Healthcare | Free Full-Text | Psychological Distress Associated with Enforced Hospital Isolation Due to COVID-19 during the “Flatten the Curve” Phase in Morocco: A Single-Center Cross-Sectional Study
1. Introduction
Like many governments, Morocco imposed a total lockdown to control the spread of the virus. In adherence to the Moroccan government’s directives during the SOE, all individuals suspected of COVID-19 were placed in hospital isolation in single rooms until the results of their PCR tests were available. Every confirmed or highly suspected case was consistently kept in hospital isolation during the viral phase, for a minimum of 7 to 10 days, without any visits allowed from relatives. After discharge, the patients were confined for an additional two weeks until their PCR returned negative. When proper isolation at home was not possible, individuals were placed in single hotel rooms, under strict surveillance from the authorities.
The main objective of our work was to evaluate the prevalence of anxiety and depression in this population using the Hospital Anxiety and Depression Scale (HADS), and secondly, to identify the various factors associated with patients experiencing these symptoms while in hospital isolation during the initial phase of COVID-19.
2. Materials and Methods
2.1. Study Design and Settings
This cross-sectional, monocentric study was conducted in an isolation unit at the Ibn Sina University Hospital Center of Rabat, Morocco, and was carried out from 1 April 2020 to 1 May 2020.
Consecutive patients aged over 18 years old and hospitalized in isolation for suspected or confirmed COVID-19 were included. Patients who died, who were unable to understand the questions or communicate, and those who did not wish to participate were excluded.
2.2. Data Collection
The sociodemographic characteristics, medical characteristics, and characteristics related to the healthcare system and environment were recorded. To evaluate symptoms of anxiety and depression among isolated patients during their hospital stay, we used the HADS. The questionnaires were delivered either by telephone or in person. The survey took approximately 20 min to complete.
2.2.1. Sociodemographic and Medical Characteristics
Epidemiological data included age, gender, marital status (married or not), academic education (none, primary school, secondary school, or post-graduate), and professional status (student, unemployed, employed, or retired). The patients’ history comprised chronic disease and toxic use (tobacco, alcohol, drugs). A history of traumatic events was noted, defined as exposure to actual or threatened death, serious injury, or sexual violence by directly experiencing it, witnessing it, learning that it had occurred to a relative, or being exposed to extreme or repeated aversive details of it (DSM V criteria).
The initial symptomatology was classified into respiratory, digestive, neurological, and general symptoms. Upon admission, the patients’ vital signs were recorded. The results of the chest CT scan and SARS-CoV-2 RT-PCR test from the nasopharyngeal swab were noted. Therapeutic management was also documented.
2.2.2. Adherence to Public Health Authorities’ Directives
We surveyed patients about their compliance with the preventive measures recommended by the Public Health Authorities during the pandemic, including confinement at home, maintaining a social distancing of at least 1 m, mask wearing in public, frequent handwashing or the use of hand sanitizer, avoiding touching the face with hands, coughing or sneezing into a single-use tissue or the sleeve of the elbow or the upper arm, immediate dispose of used tissue papers, room ventilation, and the avoidance of sick people. We categorized the patients’ adherence to these nine measures into four levels: poor (less than 4 measures applied), moderate (4 to 6 measures applied), good (6 to 8 measures applied), and very good (9 out of 9 measures applied). The patients also rated their self-perception levels of understanding of the disease, understanding of the reasons for isolation, and adherence to the infection control directives, using a scale from 0 (worst self-perception) to 10 (best self-perception).
2.2.3. Hospital Isolation and Communication
For each patient, we documented the type of accommodation (single or shared room) and the length of the hospital stay (per day). The patients’ phone disposal, network access, and social media use were specified. We noted their major sources of information concerning the outbreak and categorized them as public health authorities, health care providers, media, regular websites, and word of mouth. Furthermore, we asked patients to indicate the average number of daily rounds from the medical and paramedical staff, and to rate, using a scale from 0 to 10, their quality of communication with healthcare providers and their satisfaction with the medical care provided.
2.3. Outcome Measures
2.4. Statistical Analysis
Continuous variables were reported as mean and standard deviation for variables with normal distributions and as median and interquartile range (IQR) for variables with skewed distributions. The normality of the distribution was tested using the Kolmogorov–Smirnov test with Lilliefors correction. Categorical variables were presented as percentages within each category. Group comparisons were conducted using Pearson’s chi-squared test and a linear-model ANOVA. To evaluate the internal consistency of the HADS items, Cronbach’s coefficient alpha was employed. A high alpha coefficient (≥0.70) suggests that the items within a scale measure the same construct, supporting the construct validity. Anxiety and depression were considered the dependent variables.
3. Results
3.1. Sociodemographic and Medical Characteristics
A total of 200 participants were included. The study population consisted entirely of Moroccan individuals, with a mean age of 40 ± 15 years (18–78). The gender distribution revealed a male-to-female ratio of 1.5, with men accounting for 61% of the patients. In terms of matrimonial status, 52% of the patients were married. Educational attainment varied among the participants, with 50% having completed post-graduate education, 36% with a secondary degree, and 14% with elementary education or no formal education. The majority of patients were employed (69%), including 15% who were healthcare professionals, while 14% were unemployed, 11% were retired, and 10% were students. Past history included chronic disease (32%) and toxic use (23%). A history of traumatic events was noted in 16.5% of the cases.
Patients manifested respiratory (47%), general (47%), neurological (30.5%), and digestive (27%) symptoms. Upon admission, a mean of 20% of the patients presented with desaturation in room air, requiring oxygen support. COVID-19 was confirmed via RT-PCR tests for 132 patients (66%), while 34% had negative testing and remained in isolation as highly suspected cases. In the chest CT scan, the pulmonary extent was classified as moderate to severe in 53.5% of the cases. The patients were mainly treated with hydroxychloroquine (91%), azithromycin (95%), anticoagulants (88%), glucocorticoids (68%), and antibiotics (55%).
3.2. Adherence to Public Health Authorities’ Directives
The study participants assessed their adherence to preventive measures recommended by Public Health Authorities as poor (14.5%), moderate (22.5%), good (42.5%), and very good (20.5%). Using a self-perception scale from 0 to 10, the patients’ mean levels of understanding of the disease, understanding of the reasons for isolation, and adherence to the infection control directives were reported as 7.6, 8.9, and 9.4, respectively.
3.3. Hospital Isolation and Communication
In 68% of the cases, the patients were isolated in single rooms, while 32% of them were placed in shared rooms. The average duration of isolation was 8 ± 3 days, with a maximum duration of 25 days. During their hospital stay, nearly all patients had a mobile phone (99.5%), access to a network (93%), and social media use (89.5%). Their major sources of information regarding the COVID-19 outbreak were Public Health Authorities 78.5%), media (70.5%), healthcare providers (44%), regular websites (24.5), and word of mouth (19%). The patients stated to have received an average of five visits per day from the medical and paramedical staff. They evaluated their quality of communication with healthcare providers and their satisfaction with medical care provided as means of 8.9 and 9.0, respectively.
3.4. Hospital Anxiety and Depression Scale (HADS)
A subsequent multiple logistic regression indicated that the factors associated with anxiety were female gender (OR = 2.54; 95% CI (1.34; 4.78) p = 0.004), secondary or university level (OR = 3.55; 95% CI (1.08; 11.64) p = 0.03), longer duration of isolation (OR = 1.10; 95% CI (1.01; 1.20) p = 0.01), and poor understanding of the reasons for isolation (OR = 0.71; 95% CI (0.55; 0.92) p = 0.01).
On the other hand, the factors associated with depression were female gender (OR = 3.53; 95% CI (1.82; 6.84) p < 0.001), chronic disease (OR = 3.22; 95% CI (1.43; 7.24) p = 0.005), longer duration of isolation (OR = 1.09; 95% CI (0.99; 1.19) p = 0.05), and poor understanding of the reasons for isolation (OR = 0.67; 95% CI (0.52; 0.87) p = 0.003)
4. Discussion
This research aimed to assess the mental health status of patients who were forced into hospital isolation during the initial phase of the COVID-19 pandemic in Morocco. Among the 200 patients enrolled, we observed that 42.5% and 43% experienced high levels of anxiety and depression, respectively. In the multiple logistic regression, female gender, a higher education level, a longer duration of isolation, and a poor understanding of the reasons for isolation were statistically associated with anxiety. Conversely, the factors associated with depression were female gender, having a chronic disease, a longer duration of isolation, and a poor understanding of the reasons for isolation.
Overall, we found high levels of anxiety and depression among patients forced into hospital isolation during the COVID-19 pandemic in Morocco. The relevant factors identified to be significantly associated with patients experiencing psychological distress were female gender, a higher educational level, chronic disease, a longer duration of hospitalization, and a poor understanding of the reasons for isolation.
5. Practical Implications
Based on our findings, we recommend minimizing the duration of isolation whenever possible. Implementing common rooms for positive patients, providing various materials (TV, books, cards, board games, etc.), and facilitating communication with relatives, can help to reduce feelings of boredom and loneliness. Patients should receive comprehensive written and verbal information about the reasons for isolation, as well as regular updates on their management and care. Hence, adequate training of healthcare professionals is crucial to ensure effective communication, which includes delivering clear explanations to patients, checking their understanding, and engaging in active listening. Identifying high-risk patients is of paramount importance for early prevention through specialized psychological interventions, and ensuring appropriate follow-up when necessary.
6. Limitations
7. Conclusions
Our study highlights high levels of anxiety and depression among patients forced into hospital isolation in Morocco during the initial phase of the COVID-19 pandemic. We identified female gender, a higher education level, chronic disease, a longer duration of isolation, and a poor understanding of the reasons for isolation as significant factors associated with psychological distress. To tackle these challenges, global health strategies should prioritize patients with preparatory and accurate information regarding isolation, enhance effective communication with healthcare professionals, shorten the length of isolation, and implement measures to reduce boredom and loneliness. The early identification of individuals at high risk for anxiety and depression is crucial, allowing for timely and targeted interventions to prevent psychological distress. These findings offer valuable insights to support patients’ mental well-being during future public health emergencies, not only in Morocco, but also in other countries facing similar challenges.
Supplementary Materials
Author Contributions
J.B. and R.A. conceived the study, supervised its design, execution, and analysis, and participated in the drafting and critical review of the manuscript. S.C. conducted data management and statistical analysis and wrote the paper with input from all investigators. E.E.F. managed funding acquisition. R.N.B. and N.M. contributed to the supervision and validation of the study. All authors have read and agreed to the published version of the manuscript.
Funding
This research received no external funding. Article Processing Charges was assumed by “Academie Hassan II des Sciences et Techniques”.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee for Biomedical Research of the Faculty of Medicine and Pharmacy of Rabat at Mohammed V University (N/21) on 16 March 2020.
Informed Consent Statement
Informed consent was obtained from all subjects involved in this study.
Data Availability Statement
Acknowledgments
We thank “Academie Hassan II des Sciences et Techniques” as part of the Morocco consortium for biomedical research on COVID-19) MCBR-COVID619/2021-2023) for Article Processing Charges.
Conflicts of Interest
The authors declare no conflicts of interest.
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Table 1.
Descriptive characteristics and univariable analysis of the factors associated with anxiety and depression among COVID-19 patients in enforced hospital isolation at Ibn Sina University Hospital from 1 April to 1 May 2020.
Table 1.
Descriptive characteristics and univariable analysis of the factors associated with anxiety and depression among COVID-19 patients in enforced hospital isolation at Ibn Sina University Hospital from 1 April to 1 May 2020.
Anxiety | Depression | ||||||
---|---|---|---|---|---|---|---|
N = 200 | No Anxiety (n = 115) | Anxiety (n = 85) |
p-Value | No Depression (n = 114) |
Depression (n = 86) |
p-Value | |
Age ** (years) | 41 (15) | 41 (15) | 40.5 (16) | 0.89 1 | 41 (14) | 40 (16) | 0.52 1 |
Gender * | 0.009 2 | <0.001 2 | |||||
Male | 122 (61) | 79 (69) | 43 (51) | 82 (72) | 40 (46.5) | ||
Female | 78 (39) | 36 (31) | 42 (49) | 32 (28) | 46 (53.5) | ||
Marital status * | 0.52 2 | 0.05 2 | |||||
Non-married | 96 (48) | 53 (46) | 43 (51) | 48 (42) | 48 (56) | ||
Married | 104 (52) | 62 (54) | 42 (49) | 66 (58) | 38 (44) | ||
Academic education * | 0.35 2 | 0.65 2 | |||||
None–primary level | 26 (13) | 16 (14) | 10 (12) | 15 (13) | 11 (13) | ||
Secondary level | 74 (37) | 45 (39) | 29 (34) | 44 (39) | 30 (35) | ||
University level | 100 (50) | 54 (47) | 46 (54) | 55 (48) | 45 (52) | ||
Professional status * | 0.56 2 | 0.07 2 | |||||
Unemployed | 30 (15) | 16 (14) | 14 (16.5) | 12 (10.5) | 18 (21) | ||
Student | 21 (10.5) | 11 (9.5) | 10 (12) | 10 (9) | 11 (13) | ||
Employed | 138 (69) | 82 (71) | 56 (66) | 88 (77) | 50 (58) | ||
Retired | 11 (5.5) | 6 (5) | 5 (6) | 4 (3.5) | 7 (8) | ||
Chronic disease * | 0.19 2 | 0.01 2 | |||||
No | 63 (31.5) | 83 (72) | 54 (63.5) | 86 (75) | 51 (59) | ||
Yes | 137 (68.5) | 32 (28) | 31 (36.5) | 28 (25) | 35 (41) | ||
Toxic use * | 0.40 2 | 0.94 2 | |||||
No | 154 (77) | 91 (79) | 63 (74) | 88 (77) | 66 (77) | ||
Yes | 46 (23) | 24 (21) | 22 (26) | 26 (23) | 20 (23) | ||
History of traumatic events * | <0.001 2 | 0.009 2 | |||||
No | 167 (83.5) | 108 (94) | 59 (70) | 102 (89.5) | 65 (76) | ||
Yes | 33 (16.5) | 7 (6) | 26 (31) | 12 (10.5) | 21 (24) | ||
Level of application of the preventive measures * | 0.25 2 | 0.42 2 | |||||
Poor | 29 (14.5) | 18 (16) | 11 (13) | 19 (17) | 10 (11.6) | ||
Moderate | 45 (22.5) | 20 (17) | 25 (29) | 18 (16) | 27 (31.4) | ||
Good | 85 (42.5) | 49 (43) | 36 (42) | 51 (45) | 34 (39.5) | ||
Very good | 41 (20.5) | 28 (24) | 13 (15) | 26 (23) | 15 (17) | ||
Results of PCR test * | 0.78 2 | 0.40 2 | |||||
Negative | 68 (34) | 40 (35) | 28 (33) | 36 (32) | 32 (37) | ||
Positive | 132 (66) | 75 (65) | 57 (67) | 78 (68) | 54 (63) | ||
Duration of isolation (day) ** | 8 (3) | 1 (1) | 1 (1) | 0.14 1 | 1.3 (1) | 1.3 (1) | 0.62 1 |
Type of room * | 0.07 2 | 0.02 2 | |||||
Single | 137 (68.5) | 73 (63.5) | 64 (75) | 71 (62) | 66 (77) | ||
Shared | 63 (31.5) | 42 (36.5) | 21 (25) | 43 (38) | 20 (23) | ||
Number of staff visits (day) ** | 5 ± 2 | 5 (1.5) | 5 (1) | 0.39 1 | 5 (1.5) | 5 (1) | 0.68 1 |
Major sources of information | |||||||
Public health authorities * | 0.42 2 | 0.85 2 | |||||
No | 43 (21.5) | 27 (23.5) | 16 (19) | 24 (21) | 19 (22) | ||
Yes | 157 (78.5) | 88 (76.5) | 69 (81) | 90 (79) | 67 (78) | ||
Media * | 0.33 2 | 0.61 2 | |||||
No | 59 (29.5) | 37 (32) | 22 (26) | 32 (28) | 27 (31) | ||
Yes | 141 (70.5) | 78 (68) | 63 (74) | 82 (72) | 59 (69) | ||
Regular websites * | 0.16 2 | 0.75 2 | |||||
No | 151 (75.5) | 91 (79) | 60 (70) | 87 (76) | 64 (74) | ||
Yes | 49 (24.5) | 24 (21) | 25 (29) | 27 (24) | 22 (26) | ||
Health care providers * | 0.68 2 | 0.23 2 | |||||
No | 112 (56) | 63 (55) | 49 (58) | 68 (60) | 44 (51) | ||
Yes | 88 (44) | 52 (45) | 36 (42) | 46 (40) | 42 (49) | ||
Word of mouth * | 0.07 2 | 0.33 2 | |||||
No | 162 (81) | 98 (85) | 64 (75) | 95 (83) | 67 (78) | ||
Yes | 38 (19) | 17 (15) | 21 (25) | 19 (17) | 19 (22) | ||
Communication level ** | 8.5 (2) | 9 (1.5) | 8 (2) | 0.11 1 | 8 (2) | 8.5 (2) | 0.51 1 |
Satisfaction level ** | 9 (1) | 9 (1) | 9 (1.5) | 0.12 1 | 9 (1.5) | 9 (1) | 0.31 1 |
Disease understanding level ** | 8 (2) | 8 (2) | 7 (2) | 0.10 1 | 8 (2) | 7.5 (2) | 0.15 1 |
Isolation understanding level ** | 9 (1) | 9 (1) | 9 (1) | 0.02 1 | 9 (1) | 9 (1.5) | 0.004 1 |
Adherence to infection control directives level ** | 9 (1) | 9.5 (1) | 9 (1) | 0.28 1 | 9.5 (1) | 9 (1) | 0.14 1 |
Table 2.
Multivariable analysis of the factors associated with anxiety and depression among COVID-19 patients in enforced hospital isolation at Ibn Sina University Hospital from April 1st to May 1st, 2020.
Table 2.
Multivariable analysis of the factors associated with anxiety and depression among COVID-19 patients in enforced hospital isolation at Ibn Sina University Hospital from April 1st to May 1st, 2020.
Anxiety | Depression | |||||
---|---|---|---|---|---|---|
OR | 95%CI | p-Value | OR | 95%CI | p-Value | |
Age | 0.98 | 0.96; 1.01 | 0.35 | 0.97 | 0.94; 1.00 | 0.09 |
Gender | ||||||
Female/Male | 2.54 | 1.34; 4.78 | 0.004 | 3.53 | 1.82; 6.84 | <0.001 |
Marital status | ||||||
Married/Non-married | 1.02 | 0.52; 2.01 | 0.94 | 0.69 | 0.34; 1.41 | 0.31 |
Academic education | ||||||
None/Primary school | 2.49 | 0.78; 7.92 | 0.12 | 2.47 | 0.74; 8.22 | 0.14 |
Secondary school/University | 3.55 | 1.08; 11.64 | 0.03 | 3.09 | 0.90; 10.55 | 0.07 |
Chronic disease | ||||||
Yes/No | 1.70 | 0.79; 3.64 | 0.17 | 3.22 | 1.43; 7.24 | 0.005 |
Type of room | ||||||
Single/Shared | 1.84 | 0.87; 3.88 | 0.10 | 1.99 | 0.92; 4.33 | 0.08 |
Duration of isolation | 1.10 | 1.01; 1.20 | 0.01 | 1.09 | 0.99; 1.19 | 0.05 |
Isolation understanding level | 0.71 | 0.55; 0.92 | 0.01 | 0.67 | 0.52; 0.87 | 0.003 |
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