Patients who had severe acute COVID-19 but avoided hospitalization saw higher risks for certain mental health conditions, according to an observational study.

Among nearly 10,000 individuals, those diagnosed with COVID-19 had a higher prevalence of depressive symptoms (prevalence ratio [PR] 1.18, 95% CI 1.03-1.36) and poorer sleep quality (PR 1.13, 95% CI 1.03-1.24) compared with those without a diagnosis, reported Unnur Anna Valdimarsdóttir, PhD, of the University of Iceland in Reykjavik, and colleagues.

However, these patients did not see a higher prevalence of anxiety symptoms (PR 0.97, 95% CI 0.91-1.03), nor COVID-related distress (PR 1.05, 95% CI 0.93-1.20), the group noted in Lancet Public Health.

The factor that played the biggest part in the development of these mental health issues over the next 16 months was the severity of acute illness, the researchers said.

More specifically, those who were bedridden for more than 7 days but never hospitalized had the highest prevalence of persistent depressive symptoms (PR 1.61, 95% CI 1.27-2.05).

While the general COVID-19 population didn’t seem to have a problem with anxiety, those who were bedridden for over a week did see a significantly higher prevalence of these symptoms (PR 1.43, 95% CI 1.26-1.63) versus those who were never diagnosed.

These data are reassuring for the majority of people ever diagnosed with COVID-19, since the bulk of long-term mental health symptoms seem to be mostly isolated to the minority of patients — in this study, 22% — who had a severe acute illness phase, Valdimarsdóttir told MedPage Today.

“Clinical vigilance and longer-term follow-up may therefore be directed to this group and their mental health,” she recommended.

One unique finding from the study was that people who tested positive for COVID-19 but were never bedridden due to their illness actually had a significantly lower prevalence of depression (PR 0.83, 95% CI 0.75-0.91) and anxiety (PR 0.77, 95% CI 0.63-0.94) compared with those who never had COVID.

“This finding does make sense in retrospect as these asymptomatic individuals return to normal lives without much worry about long-term impact of COVID-19, which may render lower prevalence of adverse mental health symptoms compared to individuals still waiting to be infected and still adhering to extensive social restrictions,” Valdimarsdóttir pointed out.

Particularly for those who found themselves bedridden, consistent depressive symptoms could be at least in part due to worry of infecting others, worry of long-term health effects, or even fear of death. For those who only found themselves bedridden for a few days, depressive symptoms slowly disappeared over time, the researchers noted.

This wasn’t the first study to find these associations: a study published in The BMJ earlier this year linked COVID-19 infection with a 60% higher risk of any new mental health diagnosis or a new mental health-related drug prescription. However, this study combined hospitalized and non-hospitalized patients.

The current study included seven cohorts from six countries in Europe. Positive PCR or antibody tests for SARS-CoV-2 infection, plus time spent bedridden due to COVID-19, were all self-reported.

Depressive symptoms were measured with the Patient Health Questionnaire and Emotional State Questionnaire (EST-Q2) Depression subscale, while anxiety was measured with the Angst-Symptom-Spørgeskemaet, the EST-Q2 Anxiety subscale, and the General Anxiety Disorder scale. COVID-19-related distress was measured with the Primary Care PTSD Screen for DSM-5 and the PTSD checklist for DSM-5. Sleep quality was measured with the EST-Q2 Insomnia subscale and Pittsburgh Sleep Quality Index.

Among the 247,249-person cohort, 4% (9,979) were diagnosed with COVID-19 during a mean 5.65-month follow-up. Those who tested positive tended to have higher levels of education, were more likely in a relationship, had a lower body mass index, and had a history of smoking or chronic medical conditions.

Among this general COVID-19 population, 31.7% were never bedridden, 24.6% were bedridden for 1 to 6 days, and 16.2% were bedridden for a week or more. These data were missing for the remainder of the cohort.

Valdimarsdóttir’s group pointed out that more than 75% of the comparison group responded from March to June 2020 when pandemic fears still ran quite high, whereas responses from COVID patients were collected from March 2020 to August 2021. If replicated today, these findings may vary, they noted.

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