pandemic had consistently reported higher rates of symptoms of anxiety and/or depressive disorder compared to adults not experiencing household job loss (53% vs. 32%, respectively) [30]. Compared with local unemployment rate 6.4%, the unemployment rate was only 1% among our study participants, this might contribute to our findings. In rapidly changing COVID-19 pandemic situations, we suggested further studies to further evaluate how the financial situation would contribute to the psychological impact on patients with CMD.

Limitations
This study was subjected to several limitations. Firstly, the cross-sectional design of our study limited the establishment of causal relationship between psychological impact and the independent variables. Future studies should examine how the changes in the independent variables could predict psychological impact of patients with common mental disorders using longitudinal study designs. Secondly, other potential confounding effects on the outcomes could not be excluded. These included deteriorating mental health due to the natural disease course, their own perpetuating factors, and other social factors not related to COVID-19 pandemic. Thirdly, the sampling method might not allow for generalization of the results since the study subjects were recruited from two public primary care clinics covering only 2 of the 18 districts in Hong Kong.

Conclusions
Our study showed that there was considerably more psychological impact including an increase in anxiety and depressive symptoms due to COVID-19 pandemic in Chinese patients with common mental disorders (CMD) in primary care in Hong Kong. It is important that primary care physicians must be aware of the psychological impact of COVID-19 pandemic on their patients with CMD and provide additional support to the patients.
During COVID-19 pandemic, social distancing measures were necessary for preventing disease transmission, but it was often associated with negative psychological impact, especially on patients with existing CMD. Extra awareness and psychological support would therefore be needed for patients with CMD when social distancing measures were implemented during an infectious disease pandemic.