Mental health problems of asymptomatic or mildly symptomatic COVID-19 patients in hospitel in Thailand: A cross-sectional study

Background There is evidence that patients with COVID-19 have a higher prevalence of mental health problems than the normal population. This study aimed to investigate the prevalence of mental health problems and their associated factors in patients with asymptomatic or mildly symptomatic in the hospitel in Thailand. Methods Mental health problems were evaluated using the Depression, Anxiety, and Stress Scale - 21 items, and Patient Health Questionnaire-9. The prevalence of mental health problems was presented by frequency and percentage. McNemar's test was used to compare the prevalence of mental health problems between day 1 and day 7. Binary logistic regression was used to identify potential predictors of mental health problems. Results A total of 186 participants (68.3% female; mean age = 37.21 years (SD 13.66) were recruited. The depression, anxiety, and stress rate on day 1 of admission was 26.9%, 32.3% and 25.8%, respectively. Having mild COVID-19 symptoms was a significantly associated factor with anxiety (OR=2.69, 95%CI: 1.05-6.89) and stress (OR=4.53, 95%CI: 1.32-15.55). Conclusions There was a high rate of mental health problems in COVID-19 patients. Detecting and managing mental health problems should be considered standard care for COVID-19 patients.


Introduction
Since the World Health Organization announced the emergency statement regarding the pandemic of novel coronavirus disease 2019 (COVID-19) on 30 January 2020, Thailand, like other countries, has to face the rise of new cases of COVID-19. The number of positive COVID-19 cases exceeded the health system's capacity. However, at the beginning of the pandemic, Thailand did not have a home isolation policy and stated that all patients would be under the medical team's care. Therefore, the Thai government set up the "hospitel", a new type of health care facility. 1 The term "hospitel" is the compound noun from the "hospital" and "hotel". It is a new type of health care facility specialised for COVID-19 patients who are asymptomatic or have only mild symptoms. A hospitel is organised and run by the hotel and medical staffs from an affiliated public hospital. The team includes general practitioners, nurses and paramedics. Patients in hospitel are monitored regularly and are quarantined for seven days or until they have negative COVID-19 test results. 1 Hence, hospitels also aim to prevent the spread of COVID-19 in the community. 1 Although patients are regularly monitored for physical complications, mental health problems, especially stress adjustment, may be under-recognised. The meta-analysis study by Liu et al., 2021 found that anxiety symptoms and depression rates in COVID-19 patients were 32% and 27.6%, respectively. 2 Moreover, insomnia was found to have a prevalence of 30.30%. While the study in Thailand by Lerthattasilp et al., 2020 showed that the prevalence of depression was found to be 22.5%, whilst the anxiety rate was 30%, and the stress rate was 20%. 3 The study by Lerthattasilp et al. was conducted in a field hospital that has a similar concept of caring to "hospitel". 3 This data demonstrated that patients with COVID-19 are more likely to suffer mental health problems than the normal population. In addition, early studies revealed that the female gender, physical symptoms related to COVID-19, duration of hospitalisation, and a history of psychiatric disorders were associated factors to mental health problems. [3][4][5][6][7] The objective of the present study was to investigate the prevalence of mental health problems, including depression, anxiety and stress, as well as their associated factors in patients with asymptomatic or mildly symptomatic in the hospitel in Thailand, which is under the supervision of the Faculty of Medicine Vajira Hospital. The Faculty of Medicine Vajira Hospital is responsible for caring for COVID-19 patients from the Thonburi district in Bangkok. We hypothesise that the prevalence of mental health problems is likely to be high on day 1 at admission and will decline after 7 days. However, despite to the new outbreak of COVID-19 globally, there are still limited studies on mental health problems. Recognising this concern is essential to the Thai public health sector in order to implement appropriate measures to tackle mental health problems related to COVID-19 infection.

Ethics and consent
We obtained approval from the Ethical Committee of the Institutional Review Board of the Faculty of Medicine Vajira Hospital on July 2 nd , 2021 (COA no. 120/64E). Before starting the survey, all participants were informed of the study's objectives, method, and provided written informed consent.

Study design, setting and participants
We employed a cross-sectional descriptive study based on STROBE guidelines. 8 The sample size was calculated following the Cochrane formula. 9 As the number of COVID-19 patients (N) admitted to the hospitel between July and September 2021 was 250, the sample size was estimated by p = 0.198 according to the study by Jeong et al., 2019. 7 Using alpha at 0.05 and error (d) at 0.05, the required sample size was 124. 186 asymptomatic or mildly symptomatic COVID-19 patients, according to COVID-19 treatment guidelines by the National Institutes of Health (NIH), aged 18 years and older were recruited by purposive sampling in-person when the participant was initially admitted to the hospitel under the supervision of the Faculty of Medicine Vajira Hospital from July to September 2021. Patients who could not use the internet were excluded from this study.

REVISED Amendments from Version 1
As a reviewer recommended, we have corrected some mistakes in Tables 1, 2 and 4. In addition, we discussed more the reasons why there was a difference in stress rate between the hospitel and Thammasat University field hospital. We also mentioned the responsibility of the Faculty of Medicine Vajira Hospital in COVID-19 situation in Thailand in the introduction part.
Any further responses from the reviewers can be found at the end of the article

Data collection
The study instruments consisted of four questionnaires: 1) demographic characteristics including sex, age, education level, employment status, financial status, and living status; 2) clinical characteristics including severity of COVID-19, duration of COVID-19 infection, duration admitted in the hospitel, referring status, admission status, history of medical and mental disorders and perceived psychological support while in the hospitel, which is a close-ended question (yes or no); 3) the Depression, Anxiety, and Stress Scale -21 items (DASS-21); and 4) Patient Health Questionnaire-9 (PHQ-9) would performed if participants had moderate to severe severity from DASS-21 score in any domains. In addition, we collected participants' data on day 1 and day 7 of admission by Google form.
DASS-21 consists of three domains; each domain comprises seven items, and the depression, anxiety, and stress scores are calculated by summing. Then, the severity of each part is categorised into normal, mild, moderate, severe and extremely severe. The Cronbach's alpha coefficient of the DASS-21 Thai version is 0.75 reflecting good internal consistency. 10,11 PHQ-9 Thai version has a total of 9 depressive questions. The total score of PHQ-9 is classified into normal (0-6), mild (7-12), moderate (13)(14)(15)(16)(17)(18), and severe (≥19). The sensitivity and specificity of PHQ-9 are 84% and 77%, respectively, to detect depression. 12,13 Statistical analyses Data were analysed using SPSS software (version 28.0; IBM, Chicago, IL, USA). The prevalence of mental health problems was presented by frequency and percentage. McNemar's test was used to compare the prevalence of mental health problems between day 1 and day 7. In addition, binary logistic regression (odds ratio [OR] and 95% confidence interval [CI]) was used to identify potential predictors of depression, anxiety and stress. P<0.05 was considered statistically significant.

Results
Of 186 participants recruited in this study, they had a mean age of 37.21 years old (SD 13.66). The majority of participants were female (68.3%), single (54.8%), had an undergraduate degree (44.1%), employed (49.5%), and were living with family (59.7%) ( Table 1).  Table 2 demonstrates the clinical characteristics of the patients. Approximately 16% of participants had at least one underlying medical illness. Only 1.1% of participants had an underlying mental disorder. In addition, around 80% of participants had mild COVID-19 symptoms, and the symptoms lasted at least 7 days. The median duration of hospitel admission was 12 days (IQR 10-13). Most participants were admitted alone (86.6%), and eventually, they could be discharged from the hospitel after 7 days of admission. Interestingly, around 90% of participants perceived that they were provided psychological support while in the hospitel. Regarding the prevalence of mental health problems (Table 3), the depression, anxiety, and stress rates were 26.9%, 32.3% and 25.8%, respectively, on day 1 of hospitel admission. The most common level of depression measured by PHQ-9 was mild severity. However, after 7 days of admission, the depression, anxiety, and stress rates decreased to 18.3%, 17.2% and 12.9%, respectively. This difference in the proportion of mental health problems between day 1 and day 7 was statistically significant (P<0.05) (Figure 1). The results of binary logistic regression analysis revealed that having mild COVID-19 symptoms was a significantly associated factor with anxiety (OR=2.69, 95%CI: 1.05-6.89) and stress (OR=4.53, 95%CI: 1.32-15.55). In contrast, other factors were not associated with depression, anxiety and stress (P>0.05) ( Table 4).

Discussion
To the best of our knowledge, this is the first study to explore the prevalence of mental health problems among patients with COVID-19 in the hospitel in Thailand. The prevalence of depression was 26.9%, anxiety was 32.3%, and stress was 25.8% in patients with asymptomatic or mild COVID-19 symptoms at day 1 of their stay at the hospitel under the Faculty of Medicine Vajira Hospital supervision. Compared to the meta-analysis study from multinational countries, including China, the United States, Japan, India, and Turkey, the depression and anxiety rates had a similar trend (27.6 % vs 26.9 for depression and 32.6% vs 32.3% for anxiety). 2 On the contrary, the stress rate in this study was relatively lower than in the study at the Thammasat University field hospital (30% vs 25.8%). 3 Although we also used the DASS-21, the same questionnaire, the prevalence of stress in this study might have been lower since the study at the Thammasat University field hospital had more moderate to severe COVID-19 cases. 3 In addition, the context of hospitels and field hospitals were different in many ways; for example, the privacy and facility of hospitels might be better than field hospitals.
The mental health problems rate declined significantly on day 7 of admission (P<0.05). The potential explanation may be that most patients can adjust to acute stress over time and with perceived psychological support. 14,15 Moreover, the medical team at the hospitel always provide basic psychoeducation via a leaflet and video clip about coping with stress. 16 The high-risk cases of mental disorders would then be referred to psychologists or psychiatrists.
In this study, mild COVID-19 symptoms was the only factor associated with anxiety and stress. This could be a helpful predictor of psychological screening problems in patients admitted to hospitel. However, unlike prior studies, we could not find the association between the female gender, duration of hospitalisation, and a history of psychiatric disorders and mental health problems. This could be because there were few patients with psychiatric disorders in this study. Additionally, we did not collect data on the detail of the physical symptoms of COVID-19.
We are aware of some limitations of the present study. First, we can only indicate associated factors, not causal relationships, due to the descriptive design. Secondly, we included only asymptomatic and mild symptoms, which may not represent all COVID-19 patients. Finally, the mental health problems in this study were assessed by online selfreporting questionnaires, which could demonstrate only symptoms, not disorders and patients who could not use the internet were excluded. Thus, patients with high-risk mental disorders should be further evaluated by psychiatrists or clinical psychologists.  Future research should investigate the prevalence of posttraumatic stress disorder (PTSD), which could be occurred following COVID-19 as a traumatic stressor. 17 In addition, psychological intervention to prevent stress-related illnesses or psychological distress 18 should be performed.

Conclusions
The prevalence of mental health problems in COVID-19 patients was common, especially on the first day of admission. However, it declined on the 7th day after admission. In addition, having mild symptomatic COVID-19 infection was an associated factor with anxiety and stress. Therefore, detecting and managing mental health problems should be considered standard care for COVID-19 patients.

Sorawit Wainipitapong
Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand Thank you for the opportunity to review this article. The report was well written and organized.
Hereby, please find my suggestion for this work to become better suitable for indexing: Some general profiles of study location, Vajira Hospital, should be stated. For example, is it located in the metropolitan, urbanized, or regional area? Readers would gain benefit for generalizability regarding mental health-related profiles and conditions.

1.
Are previous mental disorders enrolled in the exclusion criteria? 2.
How did the authors measure 'perceived psychological support while in the hospitel'? Please clarify.

3.
Please kindly check the psychometric properties of PHQ-9 Thai version. Because the categorized severity of depression and the cut-off score of two cited references are not similar, the authors are suggested to carefully use the interpretation of this screening tool and specify the cut-off score used in the study.

4.
Table 1 -Does 'income' refer to 'income per month'? 5. Table 2    Compared to the finding from another Thai field hospital, the authors might provide 10.
additional discussions regarding the location or uniqueness of the hospital besides the severity of COVID-19.
Congratulations to all authors. They have done great work and I enjoyed reading this manuscript a lot.

If applicable, is the statistical analysis and its interpretation appropriate? Partly
Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes