ORIGINAL RESEARCH

published: 20 November 2020

doi: 10.3389/fpsyt.2020.586355

Effect of Psychological–Behavioral
Intervention on the Depression and
Anxiety of COVID-19 Patients
Xiangyu Kong 1† , Fanyang Kong 2† , Kailian Zheng 1† , Min Tang 1† , Yi Chen 1† , Jiahuan Zhou 3† ,
Yi Li 1† , Le Diao 3 , Shouxin Wu 3 , Piqi Jiao 1*, Tong Su 4* and Yuchao Dong 1*
1
Huoshenshan Hospital, Wuhan, China, 2 Department of Gastroenterology, Shanghai Changhai Hospital, Shanghai, China,
3
Shanghai Zhangjiang Institute of Medical Innovation, Shanghai Biotecan Pharmaceuticals Co., Ltd., Shanghai, China,
4
College of Psychology, Naval Medical University, Shanghai, China

The COVID-19 epidemic has caused increasing public panic and mental health stress.
In this study, we explore the prevalence and factors linked to anxiety and depression in
hospitalized patients with COVID-19. A total of 144 patients diagnosed with COVID-19
underwent depression and anxiety assessment by using the Hospital Anxiety and
Edited by:
Andreas Maercker, Depression Scale (HADS). Social support level was also evaluated by the Perceived
University of Zurich, Switzerland Social Support Scale (PSSS) at admission. Results showed that gender, age, oxygen
Reviewed by: saturation, and social support were associated with anxiety for COVID-19 patients.
Suqin Tang,
Shenzhen University, China In addition, age, family infection with SARS-CoV-2, and social support were the risk
Andrea B. Horn, factors associated with depression. Moreover, we designed a psychological–behavioral
University of Zurich, Switzerland
intervention (PBI) program that included psychological support and breathing exercises,
*Correspondence:
and explored its effects on patients with COVID-19. Of the 144 participants, 26 patients
Piqi Jiao
[email protected] with both anxiety and depression symptoms (cutoff score of ≥8 on HADS-A and
Tong Su HADS-D) were randomly assigned to the intervention group and the control group at
[email protected]
Yuchao Dong a 1:1 ratio. After 10-day treatment, the HADS scores of depression and anxiety were
[email protected] significantly reduced in the intervention group, and PSSS scores were also significantly
† These authors have contributed improved. However, no significant differences in HADS and PSSS scores between
equally to this work pre- and post-treatment were found in the control group. Our findings indicate that
mental concern and appropriate intervention are essential parts of clinical care for
Specialty section:
This article was submitted to
COVID-19 patients.
Mood and Anxiety Disorders,
Keywords: COVID-19, depression, anxiety, social support, psychological-behavioral intervention
a section of the journal
Frontiers in Psychiatry

Received: 03 August 2020 INTRODUCTION

Accepted: 19 October 2020
Published: 20 November 2020 Since December, 2019, an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe
Citation: acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has widely and rapidly spread in China
Kong X, Kong F, Zheng K, Tang M, and around the world (1). As of June 21, 2020, more than 8,700,000 confirmed cases and at least
Chen Y, Zhou J, Li Y, Diao L, Wu S,
460,000 deaths have been reported in 216 countries (territories/areas), according to the World
Jiao P, Su T and Dong Y (2020) Effect
of Psychological–Behavioral
Health Organization (WHO) (2). The grim epidemic has caused increasing public panic and mental
Intervention on the Depression and health stress. Mental health is becoming an issue that cannot be ignored, while trying to control
Anxiety of COVID-19 Patients. the outbreak.
Front. Psychiatry 11:586355. Previous studies have shown that depression and anxiety are common and persistent mental
doi: 10.3389/fpsyt.2020.586355 illness in various illnesses including chronic diseases (3, 4) and cancer (5). These studies indicated

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Kong et al. Mental Health of COVID-19 Patients

that patients with mental illness, including depression and

anxiety, may have difficulty with symptom control, as well as
impaired quality of life. However, recently published researches
on psychological impact of COVID-19 are mainly focused on
healthcare workers (6, 7) and the general public (8), who were
worried about the risks of infection and protective measures.
Note that patients after diagnosis of COVID-19 were more
likely to have psychological concerns such as fear of progression
of their illness, disability, or premature death. Additionally, it
has been reported that psychological distress may affect patient
compliance with medical treatment (9, 10) and disease duration
(4, 11). Therefore, it is vital to pay attention to the mental
health of COVID-19 patients, and appropriate intervention may
be beneficial for them. However, so far, the prevalence and
related factors of anxiety and depression in patients infected with
COVID-19 has been rarely reported.
It has been demonstrated that a psychological intervention
can reduce emotional distress, promote positive health habits,
and enhance immune responses for patients with cancer and
other diseases (12–14). As for infectious diseases, optimism
and related constructs could improve the anxiety control
and life quality of chronic hepatic B patients (15), as well
as the pain management in people with HIV (16). We
thought that psychological intervention may be beneficial for FIGURE 1 | A flow diagram indicating study design.
patients’ mental health and therapeutic process. Given that
the doctors involved in the fight against the COVID-19 were
not professional psychologists, we mainly referred to U.S.
SPIKES (17) and Australian Consensus Guidelines (18) on
of Huoshenshan Hospital (Wuhan, China) from 23 February
the strategies for dealing with patients’ negative emotions,
2020 to 13 March 2020. The inclusion criteria were as follows:
making the intervention protocol operable for clinical staff.
(1) aged 15–85 years; (2) patients were diagnosed with COVID-
Meanwhile, breathing exercises have been reported to reduce
19 according to WHO interim guidance. The exclusion criteria
the levels of anxiety and depression and improve pulmonary
were as follows: (1) patients with intellectual and cognitive
function (19, 20). Hence, we designed a psychological–behavioral
impairment; (2) patients did not have a smartphone. Informed
intervention (PBI) program that included psychological support
consent was provided by subjects before study commencement.
and breathing exercises for patients with anxiety and depression.
The flow diagram (Figure 1) shows that a total of 165
We intend to investigate whether this kind of intervention could
patients were admitted to two divisions of Huoshenshan Hospital
effectively lower anxiety and depression level of patients.
during that period. Nine patients refused to participate in the
From the above, two aims were included in the present study.
research study, and 12 patients were subsequently excluded
Aim 1: To explore the prevalence and factors linked to anxiety
due to not having smartphones. Eventually, 144 patients with
and depression in hospitalized patients with COVID-19. Aim
confirmed COVID-19 completed the questionnaires through
2: To determine the effect of PBI on anxiety and depression of
an online survey platform (“SurveyStar,” Changsha Ranxing
patients with COVID-19.
Science and Technology, Shanghai, China) at admission. The
This study may draw more attention to the psychological
study was approved by the Research Ethics Commission of
state of patients with COVID-19 and assist doctors to provide
Huoshenshan Hospital.
more appropriate treatment and psychological interventions to
improve mental and physical health of patients during the
campaign to contain and eradicate COVID-19. Assessments
Hospital Anxiety and Depression Scale (HADS)
The HADS is a self-assessment questionnaire designed by
METHODS Zigmond et al. in 1983, which aims to detect anxiety and
depression symptoms in general hospital patients. It has been
Prevalence and Factors Linked to Anxiety acknowledged that the Chinese version (published in 1993) of
and Depression in Hospitalized Patients the HADS had good internal consistency and favorable scale
With COVID-19 equivalence (21). The degree of anxiety and depression is rated
Participants by the accumulated scores: score 0–7, indicating no anxiety
Patients were admitted to two divisions (Division 1 of the or depression; score 8–10, indicating mild levels of anxiety or
Second Department and Division 2 of the Fourth Department) depression; score 11–14, indicating moderate levels of anxiety or

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Kong et al. Mental Health of COVID-19 Patients

depression; and score 15–21, indicating severe levels of anxiety In the present study, we mainly referred to U.S. SPIKES (17)
or depression. and Australian Consensus Guidelines (18) on the psychosocial
support protocols for delivering bad news to patients. We
Perceived Social Support Scale consulted with psychologists to develop the procedure for
The 12-item PSSS was compiled by Zimet et al. in 1987. The psychological intervention. Meanwhile, five psychological
Chinese version PSSS (published in 1996) has been widely experts were invited to provide scientific suggestions and
adopted to measures with perceived support from family, friends, feasibility assessment for the psychological intervention.
and other ways in the Chinese population (22). Total scores range The psychological intervention process includes:
from 0 to 84, classified into low (12–36), moderate (37–60), and 1. Setting up interview
high levels of social support (61–84). 2. Encouraging patients to express feelings
3. Expressing understanding and comfort patients
Effect of PBI on Patients With COVID-19 4. Giving knowledge and information about COVID-19
Study Design 5. Providing some simple relaxation techniques, and offering the
This study is a single-center, evaluator-blinded, randomized self-emotional management skills (such as listening to music
controlled trial. as a way of distraction when in a bad mood)
6. Summary (helping patients to eliminate mental tension and
Participants build up confidence to overcome disease, as well as persuading
Because all 144 participants completed the HADS questionnaires them to cooperate with treatment and care in a positive and
through an online survey platform “SurveyStar” at admission. optimistic manner)
We could obtain the scores of each patient once they finished the
The psychological support intervention was designed to be
test. We consecutively recruited the patients with both symptoms
brief within 15 min, considering the limited condition (medical
of anxiety and depression in the PBI study. A cutoff score of ≥8
workers needed to wear masks and protective clothing in
on both anxiety and depression subscales was applied to identify
isolation wards) in communication with patients.
patients with both anxiety and depression.
The psychological intervention was performed by two
Of the 144 participants, twenty-six patients with COVID-19
appointed medical staffs, who have been trained for providing the
were identified with both symptoms of anxiety and depression
psychological support.
via HADS questionnaire.
1. Regular training: Before being temporarily assigned to
Randomization Huoshenshan Hospital, the two appointed medical staffs were
Twenty-six eligible patients were consecutively and randomly medical workers of Changhai Hospital affiliated to Navy
assigned to the PBI group and the control group (13 patients in Medical University. They have received regular doctor–patient
each group), according to the order of admission. All of them communication training, including lectures on “Common
signed the informed consents. There was no difference in the psychological problems with patients” and “How to better
age and sex distribution between the control group and the communicate with patients” by psychologists at the Naval
intervention group. Each patient was isolated in a separate room Medical University.
at the Huoshenshan Hospital. The intervention group and the 2. Guidance by Psychological Intervention Manual: After the
control group have no chance to communicate with each other outbreak of COVID-19, professors from the College of
about the treatment. Psychology of the Naval Medical University compiled the
“COVID-19 Psychological Guidance Manual.” This manual
Intervention introduced potential psychological response of patients during
All patients were given their normal medical regimens and the epidemic, and some techniques of psychological care. The
basic care during hospitalization. For the control group, they two appointed medical staffs studied the manual and held
communicated with the doctors only on daily ward rounds. telephone sessions with psychologists, who gave more details
While for the intervention group, a 10-day PBI program about psychological support skills.
was carried out when stable status of patients was confirmed
after admission. The procedure of the psychological intervention was jointly
The details of PBI were as follows: designed by researchers (including the two appointed medical
staffs) and psychological experts, according to actual situation
1. Breathing exercise: of Huoshenshan Hospital. When problems appeared in the
Every morning, two trained medical workers would guide implementation process, remote assistance would be given by
patients to have a breathing exercise for 20 min around 10:00 a. psychological experts via video calls.
m. (Supplementary Figure 1). The breathing exercise is based on
Assessments
Yoga’s breathing techniques and focuses on stimulating nasal and
Hospital Anxiety and Depression Scale (HADS)
diaphragmatic breathing, increasing the expiratory time, slowing
After a 10-day treatment, anxiety and depression of patients were
the respiratory flow, and regulating the breathing rhythm.
assessed again by use of HADS. The HADS-A (Hospital Anxiety
2. Psychosocial support: and Depression Scale-Anxiety) score and HADS-D (Hospital

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Kong et al. Mental Health of COVID-19 Patients

Anxiety and Depression Scale-Depression) scores were used as TABLE 1 | Baseline demographic and clinical characteristic of patients with
indexes to evaluate the intervention effects. COVID-19.

n %
Perceived Social Support Scale
After a 10-day treatment, self-reported levels of social support Gender
were assessed again by use of PSSS. Male 70 48.6
Female 74 51.4
Statistical Analysis Age (years)
SPSS software, version 19 were used for statistical analysis. ≤50 70 48.6
Means and proportions of the given data for each variable >50 74 51.4
were calculated. Categorical variables were analyzed using the Marital status
Pearson’s chi-square test or Fisher’s exact test. Continuous Married 121 84.0
variables were analyzed using non-paired Student t-test or Single 17 11.8
paired Student t test. Multivariate regression analysis with
Divorced 2 1.4
stepwise method was performed to identify factors associated
Widowed 4 2.8
with depression and anxiety. Multivariate analysis of variance
Education status
was used to analyze the difference between the PBI group and
Primary 4 2.8
the control group in the post-treatment HADS score. Differences
Lower secondary 34 23.6
between groups were considered to be significant when the
Upper secondary 52 36.1
p-value was < 0.05.
University/master/doctorate 54 37.5
Oxygen saturation at rest
RESULTS ≤93% 16 11.1

Prevalence and Factors Linked to Anxiety >93% 128 88.9

Infection status of family members
and Depression in Hospitalized Patients
Infected 59 41.0
With COVID-19 Non-infected 85 59.0
Demographic Characteristics Clinical symptoms
A total of 165 patients were admitted to two divisions of Fever 121 84.0
Huoshenshan Hospital (Wuhan, China) from 23 February 2020 Cough 113 78.5
to 13 March 2020. The flow diagram (Figure 1) shows that Shortness of breath 73 50.7
nine patients refused to participate in the research study and
Fatigue 63 43.8
12 patients were subsequently excluded due to not having
Chest distress 28 19.4
smartphones. A total of 144 participants, including 70 male and
Myalgia 14 9.7
74 female, were eligible and completed the questionnaires in the
current study. The age of the study participants ranged from 15 to
87 years. Their average age was 49.98 ± 13.73 years. Participants
were mostly living with a spouse (121/144, 84%). About a third
of the subjects (54/144, 37.5%) were well educated (≥bachelor’s presented symptoms of anxiety and depression, respectively.
degree), and only 4 of 144 participants (2.8%) had primary Regarding the patients’ anxiety levels, it was found that 17.36,
education. Oxygen saturation is a key clinical index for evaluating 12.5, and 4.86% appeared to have mild, moderate, and severe
the severity of patients with COVID-19 (23). In the present study, anxiety, respectively. As for the depression levels of patients, 20
11.1% of participants who had an oxygen saturation ≤93% at rest were mildly depressed (13.89%), 15 were moderately depressed
were with severe disease. Other clinical symptoms of COVID- (10.42%), and 6 were severely depressed (4.17%).
19 patients were also recorded. As other COVID-19-related
studies reported (1, 24–26), fever (84%), cough (78.5%), and Correlations Among Depression, Anxiety, and Social
shortness of breath (50.7%) were the most common symptoms. Support in COVID-19 Patients
In addition, considering that other family members’ infection There is a large body of evidence that shows that social support
may cause emotional distress to the participants, we also collected plays a beneficial role in mental health (27). Self-reported levels
the infection status of family members. Fifty-nine participants of social support were assessed among the patients with COVID-
(41%) had one or more family members infected. Demographic 19. The mean social support score for all participants was
characteristics are listed in Table 1. 63.41 ± 11.99. The average score of family, friends, and other
support was 22.35 ± 4.42, 20.53 ± 4.60, and 20.52 ± 4.55,
Psychosocial Characteristics of the Participants With respectively. More than half of the participants (90/144, 62.5%)
COVID-19 exhibited high level of perceived social support.
The mean score of anxiety subscale and depression subscale for The bivariate correlations showed that less social support
all patients was 6.35 ± 4.29 and 5.44 ± 4.32, respectively. With was correlated with more anxious (r = −0.196, p < 0.05)
the reference to HADS, 50 (34.72%) and 31 (28.47%) participants and depressive (r = −0.360, p < 0.05) symptoms (Table 2).

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Kong et al. Mental Health of COVID-19 Patients

TABLE 2 | Association between anxiety, depression, and social support.

Anxiety Depression Social support Family support Friend support Other supports

Anxiety 0.512** −0.196* −0.124 −0.165* −0.230**

Depression −0.360** −0.283** −0.307** −0.363**
Social support 0.881** 0.875** 0.896**
Family support 0.642** 0.702**
Friend support 0.671**
Other supports

*p < 0.05, **p < 0.01.

In detail, friend support (r = −0.165, p < 0.05) and other mean score of anxiety and depression was 12.62 ± 2.663 and
support (r = −0.230, p < 0.05) were significantly negatively 11.69 ± 2.926, respectively.
correlated with anxiety. In addition, family support (r = −0.283, After a 10-day PBI treatment, the HADS-A score
p < 0.05), friend support (r = −0.307, p < 0.05), and other (6.15 ± 3.579) and HADS-D score (5.92 ± 3.730) were
support (r = −0.363, p < 0.05) were significantly negatively significantly reduced in the intervention group (p < 0.0001
correlated with depression. and p = 0.0001, respectively) (Figures 2A,B and Table 6),
whereas the HADS-A score (9.92 ± 3.707) and HADS-D score
Factors Associated With Depression and Anxiety (9.92 ± 3.707) of the control group were not significantly
Among Patients With COVID-19 different after 10-day hospitalization (p = 0.076 and p = 0.098,
In order to investigate the factors related to depression and respectively) (Figures 2C,D and Table 6). Additionally, the
anxiety among patients with COVID-19, anxiety and depression multivariate analysis of variance showed that there was
scores were compared between different groups. As shown in significant difference between the PBI group and the control
Table 3, anxiety and depression scores were significantly higher group in the post-treatment HADS score (p = 0.006, Table 5).
in those who were older (age > 50) and with low education. HADS-A score and HADS-D score were significantly lower
Additionally, patients with lower oxygen saturation had higher in the PBI group than those in the control group after 10-day
anxiety score, and those getting less social support had higher treatment (p = 0.014 and p = 0.013, respectively) (Table 5).
depression scores. The number of anxious patients after intervention was three,
The multiple linear regression analysis (Table 4) showed that which was lower (p = 0.111) compared with that in the control
gender (β = 1.446, p = 0.034), age (β = 0.074, p = 0.003), group (n = 8) (Table 5). Additionally, there were three depressed
oxygen saturation (β = −2.140, p = 0.049), and social support patients in the intervention group after PBI, which was less
(β = −1.545, p = 0.017) were associated with anxiety for COVID- compared with that in the control group (n = 9) (p = 0.047)
19 patients. It suggested that female, and patients who are older, (Table 5). The above data indicate that PBI is effective in reducing
with lower oxygen saturation, and less social support would anxiety and depression level in patients with COVID-19.
tend to present anxiety symptoms. Moreover, age (β = 0.084,
The Effect of PBI on Social Support Level of Patients
p = 0.001), family infection with SARS-CoV-2 (β =1.515,
p = 0.027), and social support (β = −2.236, p < 0.001) were With COVID-19
the factors associated with depression. The results indicate that We also investigated the level of social support among 26
patients with older age, family member infection, and less social patients after 10-day treatment. It was found that the PSSS
support are more likely to be depressive (Table 4). scores were improved after PBI in the intervention group (pre-
treatment = 54.69 ± 15.59, post-treatment = 64.46 ± 11.05,
p < 0.0001), while the PSSS scores in the control group did
The Effect of PBI on Patients With not alter significantly (pre-treatment = 62.46 ± 9.62, post-
COVID-19 treatment = 65.62 ± 8.13, p = 0.241) (Figure 3 and Table 7).
The results imply that the intervention could enhance patients’
The Effect of PBI on Anxiety and Depression of
perceived social support.
Patients With COVID-19
Of the 144 participants, 26 patients with COVID-19 were
identified with both symptoms of anxiety and depression via DISCUSSION
HADS questionnaire. They were consecutively and randomly
assigned to the PBI group and the control group according to the
Prevalence and Factors Linked to Anxiety
order of admission. Figure 1 shows that there were 13 patients and Depression in Hospitalized Patients
in each group. There was no significant difference in baseline With COVID-19
scores of anxiety and depression between the control group and A number of studies have interlinked depression and anxiety
the PBI group (p = 0.244 and p = 0.431, respectively) (Table 5). to patients with different diseases (3–5). This study firstly
The mean score of anxiety and depression for the control group reports the prevalence of anxiety and depression in patients with
was 11.23 ± 3.219 and 10.77 ± 2.948. For the PBI group, the COVID-19 during the epidemic. The results of the present study

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Kong et al. Mental Health of COVID-19 Patients

TABLE 3 | Comparison of anxiety and depression scores on different variables (N = 144).

Anxiety score Depression score

Mean ± SD t df p Mean difference (95% CI) Mean ± SD t df p Mean difference (95% CI)

Gender
Male 5.71 ± 3.98 −1.752 142 0.082 −1.245 (−2.650 to 0.160) 5.47 ± 4.30 0.073 142 0.942 0.053 (−1.379 to 1.484)
Female 6.96 ± 4.51 5.42 ± 4.39
Age (years)
≤50 4.91 ± 3.40 −4.129 142 <0.001 −2.802 (−4.143 to −1.460) 4.33 ± 4.44 −3.098 142 0.002 −2.171 (−3.557 to −0.786)
>50 7.72 ± 4.62 6.50 ± 3.97
Marital status
Married 6.53 ± 4.24 1.122 142 0.264 1.094 (−0.834 to 3.023) 5.50 ± 4.13 0.326 142 0.745 0.322 (−1.631 to 2.275)
Single/divorced/widowed 5.43 ± 4.54 5.17 ± 5.36
Education level
Primary/secondary 7.09 ± 4.66 2.710 142 0.008 1.959 (0.530 to 3.389) 6.06 ± 4.47 2.217 142 0.028 1.630 (0.176 to 3.083)
University/master/doctorate 5.13 ± 3.30 4.43 ± 3.92
Oxygen saturation at rest
≤93% 8.75 ± 5.88 2.407 142 0.017 2.695 (0.482 to 4.909) 6.50 ± 5.53 1.035 142 0.303 1.188 (−1.081 to 3.456)
>93% 6.05 ± 3.98 5.31 ± 4.16
Infection status of
family members
Infected 6.92 ± 4.33 1.310 142 0.192 0.951 (−0.484 to 2.385) 6.19 ± 4.63 1.726 142 0.087 1.257 (−0.183 to 2.697)
Non-infected 5.96 ± 4.25 4.93 ± 4.05
Social support
High 5.89 ± 4.28 1.690 142 0.093 −1.241 (−2.692 to 0.211) 4.53 ± 3.89 3.377 142 0.001 −2.430 (−3.852 to −1.008)
Low–Moderate 7.13 ± 4.23 6.96 ± 4.63

95% CI, 95% confidence interval. The values in bold mean statistically significant.

showed that 34.72 and 28.47% of patients with COVID-19 had Meanwhile, older age and lower oxygen saturation are the
symptoms of anxiety or depression, respectively. other factors considered for patients to be anxious. Previous
In the present study, it is noteworthy that social support research has revealed that older patients are at increased risk
is one of the key factors linked to anxiety and depression with severe COVID-19 symptoms and death (26). Additionally,
for patients with COVID-19 (Table 4). The results show oxygen saturation is a key index to evaluate the severity of
that less social support is correlated with more anxious patients with COVID-19. According to the Chinese management
and depressive symptoms (Table 2). Numerous studies have guideline for COVID-19 (30), patients who have an oxygen
demonstrated that in the case of disease, patients need more saturation ≤93% at rest are defined as severe-type patients.
social support, including physical and psychological assistance In this study, 11.1% participants were with low oxygen
provided by family members, friends, medical workers, and saturation. These results indicate that patients with severe
relevant institutions to cope with difficulty (27). There is illness are more likely to be anxious. More psychological care
consistent evidence that shows that social isolation and loneliness and health attention needs to be given to these critically
are linked to worse mental health outcomes (28). During the ill patients.
COVID-19 epidemic, many isolated patients often felt helpless Consistent with previous report, which focused on the
and lonely due to the lack of family or friends accompanying psychological responses among general population during the
them. In such circumstances, medical workers as the major peer COVID-19 epidemic in China (8), female patients are also prone
support are of great significance to infected patients. In clinical to developing higher levels of anxiety as shown in the current
practice, Chinese medical members would keep in touch with study. Meanwhile, education background is another associated
patients and try various psychological support methods to help factor to the mental distress among infected patients. As we
isolated patients rebuild confidence. In some Wuhan makeshift expected, family member infection is another factor affecting
hospitals, patients with mild symptoms did Tai Chi practice patients to be depressed. High levels of concern about other
[which has been verified as an effective way to improve lung family members and lack of family care may magnify pessimism
function for COPD patients; (29)] and singing and dancing as over the illness.
physical relaxation, accompanied and guided by medical staff. This study shows that hospitalized patients with COVID-19
This kind of doctor–patient interaction may encourage patients experience features of anxiety and depression. The significant
to maintain a positive mindset. factors found in the present study may draw medical workers

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Kong et al. Mental Health of COVID-19 Patients

TABLE 4 | Multivariate regression analysis of factors associated with anxiety and depression.

Unstandardized coefficients Standardized coefficients t p

b 95% CI for b SE β

Anxietya
Gender (male/female) 1.446 0.111 to 2.780 0.675 0.169 2.142 0.034
Age 0.074 0.025 to 0.123 0.025 0.236 2.987 0.003
Oxygen saturation (≤93%/>93%) −2.140 −4.268 to −0.012 1.076 −0.157 −1.988 0.049
Social support (low/moderate/high) −1.545 −2.804 to −0.286 0.637 −0.191 −2.427 0.017
Excluded variables
Marital status (married/other) 0.029 – – – 0.327 0.744
Infection status of family members (yes/no) −0.128 – – – −1.618 0.108
Education level 0.045 – – – 0.547 0.585
Depressionb
Age 0.084 0.035 to 0.132 0.024 0.266 3.429 0.001
Infection status of family members (yes/no) 1.515 0.172 to 2.858 0.679 0.173 2.230 0.027
Social support (low/moderate/high) −2.236 −3.477 to −0.996 0.627 −0.275 −3.564 <0.001
Excluded variables
Gender (male/female) 0.004 – – – 0.052 0.959
Marital status (married/other) 0.141 – – – 1.617 0.108
Oxygen saturation (≤93%/>93%) −0.051 – – – −0.646 0.519
Education level −0.003 – – −0.040 0.968

95% CI: 95% confidence interval.

a Dependent variable: anxiety score.

Predictive variables tested by multiple linear regression (stepwise method): Gender, Age, Oxygen saturation, and Social support.
R2 = 0.153, F = 6.274, p = 0.000.
b Dependent variable: depression score.

Predictive variables tested by multiple linear regression (stepwise method): Age, Infection status of family members, and Social support.
R2 = 0.169, F = 9.469, p = 0.000.
The values in bold mean statistically significant.

TABLE 5 | Comparison of anxiety and depression level between the PBI group and the control group.

Number of patients Score

a
PBI Control Chi-square df p PBI Control Mean difference t df pb
(N = 13) (N = 13) value (N = 13) (N = 13) (95%CI)

Pre-treatment
Anxiety 13 13 – – – 12.62 ± 2.663 11.23 ± 3.219 1.385 (−1.006 to 3.776) 1.195 24 0.244
Depression 13 13 – – – 11.69 ± 2.926 10.77 ± 2.948 0.923 (−1.455 to 3.301) 0.801 24 0.431
Post-treatment 0.006c
Anxiety 3 8 3.939 1 0.111 6.15 ± 3.579 9.92 ± 3.707 −3.769 (−6.719 to −0.820) −2.637 24 0.014
Depression 3 9 5.571 1 0.047 5.92 ± 3.730 9.38 ± 2.785 −3.462 (−6.126 to −0.797) −2.681 24 0.013

a Pearson chi-square test or Fisher’s exact test.

b Student t-test for independent samples.
c Multivariate analysis of variance (MANOVA), F = 6.539, Hypothesis df = 2, Error df = 23, p = 0.006.

PBI, psychological–behavioral intervention.

paying more attention to the mental health of patients from depression and anxiety, according to the above results. In
with COVID-19. this study, we conducted a PBI program to investigate its effect
on patients with COVID-19.
The Effect of PBI on Patients With Due to the fact that COVID-19 is a newly emerging pandemic,
COVID-19 few studies on psychological intervention for patients have been
Anxiety and depression are related to longer hospitalization (4, reported. In order to make the intervention protocol operable
11) and non-adherence to treatment (9, 10) in several diseases. A for non-psychological clinical staff, we mainly referred to U.S.
considerable number of patients with COVID-19 indeed suffered SPIKES (17) and Australian Consensus Guidelines (18) on

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Kong et al. Mental Health of COVID-19 Patients

TABLE 6 | Comparison of anxiety and depression scores between pre- and post-treatment in the PBI group and the control group.

Pre-treatment Post-treatment Mean difference (95% CI) t df pa

PBI HADS-A 12.62 ± 2.663 6.15 ± 3.579 6.462 (4.152 to 8.771) 6.097 12 <0.0001
HADS-D 11.69 ± 2.926 5.92 ± 3.730 5.769 (3.631 to 7.908) 5.877 12 0.0001
Control HADS-A 11.23 ± 3.219 9.92 ± 3.707 1.308 (−0.160 to 2.775) 1.942 12 0.076
HADS-D 10.77 ± 2.948 9.38 ± 2.785 1.385 (−0.298 to 3.068) 1.793 12 0.098

aPaired Student t-test.

HADS-A, Hospital Anxiety and Depression Scale-Anxiety score; HADS-D, Hospital Anxiety and Depression Scale-Depression score.

FIGURE 2 | Reduced anxiety and depression by PBI in patients with COVID-19. The alteration of HADS-A score in the intervention group (A) and control group (B).
The alteration of HADS-D score in the intervention group (C) and control group (D).

the psychosocial support protocols for disclosing unfavorable after PBI, which suggested that PBI effectively reduced anxiety
information to patients. It is necessary for medical workers and depression in patients with COVID-19. This might be
to develop relevant communication skills to reduce patients’ attributable to the fact that patients in the intervention group
negative emotions toward their own diseases in clinical practice received frequent communication with medical staff, which
(30). Meanwhile, it was found that cough (78.5%) and shortness resulted in obtaining more information about the disease
of breath (50.7%) were two of the most common symptoms and their condition, thereby alleviating the anxiety and fear
of COVID-19 in the current study, consistent with other caused by being blind to the disease. In addition, the self-
COVID-19 reports (1, 24–26). Breathing exercises have been assessment of social support among 26 patients showed that
proven to improve pulmonary function, as well as reduce the PSSS scores were significantly improved after PBI in the
the levels of anxiety and depression (19, 20). Therefore, we intervention group, while the PSSS scores in the control group
designed the PBI program with psychological support and did not change significantly. The psychological counseling and
breathing exercises. breathing exercises gave more opportunities for patients to
The results showed that anxiety and depression were relieved contact other people, which reduced the sense of solitude
in the intervention group compared with the control group and let them feel support and concern from others, thereby

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Kong et al. Mental Health of COVID-19 Patients

FIGURE 3 | Better self-reported levels of social support by PBI in patients with COVID-19. The alteration of PSSS score in the intervention group (A) and control
group (B).

TABLE 7 | Comparison of PSSS scores between pre- and post-treatment in the PBI group and the control group.

Pre-treatment Post-treatment Mean difference (95% CI) t df pa

PBI 54.69 ± 15.585 64.46 ± 11.050 −9.769 (−14.065 to −5.474) −4.955 12 <0.0001
Control 62.46 ± 9.623 65.62 ± 8.130 −3.154 (−8.719 to 2.411) −1.235 12 0.241

aPaired Student t-test.

PSSS, Perceived Social Support Scale.

reducing the psychological distress of patients with COVID- depression assessment was based on a single measurement
19. This is consistent with the discovery that social support scale. Additionally, blinding was not feasible for participants
is one of the key factors linked to anxiety and depression for and researchers in this study; only the evaluator (who gave
patients with COVID-19. Furthermore, we followed up patients the link of questionnaires) and data analyst were blinded for
in the intervention group using a discharge questionnaire. the treatment. Moreover, we found that PBI alleviated anxiety
All of the 13 patients in the intervention group felt that and depression in patients with COVID-19. The PBI program
they received social support and social care a lot, and they included psychological support and breathing exercises, while
experienced the warmth of the society while hospitalized (data the control group only received treatment as usual. Additional
not shown). evidence is needed to explain whether the effectiveness of PBI
These findings suggest that PBI, as a way of social support, is due to the intervention program or more attention offered by
may have a beneficial effect on COVID-19 patients’ mental medical workers. Lastly, the intervention study has a relatively
health. We believe that this program can also be applied to small number of subjects. A large-scale study is still needed to
other patients with anxiety and depression. In the setting of validate our results.
non-epidemic, this psychological intervention may have a better
effect on patients with sufficient time and diverse methods
DATA AVAILABILITY STATEMENT
(such as body language, facial expressions, group discussions,
lectures, etc.). Early prevention of mental health problems The original contributions presented in the study are included
is of vital importance to help patients have good clinical in the article/Supplementary Material, further inquiries can be
outcomes and better life quality. As the COVID-19 epidemic directed to the corresponding author/s.
continues to spread, our findings are particularly instructive
to develop a psychological support strategy for hospitalized
patients with COVID-19 in China and other areas affected by ETHICS STATEMENT
the epidemic.
The studies involving human participants were reviewed and
approved by the Research Ethics Commission of Huoshenshan
Hospital. Written informed consent to participate in this study
STUDY LIMITATION
was provided by the participants.
It is important to take into account several limitations in this
study. For instance, the present study was single-centered; the AUTHOR CONTRIBUTIONS
study sample was not representative of all patients with COVID-
19 in China, which limited the generalizability of the results. YD, XK, and TS conceived and designed the study.
Due to the restriction of the condition, patients’ anxiety and YC and YL performed the PBI. PJ, KZ, and MT

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Kong et al. Mental Health of COVID-19 Patients

collected the clinical data. FK and JZ analyzed the ACKNOWLEDGMENTS

data. JZ, LD, SW, and XK were involved in drafting
the manuscript. YD and TS revised the manuscript. We thank all of the patients for their participation in the study.
All authors contributed to the article and approved the
submitted version. SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
FUNDING online at: https://www.frontiersin.org/articles/10.3389/fpsyt.
2020.586355/full#supplementary-material
This research was supported by the Military Research Project Supplementary Figure 1 | Photo of COVID-19 patients hospitalized in
for COVID-19 Psychological Protection and Intervention Huoshenshan Hospital, who were having breathing exercises guided by trained
Research (GWS20J007). medical workers.

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