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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 3  |  Page : 122-131

Effect of anxiety, stress, and depression on hypertension and diabetes during COVID-19 lockdown period in Faridabad: A cross-sectional study


1 Medical Student, Rangaraya Medical College, Kakinada, Andhra Pradesh, India
2 Department of Community Medicine, Government General Hospital, Kakinada, Andhra Pradesh, India

Date of Submission24-Feb-2021
Date of Decision28-May-2021
Date of Acceptance28-May-2021
Date of Web Publication25-Sep-2021

Correspondence Address:
Mr. Utkarsh Arora
Medical Student, C/O Community Medicine Department, Rangaraya Medical College, Kakinada
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjhs.mjhs_18_21

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  Abstract 


Background: The SARS-CoV-2 pandemic with a high contagion potential poses a pathological threat to the community but has a larger psychological impact, elemental in the aggravation of blood pressure and blood glucose levels. The aim of this study is to examine and interpret the effect on individuals, with or without preexisting diabetes and hypertension, of depression, anxiety, and stress and to assess the factors associated with exacerbation of blood pressure and blood glucose levels.
Materials and Methods: A cross-sectional observational study was carried out through a snowball sampling method in Faridabad. A predesigned and pretested questionnaire was circulated on Google Forms. A total of 1002 responses accorded with our inclusion criteria and were involved in the final analysis.
Results: In the general population, 20.7%, 42.4%, and 39.4% of individuals experienced moderate-to-severe stress, anxiety, and depression, respectively. The prevalence of stress (22.6%) and anxiety (52.9%) was higher in people with preexisting hypertension and diabetes as compared to people without these preexisting comorbidities. Participants with severe depression and severe anxiety had blood sugar level aggravation 5.55 times and 10.10 times more than the ones with lower depression and lower anxiety. Individuals with severe anxiety experienced exacerbation of blood pressure levels 7.35 times more than individuals with lower anxiety.
Conclusion: Individuals experienced high mental distress during the lockdown period, especially the ones with preexisting health conditions, who displayed a higher incidence of depression, anxiety, and stress. The results further point toward a bidirectional relationship between hypertension and diabetes with mental health as people with preexisting health conditions experienced greater psychological stress than others.

Keywords: Anxiety disorder, COVID-19, depression, diabetes mellitus, hypertension, psychological stress, SARS-CoV-2


How to cite this article:
Arora U, Chaudhary C, Babu G K, Prabha Kona J S, Babji K. Effect of anxiety, stress, and depression on hypertension and diabetes during COVID-19 lockdown period in Faridabad: A cross-sectional study. MRIMS J Health Sci 2021;9:122-31

How to cite this URL:
Arora U, Chaudhary C, Babu G K, Prabha Kona J S, Babji K. Effect of anxiety, stress, and depression on hypertension and diabetes during COVID-19 lockdown period in Faridabad: A cross-sectional study. MRIMS J Health Sci [serial online] 2021 [cited 2021 Oct 25];9:122-31. Available from: http://www.mrimsjournal.com/text.asp?2021/9/3/122/326730




  Introduction Top


The COVID-19 pandemic is an unprecedented situation. Its spread has been rapid and has affected individuals of all economic and social backgrounds. The WHO on March 11, 2020, declared COVID-19 as a pandemic after China had reported the first case in November–December 2019.[1] Recent globalization has facilitated the spread of the disease leading to public health challenges.[2] Due to the high contagion potential, governments of various countries including India had declared a nationwide lockdown to curb the spread of the virus. The lockdown has not only affected individuals economically but there has been a greater mental effect in the form of various mental disorders such as anxiety, stress, and depression.

As of November 4, 2020, there were 47,362,304 confirmed cases of COVID-19 globally with 1,211,986 deaths.[3] In India, from January 30 to November 4, 2020, there were 8,313,876 confirmed cases of COVID-19 with 123,611 deaths.[4] In Haryana, 174,177 cases of COVID-19 were confirmed till November 4, 2020 and Faridabad district had recorded 26,471 with 255 deaths, the highest number in the state[5] During the survey period between June 19 and June 30, 2020, about 16,660 positive cases were reported every day in India.[4]

The present scenario of the COVID-19 pandemic, a long incubation period,[6] common flu-like symptoms,[7] and the threat of human-to-human transmission without one's knowledge[8] makes the identification of an infected person, a complex and perplexing task. This has led to a wave of uncertainty and fear in the general population.[9] Fear, although an important adaptive response, can manifest itself into various psychiatric disorders.[10],[11]

Depression, anxiety, and mental stress are omnipresent. Globally, more than 320 million people are diagnosed with depression, out of which more than 55 million are present in India.[12] Greater than 260 million people are diagnosed with anxiety around the world, out of which over 38 million individuals reside in India.[12]

Initial findings from China have indicated that about 25% of the population were suffering from moderate-to-severe stress- and anxiety-related symptoms in response to the spread of the SARS-CoV-2.[13],[14] Other related studies have also shown consistent results, with about 28% of the general population sample showing signs of elevated anxiety and 22% with significant depressive symptoms.[15] A similar study from India suggested that more than 80% of participants felt that they required consultation from a medical health expert regarding their current psychological and emotional status.[6]

Worldwide, more than 1.13 billion people have been diagnosed with hypertension (one in every 4 males and one in every 5 females).[16] Hypertension is a notable etiological factor of ischemic heart disease, coronary artery disease, and heart failure. Around the globe, more than 420 million people have been diagnosed with diabetes mellitus and its prevalence in adults ≥18 years of age rose from 4.7% (1980) to 8.5% (2014).[17]

Anxiety and depression have a two-way relationship with hypertension and diabetes mellitus.[18],[19] Individuals who have hypertension and diabetes are more likely to develop anxiety, stress, or depression, and individuals with these mental conditions are at a higher risk of aggravating their preexisting high blood pressure or glucose levels.[19],[20]

A systematic review and meta-analysis study suggests that depression is 3 times more common among those with heart failure or coronary artery disease as compared to the general population.[21] Depression has been correlated to hyperglycemia, which increases the risk for further diabetic complications such as blindness, stroke, kidney failure, and heart attack.[22]

Stressors (chronic or daily) increase the risk of loss of life from cardiovascular diseases. A meta-analysis of prospective observational studies found that common daily stressors such as social isolation and loneliness over an extended span of time, as seen during the home quarantine period, are associated with a 50% increased risk of incident cardiovascular disease events.[23]

In pandemic situations, the fear of contracting the disease can result in raising depression, anxiety, and stress levels in the general population.[9] This study aims to analyze the effect of stress, anxiety, and depression among individuals with or without preexisting hypertension and diabetes to examine and bring out factors associated with the aggravation of blood pressure and blood glucose levels.


  Materials and Methods Top


Study area and population

The study was conducted in the city of Faridabad in Haryana state, India. It has an area of 741 square km. The population according to the 2011 census is 18 lakh individuals.

Study period

The study was conducted for 12 days between June 19, 2020, and June 30, 2020.

Study design

This was a cross-sectional observational study. Following the government's standard operating procedures of social distancing, the snowball sampling method was adopted, which eliminates selection bias. The questions in the survey were stated in English as well as Hindi to make it comprehensible for every respondent in the study sample. The reliability as internal consistency was calculated by Cronbach's coefficient alpha (anxiety-related questions: 0.86, stress: 0.70, and depression: 0.66). The online questionnaire was pretested on 20 individuals. The predesigned and pretested online questionnaire on Google Forms was circulated among our acquaintances and the respondents were encouraged to circulate the survey to their contacts in Faridabad. Total 1002 individuals were included in the study.

Inclusion and exclusion criteria

All respondents above the age of 18 years who have completely filled the questionnaire were included in the study sample.

Questionnaire

The questionnaire was constructed by referring to the Depression Anxiety Stress Scales and by examining related literature.[24],[15] The questionnaire included a total of 37 questions. In addition to the questions related to mental distress during the lockdown and the various health conditions, the survey also comprised questions related to demographics and various trait characters. Five domains were created with questions related to (1) demographic data, (2) anxiety, (3) stress, (4) depression, and (5) hypertension and diabetes. Questions related to anxiety, stress, and depression were rated on a 5-point Likert scale ranging from 1 (never) to 5 (everyday).

Evaluation procedure

The goal was to construct a reliable questionnaire that would enable us to correlate the mental distress with hypertension, diabetes, and the sociodemographic data. For further assessment, 6 questions (related to trait/characters and other optional questions) were eliminated on rational bases.

Percentages of response to a specific question were calculated and presented as categorical variables. For the response entered by a respondent pertaining to a particular question related to mental status, three categories were formulated, namely, (a) 1–2, low; (b) 3, moderate; and (c) 4–5, severe. The responses from the individuals participating in the study were entered into Microsoft Excel. These data were then exported to and analyzed using SPSS software (free trial version of IBM SPSS Statistics 26.0.0). Multinomial regressions were carried out to determine the association between the various dependent and independent variables. Regression analysis eliminates confounding bias in the study.

Ethical clearance

This study has been conducted following all the required guidelines of the institutional ethical committee.


  Results Top


Sociodemographic data

The data of 1002 individuals were included in the analysis, 54% (544) were male and 46% (458) were female. The age of the participants ranged from 18 years to 83 years with a mean age of 38.88 years in males and 33.86 years in females. The age distribution suggests that 44% (439) of respondents belonged to the age group of 20–39 years. In our study, 50% (498) of respondents were unemployed (jobless, retired individuals, homemakers, and students), while 33% (330) were professionals. In our sample, 32% (323) of respondents had physical health morbidities, among which 50% (162) had preexisting hypertension alone, 22% (71) of participants presented with preexisting diabetes mellitus, 10% (33) of participants had both hypertension and diabetes mellitus, and 18% (57) of participants had other comorbidities (chronic kidney disease with hypertension and high cholesterol with hypertension).

Substance and alcohol abuse

Two hundred and thirty-eight (23.8%) of the participants were habituated to the use of one or more substances (alcohol, cigarette, bidi, etc.,). Among them, alcohol was found to be the most prevalent with 191 (80.2%) consuming it followed by 74 individuals (31.1%) smoking cigarettes [Table 1].
Table 1: Sociodemographic data of study subjects

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Prevalence of moderate-to-severe anxiety

In this study, among the total 679 participants with no preexisting comorbidities, 37.4% experienced moderate-to-severe anxiety. When compared to the participants with preexisting comorbid conditions, 53% (171 out of 323 individuals) experienced moderate-to-severe anxiety. Out of the 219 participants with preexisting hypertension, 53.4% experienced moderate-to-severe anxiety. Among the 71 participants with preexisting diabetes mellitus, 56.3% experienced moderate-to-severe anxiety.

Prevalence of moderate-to-severe stress

19.7% of study subjects without any comorbidity were found experiencing moderate-to-severe stress, as compared to 22.4% of participants with preexisting hypertension and 28.2% of individuals with preexisting diabetes mellitus.

Prevalence of moderate-to-severe depression

41.1% of individuals without any comorbidity have moderate-to-severe depression as compared to 33.8% of participants with preexisting hypertension and 49.3% of individuals with preexisting diabetes mellitus.

Factors associated with anxiety

During the evaluation, a regression model was made and logistic regression was performed keeping all the sociodemographic variables as independent variables and anxiety level as the dependent variable. P < 0.05 was considered statistically significant. Gender, occupation, education, monthly income, substance use, and comorbid conditions were found to be statistically associated with anxiety. Females developed moderate-to-severe anxiety 2.51 times and 1.63 times, respectively, more than men (odds ratio [OR]: 2.51, 95% confidence interval [CI]: 1.89–3.33) (OR: 1.63, 95% CI: 0.89–2.98).

Individuals with both hypertension and chronic kidney disease had moderate and severe anxiety 6.11 and 3.93 times, respectively, more than individuals without any comorbidities (OR: 6.11, 95% CI: 1.62–23.02) (OR: 3.93, 95% CI: 0.39–39.03) [Table 2].
Table 2: Distribution and logistic regression output of anxiety among the study participants

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Factors associated with stress

Logistic regression with factors associated with stress was performed. Factors with P value < 0.05 were age, gender, occupation, education, and monthly income, and these were considered statistically significant. According to the result, individuals with low family monthly income (between Rs. 4,000 to Rs. 10,000) experienced moderate and severe stress 2.17 and 8.42 times more than the individuals with monthly family income above Rs. 75,000 (OR: 2.17, 95% CI: 1.17–4.02) (OR: 8.42, 95% CI: 2.77–25.55).

Although pre-existing morbid conditions were not found to be associated with stress as a whole, hypertension (P = 0.02) and diabetes mellitus (P = 0.12) had significantly high OR. Participants with these conditions developed severe stress 2.21 times and 2.79 times more than the individuals without these conditions (OR: 2.21, 95% CI: 0.61–7.98) (OR: 2.79, 95% CI: 0.53–14.54) [Table 3].
Table 3: Distribution and logistic regression output of stress among the study participants

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Factors associated with depressionss

Logistic regression to find the factors associated with depression was performed. Age, gender, occupation, substance use, and preexisting morbid conditions were found to be statistically significant (P < 0.05). Individuals <20 years experienced moderate and severe depression 2.47 and 4.39 times more than individuals between the age of 60 and 83 (OR: 2.47, 95% CI: 1.18–5.17) (OR: 4.39, 95% CI: 1.40–13.76). Unemployed subjects of this study reported that they experienced severe depression 2 times and moderate depression 1.47 times than the individuals with occupations other than professionals and legislatures (OR: 2, 95% CI: 0.75–5.28) (OR: 1.47, 95% CI: 0.83–2.61) [Table 4].
Table 4: Distribution and logistic regression output of depression among the study participants

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Factors associated with aggravation of blood pressure level

During the evaluation, a regression model was made and logistic regression was performed, keeping anxiety levels, stress levels, depression levels, and comorbid conditions as the independent variable and blood pressure level aggravation as the dependent variable. All the P values were found to be <0.05 and were considered statistically significant. According to the results, it was seen that individuals with severe anxiety experienced aggravation of blood pressure levels 7.35 times more than the participants with low anxiety (OR: 7.35, 95% CI: 3.99–13.52, P < 0.0001). Participants had 4.25 times and 3.22 times more aggravation of blood pressure if they had preexisting hypertension and diabetes mellitus, respectively (OR: 4.25, 95% CI: 2.96–6.09, P < 0.0001) (OR: 3.22, 95% CI: 1.96–5.30, P < 0.0001) [Table 5].
Table 5: Distribution and logistic regression output of factors associated with blood pressure aggravation among the study participants

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Factors associated with aggravation of blood sugar level

Logistic regression to find the factors associated with aggravation of blood sugar levels was performed and all the variables were found to be statistically significant. Participants with severe anxiety and severe stress had blood sugar levels aggravation 10.10 times and 5.72 times more than the ones with low anxiety and low stress, respectively.(OR: 10.10, 95% CI: 5.45–18.69, P < 0.0001) (OR: 5.72, 95% CI: 2.27–14.36, P < 0.0001). The study sample with preexisting diabetes mellitus experienced blood sugar level aggravation 12.99 times more than the individuals without any comorbidity (OR: 12.99, 95% CI: 7.05–23.93, P < 0.0001) [Table 6].
Table 6: Distribution and logistic regression output of factors associated with blood sugar aggravation among the study participants

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  Discussion Top


Our study brought out the various factors associated with the mental health morbidities and aggravation of blood sugar and blood pressure levels during the nationwide lockdown period. Moderate-to-severe stress was noted in 20.7% of study subjects. This finding is comparable to similar studies related to mental health effects during the COVID-19 pandemic from China (25%).[13],[14] The prevalence of moderate-to-severe anxiety and depression in the general population in our study was found to be 42.4% and 39.4%, respectively. This was higher than the study done by Taylor et al., where the prevalence of anxiety and clinically significant depression was found out to be 28% and 22%, respectively.[15] This variation could be due to the difference in the study period, population, and sociodemographic differences.

In this study, a formidable association between gender and anxiety (P < 0.0001), stress (P < 0.0001), and depression (P < 0.0001) was found. The study further reveals that females stand at greater than twice the odds of males in experiencing moderate mental health morbidities. Females also experience severe mental health morbidities nearly 1.5 times more than men. These outcomes were parallel with the conclusions of many meta-analytic reviews done by Christiansen,[25] Van de Velde et al.,[26] and Matud.[27]

An association between severe anxiety and monthly family income was found in this study (P = 0.04). Individuals with very low family income, i.e. below Rs. 4000 per month are at a higher risk of developing severe anxiety (OR: 3.82, 95% CI: 1.27–11.49). These results were coherent with the conclusions of the study carried out in USA by Holzer et al., 1986.[28]

Substance use also revealed an association with anxiety (P = 0.02) and depression (P = 0.03) in the study. It was observed that individuals who consume alcohol, charas, gaanja, or smoke bidi or cigarettes were more likely to develop anxiety and depression 1.57 and 1.59 times than their counterparts (OR: 1.57, 95% CI: 1.13–2.19) (OR: 1.59, 95% CI: 1.11–2.27). These results were in line with studies conducted in Ethiopia and USA.[29],[30],[31],[32]

In this study, the prevalence of moderate-to-severe anxiety among the participants with diabetes and hypertension was 52.9%. This finding is higher than in studies conducted in Saudi Arabia (45.6%) and Brazil (33.7%).[33],[34] The reason for the higher anxiety levels in our study can be attributed to the fact that our study has been conducted during the lockdown period of the COVID-19 pandemic, whereas the other studies cited were conducted under normal circumstances.

The prevalence of stress (22.6%) and anxiety (52.9%) was found to be higher in people with preexisting hypertension and diabetes as compared to people without these preexisting comorbidities (19.7% for stress) (37.4% for anxiety). The study also revealed that individuals with preexisting diabetes mellitus were at a higher risk, 1.7 times, of having comorbid depression than individuals without diabetes (OR: 1.70, 95% CI: 1.01–2.86, P value: 0.017). These results were consistent with the findings of a meta-analysis done by Anderson et al., 2001.[35]

Participants suffering from severe anxiety, depression, and stress experienced an aggravation of blood pressure levels 7.35 times, 3.79 times, and 4.86 times more than the participants with low anxiety, depression, and stress, respectively (OR: 7.35, 95% CI: 3.99–13.52, P < 0.0001) (OR: 3.79, 95% CI: 2.51–5.72, P < 0.0001) (OR: 4.86, 95% CI: 1.86–12.67, P < 0.0001). This result was in step with the most commonly cited biological model, which states that mental distress causes excess activation of the autonomic nervous system. The hypothalamic–pituitary–adrenal axis and sympathetic nervous system gets excessively stimulated, which increases the release of catecholamines, i.e. epinephrine and norepinephrine, which leads to vascular constriction ultimately leading to an increase in the blood pressure levels.[23]

Participants had 4.25 times more aggravation of blood pressure if they had preexisting hypertension (OR: 4.25, 95% CI: 2.96–6.09, P < 0.0001). This finding was harmonious with experimental data, which reported that when subjected to mental stress, people with preexisting hypertension experienced a significantly higher change in the cardiac index than people without preexisting hypertension.[36]

Experimental results have suggested that mental distress can affect glycemic control adversely as well.[37] Similar outcomes were seen in our study where participants with severe depression, severe anxiety, and severe stress had blood sugar levels aggravation 5.55 times, 10.10 times, and 5.72 times more than the ones with low depression, low anxiety, and low stress, respectively (OR: 5.55, 95% CI: 3.65–8.43, P < 0.0001) (OR: 10.10, 95% CI: 5.45–18.69, P < 0.0001) (OR: 5.72, 95% CI: 2.27–14.36, P < 0.0001).

The bedlam caused due to the spread of the COVID-19 infection dictates the need for prioritizing the mental health of the general population. The results of this research study shows that people with hypertension and diabetes experienced higher levels of mental distress and at the same time, people with high levels of stress, anxiety, or depression exhibited aggravation of blood sugar and blood pressure levels more than the individuals showing low levels of mental distress, suggesting a bidirectional relationship between these parameters.

Similar studies can be conducted to obtain a generalized association between these factors. This will immensely help in proper understanding and management of the concerned morbidities in the post-COVID-19 period in India. It will further help the health-care system in India to focus on the upcoming problems.


  Conclusion Top


Health care management of diseases like COVID-19 should include strategies for early diagnosis and treatment of mental health disorders as they have impact on health outcome .

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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