Online Identification of Obsessive-Compulsive Symptoms and Relevant Factors in Patients with Covid-19 in Turkey During Quarantine
Abstract
Abstract.Aim: Via online interviews, this study identifies the obsessive-compulsive symptoms (OCSs) of patients diagnosed with Covid-19 and quarantined at home for 14 days, to determine the incidence of these symptoms, to detect OCSs in the early period, and to identify the associated risk factors. Method: This research was designed as a descriptive and cross-sectional study. The study population consisted of patients who had tested positive in the real-time PCR test for Covid-19 and were quarantined at home in the Şanlıurfa Province of Turkey. The study sample comprised 800 patients contacted between January and April 2021. The data were collected online using a questionnaire that included sociodemographic characteristics, questions on postinfection changes, and the Padua Inventory, a valid tool for determining the level of OCSs. Results: The frequency of obsessive-compulsive symptoms during quarantine was calculated as 11.2%, and the mean Padua Inventory score was 48.19 ± 19.17. Conclusion: The results of this study show that patients quarantined at home for 14 days with the diagnosis of Covid-19 are less likely to exhibit obsessive-compulsive symptoms during this period. It also shows that the risk of OCSs was lower particularly in patients who had completed a university or higher education and had no previous psychiatric disease or chronic disease diagnosis.
Covid-19, which was first detected in December 2019 and then spread all over the world, continues its global impact as a serious public health threat. The World Health Organization declared Covid-19 a pandemic, and it has now affected millions of people across all continents and caused disease and death in susceptible individuals (Abba-Aji et al., 2020; Fontenelle et al., 2021; Zheng et al., 2020). Covid-19 is transmitted from person to person via droplets, and the fatality rate is 2–5%. In the light of this information, based on the recommendations of the health authorities, various measures have been proposed to break the chain of transmission and reduce the death rate. Some of the measures are hand-washing, giving increased importance to personal hygiene, mask-wearing, complying with the social-distance rule, not leaving the house except for necessities, closing schools, and telecommuting in public offices (Abba-Aji et al., 2020; Wheaton et al., 2021). The Covid-19 pandemic caused a serious and permanent threat to human health, given the unprecedented danger and uncontrollability of this infectious disease in modern times. In addition, with the increase in social isolation, people started living an unusual life, and their fears intensified, which led to significant effects on mental health (Arı & Duman, 2020; Fontenelle & Miguel, 2020; Fontenelle et al., 2021; Gürbüz et al., 2021; Zheng et al., 2020). Ritualized behaviors such as frequent hand-washing, one of the Covid-19 preventive measures, were emphasized all over the world, and repetitive thoughts such as fear of contamination have increased the number of obsessive-compulsive symptoms (OCSs) in humans (Arı & Duman, 2020; Chakraborty & Karmakar, 2020; Jelinek, Göritz, et al., 2021; Okur & Demirel, 2020; Samuels et al., 2021; Stein et al., 2019; Wheaton et al., 2021).
OCSs are defined as involuntary, inappropriate, dysfunctional, disturbing, and worrying thoughts (obsessions) and repetitive behaviors (compulsions) developed to cope with the anxiety created by these obsessions (Ruscio et al., 2010). Although the symptoms and clinical pictures may differ, obsessive-compulsive disorder (OCD) is seen all over the world. In a 2010 study by Russia et al., it was reported that 28.2% of individuals exhibited OCSs at least once in their lifetime. According to the APA, the 12-month incidence of OCD internationally lies in the range of 1.1–1.8%. However, in Turkey the incidence of OCD over a 12-month period was found to be 3% (Çilli et al., 2004). The worldwide lifetime prevalence of OCD was estimated to be 2–3% (Arı & Duman, 2020; Fontenelle & Miguel, 2020; Okur & Demirel, 2020; Wheaton et al., 2021). Obsessions or compulsions are time-consuming, often taking up more than an hour a day and thus causing pain and deterioration in both professional and social life (Ornell et al., 2021). Subclinical OCSs are more common, with > 20% of the general population being affected (Fontenelle & Miguel, 2020). This rate is likely to increase further with the Covid-19 pandemic, especially in patients quarantined at home for 14 days with a diagnosis of Covid-19. OCSs likely affect a significant part of the society and will continue to do so for a long time. Hence, it is essential to study the symptoms, investigate the psychotherapeutic approaches based on different schools, and conduct research to develop new approaches (Abba-Aji et al., 2020; Fontenelle et al., 2021; Perkes et al., 2020; Zheng et al., 2020). Because the risk of pneumonia increases in persons with psychiatric disorders, this makes the treatment of Covid-19 difficult and potentially increases the mortality rates. There is thus an urgent need for measures and actions to enhance the mental health of individuals and society in general (Jelinek, Moritz, et al., 2021; Perkes et al., 2020; Seminog & Goldacre, 2013).
This research was conducted with the following aims:
- (1)To identify OCSs in patients diagnosed with Covid-19 and quarantined at home for 14 days, determining the incidence of these symptoms and detecting OCSs during the early period.
- (2)To determine associated risk factors.
Additionally, this research expects to make significant contributions to the literature, being the first study on patients quarantined at home for 14 days with a diagnosis of Covid-19.
Methods
Study Design and Topics
This research was designed as a descriptive and cross-sectional study. It included patients who had been diagnosed with Covid-19 and quarantined at home for 14 days. No control group was included. Rather, the priority of this study was to take a snapshot of the situation. The study population comprised 3,738 individuals who obtained positive real-time PCR test results for Covid-19 across the Şanlıurfa province between January 2021 and April 2021 in Turkey. All individuals who volunteered to participate were included in the study without selecting a sample. The research was completed with 800 participants. Individuals under the age of 18 years (902 individuals) and those who did not want to participate in the study (2,036 individuals) were excluded.
Data Collection Tools
The data were collected with a questionnaire consisting of two sections. The first section included questions about the sociodemographic characteristics of the participants, presence of comorbid disease, time of Covid-19 diagnosis, complaints related to the disease, and lifestyle changes after the disease (12 questions). The second section included the Padua Inventory-Revised, a valid measurement tool for studying and measuring OCSs. The questionnaire was prepared using Google Forms. An access link was sent to the participants over their registered mobile phones stating the purpose of the study and asking for their approval. Then, those participants who volunteered to participate were asked to answer the Google Forms questionnaire on this link.
The Padua Inventory-Revised (PI-R) is a widely applied instrument to measure OCSs in clinical and nonclinical samples (Núñez-Núñez et al., 2022). It was developed by Sanavio (1988) and revised by Van Oppen (1992) to measure the common subtypes of OCSs. The scale consists of 41 questions and five subdimensions: Cleanliness, Impulses, Checking, Rumination, and Precision. The Padua Inventory uses a 5-point Likert-type scale, and each question is scored between 0 and 4: (0) not at all, (1) a little, (2) quite a lot, (3) a lot, and (4) very much. The revised form is a valid measurement tool not only for determining the nonclinical group but also for examining and measuring the OCSs. The Turkish version of both the original and revised versions of the inventory was adapted and validated by Beşiroğlu et al. (2005). The Cronbach’s α value of the scale was 0.95, and the test-retest reliability was 0.91. The scale is a valid tool that measures the symptoms of OCSs. The total scale score indicates the levels of OCSs of the individuals. Because it is not recommended to use the Padua Inventory on its own to determine the disease severity, a cut-off point has not been calculated.
Ethical Approvals and Permissions
Prior to the research, we obtained the necessary study permit for the online application submitted to the Scientific Research Platform of the Ministry of Health (2020-11-06T21_06_14.). Ethical approval was obtained from Harran University Clinical Research Ethics Committee (decision no.: 23 Nov. 2020/20), and the necessary administrative permissions were obtained from the Şanlıurfa Provincial Health Directorate. Based on the principle of voluntariness, the research was conducted in accordance with research and publication ethics. The purpose of the study was explained to the participants in the online link, and informed consent was obtained. Consent forms and scales filled out by the participants were recorded and stored digitally.
Statistical Analysis
The obtained data were evaluated using IBM SPSS Statistics v.22.0 (IBM Corp.; Armonk, NY, USA) package program. In the statistical analysis, we used mean ± standard deviation and minimum and maximum values for the continuous variables and numbers and percentages for the nominal variables. We determined the conformity of the continuous variables to the normal distribution using the Shapiro–Wilk test, normal distribution graphs, and skewness and kurtosis coefficients. For the continuous variables, we investigated the differences between the groups using independent samples t-test and F-test (one-way analysis of variance). Pearson’s analysis was used to find the degree and direction of the relationship between two numerical variables. A p-value of < .05 was considered significant for all analyses.
Results
Of the patients diagnosed with Covid-19 and quarantined at home, 54.9% (n = 439) were men, 44.1% (n = 353) were in the age group of 18–30 years, 67.4% (n = 539) were married, and 51.1% (n = 409) had university or higher education. Furthermore, 62.0% (n = 496) of the participants had at least one child, and 26.4% (n = 211) evaluated their socioeconomic status as good.
It was found that 11.2% of the patients scored ≥ 82 points on the Padua Inventory, which is the midpoint of the score range (0–164 points). The mean Padua Inventory score of the patients was 48.19 ± 19.17. Table 1 shows the mean scores of the five subdimensions (Cleanliness, Rumination, Checking, Precision, and Impulses).
Table 2 provides the comparison of the sociodemographic characteristics of individuals with Covid-19 and the Padua Inventory scores. There was no significant difference between the total scale scores and subscale scores in terms of sex (p > .05). When age groups were compared, a significant difference emerged only in the Rumination subdimension caused by the difference between the group ≥ 41 years and the 31–40 age group (the highest score) (p < .05). There was a significant difference between the Total Scale and the Checking and Impulses subscale scores according to the level of the education of the participants; the difference resulted because of the mean scores of the participants with the undergraduate/graduate education level in all groups (p < .05). The mean score of the Cleanliness subscale was higher in the participants who evaluated their socioeconomic level as good (p < .05). The mean scores of the Rumination, Impulses, and Checking subscales and the mean total scores of the participants with chronic comorbidity (6.9% chronic obstructive pulmonary disease, 4.9% hypertension, 5.8% heart disease, 5.8% diabetes mellitus) were higher than those of participants without any comorbidity (p < .05). Participants with a diagnosed psychiatric illness had higher scores in the Total Scale, Impulses, and Rumination subscales (p < .05).
In the correlation analysis, performed by removing individuals with psychiatric illness from the sample, we found a positive and moderate correlation between the time elapsed since the diagnosis of Covid-19 and the total scale and all subscale scores (p < .005). Upon examination of the correlation analysis between the participants’ Padua Inventory scores, a positive and moderate–high correlation emerged between all subscale and total scale scores (p = .0001) (Table 3).
Table 4 gives a comparison of some lifestyle changes after Covid-19 diagnosis and the Padua Inventory scores of the participants. The mean scores of Cleanliness, Checking, Precision, and Total Scale of the participants who stated that the importance they attached to personal hygiene had changed were found to be significantly higher (p < .05). The mean total scale scores and all subscale scores of individuals who declared that their psychological state had changed after the diagnosis was found to be significantly higher (p < .05).
Discussion
In this study, the incidence of OCSs in patients quarantined at home for 14 days with the diagnosis of Covid-19 was calculated to be 11.2%, and the mean Padua Inventory score was found to be 48.19 ± 19.17 (Table 1). Because no similar studies in the literature have investigated the OCSs of patients quarantined at home with the diagnosis of Covid-19, the results of this study cannot be compared. Studies investigating the incidence of OCSs during the Covid-19 pandemic have reported rates of 18% (Jelinek, Göritz, et al., 2021) and 14.5% (Fontenelle et al., 2021) in the general population and 31% in pregnant women (Gürbüz et al., 2021). Two studies stated that subclinical OCSs can be seen in ≥ 20% of the general population (Fineberg et al., 2013; Ruscio et al., 2010). Based on these results, we conclude that the incidence of OCSs or the total Padua Inventory score of the patients in this study who were quarantined for 14 days with the diagnosis of Covid-19 is low, which we consider a positive result. Anxiety and fear experienced after being sick are likely to increase repetitive behaviors, such as hand-washing, which play an important role in the recovery from this disease anyway. An examination of the subscales revealed similar findings. However, more valid and meaningful results could have been achieved if the results had been compared with a control group consisting of individuals who did not have Covid-19 but were quarantined in line with the Covid-19 measures in Turkey. That is one limitation of this research.
The present study found a significant difference in the Rumination subdimension score concerning the age groups of the patients, and the mean score was lower in patients aged ≥ 41 years (p < .05). In the present study, 26.6% of the patients with the diagnosis of Covid-19 comprised individuals aged ≥ 41 years. Nearly two-thirds of the participants were in the age group of 18–40 years, were socially active, and were more likely to be infected. This situation is of concern in terms of the spread of the disease. In Turkey, as observed in the rest of the world, the most frequently diagnosed and affected age group with Covid-19 was individuals aged ≥ 50 years (İskit, 2021). Considering that the study was conducted throughout a province and over a wide time interval, we conclude that the age of susceptibility to Covid-19 has decreased. In terms of contamination, it is important for individual and public health that the social-protection measures be modified for this age group and control ensured with appropriate mechanisms.
This research determined that as the education level increased, the Total Scale and “checking” and Impulses subscale mean scores decreased (p < .05). In a study conducted by Tian et al. (2020) in China during the pandemic, it has been reported that individuals in the age group of 18–50 years with higher education levels showed fewer OCSs. In the study by Seçer and Ulaş (2021), it has been stated that OCSs were more common in men, in individuals who had received higher education, and in individuals > 60 years of age. Two other studies on the subject (Meng et al., 2020; Okur & Demirel, 2020) reported that OCSs were more common in women, and another study (Khoury & Karam, 2020) reported that OCSs were more common in the elderly population. In the present study, no significant relationship was found between sex and the scale scores.
In this study, the scores of the participants with any diagnosed psychiatric disease (such as depression, anxiety, panic attack, and mood disorders) in the Total Scale, Impulses, and Rumination subscales were found to be higher than those of participants without a psychiatric disease (p < .05). The study by Zheng et al. (2020), which involved people living in the city after the quarantine had been lifted in Wuhan, stated that OCSs were observed at a higher rate in those with a history of psychiatric illness. The findings of two similar studies support this result (Abba-Aji et al., 2020; Jelinek, Moritz, et al., 2021).
The present study found a positive and moderate to high correlation between all subdimensions of the Padua scale and total scores (p = .0001; see Table 3). This observation is important in terms of establishing the consistent relationship between the total scale and all subscales of the Padua Inventory, which is internally consistent and highly representative (Cronbach’s α value of 0.95 and test–retest reliability of 0.91). Inferential evaluations can be made in large population surveys for OCSs with the mean subscale scores.
Approximately half of the participants stated that they had experienced some lifestyle changes after being diagnosed with Covid-19. In those participants who stated that they had experienced changes in the seven variables of “the importance given to personal hygiene,” “the perspective on housekeeping,” “relations with family members and friends,” “the importance given to social distancing,” “eating habits,” and “psychological state,” the mean Padua score was significantly higher than that of those who stated that they experienced no changes (p < .05, Table 4). In line with these results, we recommend a close follow-up by public health nurses to enhance the quality of life of the patients diagnosed with Covid-19 and to ensure that they lead a healthy life.
Conclusion and Recommendations
In the present study, the incidence of OCSs was 11.2% in patients diagnosed with Covid-19 and quarantined at home, and the mean Padua Inventory score was low. Significant differences were found in the OCS status regarding age, education, income status, presence of disease/psychiatric illness, and lifestyle (p < .05). It is, therefore, important to investigate several parameters that may affect the emergence of OCSs and to compare the results with those from other studies conducted in different cultures. The Covid-19 pandemic can exacerbate an existing mental disorder of the individual and affect the symptoms of that disease. Additionally, the pandemic poses various difficulties in the healthcare services provided to individuals with mental disorders. During this period, it should not be forgotten that persons with mental disorders are a vulnerable group that requires more attention and care. The continuity of the preventive, therapeutic, and rehabilitative healthcare services received by the mentally ill and healthy groups is very important, especially when they are under threat from agents that may disrupt the integrity of their mental health. In this sense, mental-health units should adopt the effective use of telepsychiatry and other digital health interventions to support the continuity of care. Public-health nurses have significant responsibilities to be prepared for adverse situations during and after a pandemic, to teach individuals how to cope with stress, to recognize OCSs in the early period, to take precautions, and to rehabilitate the patients.
Limitations
The cross-sectional design of the study and the data obtained over a certain period might have limited the analysis of the relationship between OCSs and their causes. Furthermore, there was no control group in the study. Psychiatric disease histories of the participants were evaluated based on self-report only. Hence, it is important to monitor the individuals included in our study as well as larger sample groups over time to observe the changes.
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