On 30th January 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a public health emergency of international concern.² Symptoms of COVID-19 include fever, chills, cough, nausea, coryza, sore throat, myalgia, nausea and breathing difficulty at varying proportions.³

Other than the physical symptoms, patients with COVID-19 also present with psychological symptoms.⁴ The psychological symptoms of COVID-19 include a range of psychiatric morbidities such as depression, anxiety, panic attacks, delirium and suicidality.⁵ Studies analyzing the psychological impact of COVID-19 infection among the people infected with the illness across the world indicates moderate levels of depression and anxiety.⁶ In India, studies assessing the psychological impact of the COVID-19 pandemic are increasing.^7-11 These studies assessed the psychological impact in different clinical scenarios ranging from during quarantine/isolation, follow-up visits and among high-risk population such as frontline workers.

Even though many studies have examined the psychological impact of COVID-19 among patients affected, very few studies have assess ed the psychological morbidity of these patients during the post-COVID-19 follow-up period.^{12, 13} It is important to understand the long-term impact of COVID-19 on the psychological wellbeing of the patients affected by COVID-19 and to provide the needed psychological help during the follow-up for better outcomes.¹⁴ Hence, the aim of the study was to understand the psychological morbidity among patients affected by COVID-19 during their post-COVID-19 follow-up period and to examine the socio-demographic and clinical factors associated with high psychological morbidity.

Study site: The study was conducted in the COVID follow-up clinic at a large tertiary care hospital in Chennai, Tamil Nadu. This center is one of the largest hospitals dedicated to the management of COVID-19 in Tamil Nadu. The study was conducted between August November 2020. Prior ethical approval was obtained before the start of the study.

Participants: All the previous COVID positive patients (recovered patients) attending the follow-up clinic after one-month post-recovery were approached and included into the study after informed consent. Participants were recruited into the study in a consecutive sampling method. No specific inclusion and exclusion criteria were applied for the recruitment into the study other than not willing to provide an informed consent. Persons with pre-existing psychological symptoms or mental disorders were not excluded from the study.

The aim of the study was to assess the prevalence of depression and anxiety among post-COVID-19 patients visiting a tertiary care center for review and to examine the factors associated with depression and anxiety among them.

The study results indicate that the prevalence of depression and anxiety among post-COVID-19 patients was 21.9% and 11.9%, respectively. Insomnia was observed among 21.7%. In a study conducted among the Fangcang shelter hospitals established in China, during the COVID virus pandemic 18.6% experienced anxiety symptoms, 13.4 % experienced depression and 84.7% had poor sleep quality. 18 The three most current physical symptoms experienced were coughing (26.4%), shortness of breath (24.4%) and soreness or discomfort in throat in (17.9%). Among the patients we studied, the three most common physical symptoms were sleep disturbances, cough and myalgia. These findings are similar to the findings obtained in our study. Also, studies indicate impact of the pandemic was more on women and young adults compared to others.^{19, 20}

Among various socio-demographic and clinical variables examined, it was observed that female gender, patients with ongoing stressors and patients with post-COVID-19 persistent physical symptoms were found to be associated with depression and anxiety among the study population. In this study, women were observed to suffer more from insomnia and anxiety when compared with males. These findings are similar to the previous studies where females showed higher psychological distress scores.^21,22,23 These findings were also echoed in a Nationwide survey of psychological distress among Chinese people in the COVID 19 epidemic.²⁴ Response and responsiveness to stress appear to be different by gender. Female sex hormones attenuate the sympathetic-adrenal and HPA responsiveness. This leads to sluggish control feedback on the brain and less or delayed containment of the response among women.²⁵ In addition to this, their role as the main caregiver in the family, being responsible for the household tasks and care for the children makes them vulnerable for the anxiety and insomnia symptoms.

Nearly one third of patients had ongoing stressors in the current study. These various stressors are financial instability, family conflicts and presence of chronic illnesses. These patients had higher levels of depression compared to the other two thirds of patients. In a study from the UK, many people entered the COVID-19 pandemic from positions of disadvantage. Certain population groups in the society already had a higher risk of experiencing poor mental health and wellbeing than people from more advantaged positions and they had significant impact owing to their pre-existing vulnerable state.²⁶ Similarly, our study population who have been facing ongoing stressors had significant levels of depression.

Nearly 50% of the study participants had continuous physical symptoms in the post-COVID-19 period. The most common post-COVID-19 persistent physical complaints reported by the study participants in the study were sleep disturbances, cough, palpitations, myalgia and breathlessness. In a study conducted in Italy, 87.4% patients had at least one post-COVID-19 persistent symptom particularly fatigue and dyspnoea.²⁷ The causes of prolonged physical symptoms experienced by the patients in the post-COVID state could be due to various reasons. Viral infections elicit an inflammatory response from the immune system and a number of pro inflammatory mediators such as IL-6, TNF-alpha and Interleukin beta are involved in the innate and adaptive responses.²⁸ Noradrenaline has a potential role in the immune response at systems level and is also involved in regulating depression like symptoms such as fatigue, aches, pains and loss of appetite.²⁹

This study is not without limitations. The major limitations of the study are: 1. Study subjects were assessed in the initial four weeks duration(post infection and discharge from the hospital) where most of them still had fatigue, myalgia, cough and palpitations. Hence the patients could not have achieved a complete sense of well-being They have also spent their time in isolation and hospitalization in the immediate past period. These could be possible reasons for the anxiety and depressive symptoms experienced by our patients; 2. This is a single center study from a city in south India. Hence, the results may not be generalizable to other populations in India; and 3. Since it is a cross-sectional study, only associations can be identified while directionality and causality could not be suggested.

Future studies should look at the long-term regular follow-up of the post-COVID-19 patients to look into the long-term sequelae of the COVID-19 infection. Cohort studies could throw light on the various factors playing a role in the onset of psychological symptoms in post-covid patients.

Persistent physical symptoms and ongoing life stressors are found to be associated with depression and anxiety among post-COVID-19 patients. Hence, periodic screening for individuals with persisting physical symptoms and care for the vulnerable population such as those with ongoing stressors will provide a significant advantage in the follow up of the mental health of the patients affected with COVID-19.