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Introduction

The 2019 novel coronavirus disease (COVID-19) is an astute respiratory communicable diseases caused by the new coronavirus (SARS-CoV-2) (1). In Wuhan, Hubei province, the actual number of SARS-COV-2 infection cases might exist much higher than that has been reported (2). The rapid spread of the COVID-19 and its serious consequences pose severe challenges to public health in China and around the world (3, four).

Since the outbreak of COVID-19, researchers have fabricated numerous reports on the epidemiological characteristics, clinical characteristics, and prognosis of infection cases (5–8). As a stressful event with unknown treatment efficacy, prognosis, and mortality in the early stage of the epidemic, the population exposed to COVID-19 faced the severe challenge of psychological tolerance. Co-ordinate to a recent study past Wang et al. (9), in the early stage of the COVID-nineteen outbreak, more than than half of the respondents in the full general population were rated as moderate-to-severe in their psychological impact, and approximately one-third exhibited moderate-to-severe anxiety. Meanwhile, Hao et al. also confirmed that the strict lockdown measures accompanied by COVID-19 take a serious negative impact on psychiatric patients (10). A recent Italian study as well reported that the COVID-19 pandemic has brought negative emotions to patients with bipolar disorder (11). For mental patients, stressful events are important factors that aggravate mental symptoms (12, xiii).

Owing to the highly contagious nature of viruses, a considerable number of severe mental patients in Wuhan City, Hubei Province, accept not been spared, including long-term hospitalized schizophrenic patients. However, due to the special direction of mental diseases and requirements for epidemic prevention and command, few researchers have studied the effects of COVID-19 on the mental symptoms of severe psychotic patients. Hence, nosotros examined schizophrenia patients with COVID-19 in a psychiatric specialty hospital located in Wuhan, Hubei Province, and conducted a study on the outcome of COVID-19 and the accompanying social isolation on psychopathology and stress.

Methods

Subjects

We collected long-term hospitalized psychiatric patients who were required to meet the diagnostic criteria of schizophrenia in the Diagnostic and Statistical Transmission of Mental Disorders, Fifth Edition (DSM-5). They were between 20 and 65 years quondam, had stayed in the hospital for more than 2 years, and had infirmary-acquired infections and were diagnosed with COVID-xix. Polymerase chain reaction (PCR) testing for SARS-CoV-2 was positive, and breast CT scans showed patchy or frosted ground glass-like images, regardless of sex activity, unrestricted type, and measurement of antipsychotic drugs, and whether information technology was accompanied by common physical diseases such as hypertension, diabetes, and hyperlipidemia.

Patients with bipolar disorder, substance dependence, personality disorder, intellectual developmental disorder, severe cognitive damage, and mental disorders acquired by physical diseases were excluded. In addition, critically ill patients with claret oxygen saturation below 93%, dyspnea, and patients with unstable vital signs were excluded. These patients were all transferred to designated hospitals for the treatment of astringent diseases. Patients who were unable to cooperate with isolation treatment, such every bit astringent violence and suicide, were besides excluded, and these patients were transferred to special wards with a dedicated work team for intervention.

This report was reviewed and approved past the ethics committee of the medical institution where the patients were housed. All enrolled patients received written consent from the patient's family.

Instruments

The electronic medical records were used to excerpt clinical characteristics, chest imaging characteristics, claret convention, biochemical indicators, and C-reactive protein (CRP) of the patients. The Positive and Negative Symptom Calibration (PANSS) was used to assess the psychopathological changes of the included patients, and the Chinese Perceived Stress Scale (CPSS) was used to assess patients' perception of stress. According to PANSS's classification of mental symptoms, PANSS has three subscales: PANSS positive symptom subscale (PSS, items P1-7), PANSS negative symptom subscale (NSS, items N1-7), and PANSS Full general Psychopathology calibration (GPS, items G1-xvi).

We added vii additional questions to appraise the perception of COVID-19 in the included cases (called the COVID-19 perception questionnaire, CPQ), which were equally follows:

i. Have you heard of the 2019 novel coronavirus disease?

ii. Options setting: yes and no

iii. Do you lot know that the patients around you lot are also infected with this disease?

iv. Options setting: yes and no

5. Do yous know why you transferred to this ward?

6. Options setting: yeah and no

7. Are you worried about the treatment effect later infection?

8. Options setting: very worried, general, not worried

ix. Are yous worried almost the apparel of medical workers?

10. Options setting: very worried, general, not worried

11. Are y'all worried about your family being infected?

12. Options setting: very worried, general, non worried

13. Do you know the epidemic tendency of the 2019 novel coronavirus illness?

14. Options setting: yes and no

Scoring principle: We mark "aye" and "generally" equal to 1 signal, "no" or "non worried" equal to 0 points, and "very worried" equal to two points. The higher the total score, the more comprehensive the patient's perception of COVID-xix, and vice versa.

Procedures

This study was designed every bit a clinical observation written report. As early on as Jan 2020, when the epidemic had not been reported on a large scale, we completed the initial assessment of PANSS and CPSS for the long-term hospitalized schizophrenic patients. At that fourth dimension (baseline), the patients were uninfected. Equally the epidemic continued to spread, isolation wards were gear up in a sure psychiatric institution in Wuhan, Hubei Province, People's republic of china on January 30, 2020, for the isolation and treatment of psychotic patients who were diagnosed with or suspected to have COVID-19. The isolation ward is set ranging from 1 to 3 patients per room. After a week's work of ward reconstruction, the admission of patients began. From and then on, the cured cases would exist transferred out of the isolation ward, and at the same time, newly infected patients would be transferred into the isolation ward. Nosotros selected the confirmed cases of COVID-19, from transferred to the isolation ward to cured and transferred out for farther follow-upwardly observation. All medical services followed the Diagnosis and handling of corona virus affliction-xix issued by the National Health Committee of China. Co-ordinate to the guidelines, the drugs taken are antiviral, anti-inflammatory, and Chinese patent medicine. The 2nd PANSS and CPSS were estimated within 3 days of diagnosis after the patient was transferred to the isolation ward. At this fourth dimension, the routine blood, C-reactive poly peptide, and biochemical indexes of the patient were extracted from the electronic medical record and CPQ were estimated. After the cases were cured, before they were transferred out of the isolation ward, the third PANSS and CPSS evaluation were performed. The raters in this study were all psychiatrists with professional training and feel in managing psychopathological tests.

We used a table to show the detailed characteristics of the general clinical information and longitudinally compared the differences in the total score of PANSS, the scores of the three subscales of PANSS and CPSS at dissimilar time points. We also analyzed the factors affecting the stress levels of the included patients.

Data Assay

Co-ordinate to the characteristics of the final data, if the continuous measurement data obtained were normally distributed, they were expressed as the mean and standard deviation (SD). The categorical variables were expressed as counts and percentages. Paired t-test was performed on continuous variables with normal distribution, and multiple linear regression was used to analyze stress factors. The significance level of all statistical tests was set as p < 0.05 (2 tails). Data analysis was performed using IBM SPSS version 26.0 statistical software (SPSS Inc., Chicago, IL, U.s.a.), and figures were plotted using GraphPad Prism version 8.iv software (GraphPad Software Inc., La Jolla, CA, U.s.a.).

Results

General Clinical Treatment Characteristics

A full of 57 patients entered the ward for screening because of suspected or confirmed COVID-xix, and 21 schizophrenic patients with COVID-19 were cured and discharged. Following the requirements of epidemic command, the transfer of the last cured patient to the designated site for continued observation was completed at 6 p.m. on thirty March 2020.

The general clinical characteristics of the 21 patients who completed this study are shown in Table 1.

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Table 1. Clinical characteristics of schizophrenia patients with COVID-19.

The Difference of the PANSS and Its Subscales and CPSS

There were no significant differences in PANSS scores of the included patients at the three time points of the early stage of the epidemic (baseline), within 3 days later on diagnosis with COVID-19 and transported to the isolation ward (diagnosed) and cured (cured) (p = 0.225 baseline vs. diagnosed, p = 0.399 cured vs. diagnosed) (Figure 1A). In addition, the positive symptom subscale scores of "diagnosed" were significantly lower than those of "baseline" (p < 0.001) (Figure 1B). The negative symptom subscale scores were significantly higher when "diagnosed" compared to "baseline" (p < 0.001) and "cured" compared to "diagnosed" (p < 0.001). The CPSS scores of "diagnosed" patients were significantly higher than those of "baseline" (p < 0.001) and "cured" (p < 0.001) (Effigy 1C).

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Figure 1. (A) Comparing of PANSS scores at iii time points. There is no statistical difference in PANSS score at different time. (B) Comparison of PANSS subscale scores at 3 fourth dimension points. The PSS score was significantly lower at the time of diagnosis than at the baseline. The NSS score at diagnosed is significantly higher than at baseline and significantly lower than at cured. At that place is no divergence in GPS scores at unlike time. (C) Comparing of CPSS scores at 3 fourth dimension points. The CPSS score at the time of diagnosed is significantly college than that at baseline and cured.

Multiple Linear Regression Analysis of Influencing Factors of Patients' Psychological Stress

Multiple linear regression analysis was used to analyze the psychological pressure of patients (CPSS) when diagnosed every bit a dependent variable, and gender, historic period, class of schizophrenia, duration of hospitalization, years of education, symptoms associated with infection and COVID-19 perception questionnaire (CPQ) were contained variables, as shown in Table two. The grade of schizophrenia was a protective factor of stress levels to cases (p = 0.006), and patients' perception of COVID-19 was a take chances factor (p = 0.038). The last multiple linear regression model was statistically significant (F = 8.xvi, p < 0.001).

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Table ii. Multiple linear regression analysis of influencing factors of patients' psychological stress.

Discussion

To the best of our cognition, this is the start clinical written report on schizophrenia patients with COVID-19, investigating the changes in psychological pressure and psychiatric symptoms in cases with COVID-19 infection and isolation therapy. We plant that patients with COVID-19 did experience increased stress levels and negative symptoms but alleviated positive symptoms. The grade of schizophrenia was a protective cistron of stress levels in cases; in contrast, patients' perception of COVID-19 was a run a risk factor.

Equally a global pandemic impacting public safety, the general population is susceptible to COVID-nineteen. The rapid spread of the virus and the doubt of the virus significantly increased the psychological burden of the full general population (ix). People with stable clinical symptoms subsequently COVID-19 infection likewise showed obvious symptoms of posttraumatic stress (14). Another written report recently studied people who developed psychiatric symptoms and found that psychotic episodes were significantly associated with coronavirus exposure (fifteen). The latest research suggests that more than one-third of psychiatric patients might fulfill the diagnostic criteria post-traumatic stress disorder (PTSD) during the peak of COVID-nineteen epidemic with strict lockdown measures (ten). Another study from the United Kingdom showed that those who accept or had COVID-19-related symptoms are more likely to develop general psychiatric disorders (xvi). In addition, the general population without a history of psychiatry also showed psychotic symptoms with structured delusions mixed with defoliation as a common feature afterwards existence infected with COVID-nineteen (17). However, none of these studies could specifically target schizophrenia patients with COVID-19. SARS-CoV-ii, a novel coronavirus with similar neurotrophic effects (18), was only reported for the first time after the outbreak. To engagement, we have non had enough fourth dimension to track the future incidence of mental affliction of nonpsychotic patients who were exposed to COVID-xix and the long-term impact of psychiatric symptoms on schizophrenic patients exposed to COVID-19. As far as this study, there were no pregnant changes in psychiatric symptoms in schizophrenia patients with COVID-nineteen during short-term follow-up observations. Nevertheless, this is not the end, as COVID-19 may have a long-term bear on on the mentally sick, and nosotros will perform in-depth follow-up observations.

Regardless of the effect of nervous system infection on mental illness, stressful events have always been considered one of the important factors for the occurrence and deterioration of mental disease (12, 13). An interaction between external stressors and intrinsic vulnerability was one of the longest continuing pathoaetiological explanations for schizophrenia, also known as Diathesis-Stress Hypothesis (nineteen). The hypothesis advise that psychosocial stress may promote pathological microglia activation, which may lead to excessive synapse pruning and loss of cortical grayness matter. Based on this, if the stress-sensitive expanse is damaged, this may atomic number 82 direct to cognitive and negative symptoms; and loss of cortical control may as well lead to disinhibition of subcortical dopamine—thereby leading to positive psychotic symptoms.

In this study, we confirmed that COVID-nineteen and transfer to isolation wards significantly increased the perception of psychological pressure. Still, the increment in psychological force per unit area may not just be limited to COVID-19 itself, which as well includes the strict isolation measures that have led to more narrow living spaces and the touch of environmental changes such as the different dress of the medical staff during wards rounds. Assay of the factors that impact patients' psychological stress constitute that the grade of schizophrenia constitutes an independent influencing factor for the reduction in psychological stress, that is, the longer the course of illness, the less psychological stress the patient would feel. A vi-year follow-up study found that the cognitive function of long-term hospitalized schizophrenia patients volition gradually deteriorate over time (20). Based on this, we infer that the cognitive capacity of the enrolled patients decreased significantly due to the longer grade of schizophrenia, thereby reducing the patients' awareness of the threat and danger of COVID-nineteen, and thus reducing the psychological stress they presented. It should be emphasized that this psychological stress but manifested in the early phase of diagnosis of COVID-19, and the accommodation to the environment afterward a longer period of isolation may alleviate the patient's perception of stress.

Our study constitute that the severity of psychiatric symptoms of patients during isolation did not change significantly, which corresponds with the fact that the dosage of antipsychotic drugs is rarely adjusted during isolation therapy. This is different from the results of previous studies (21–23), which supposed stress and the severity of psychiatric symptoms were significantly related. However, without exception, all the previous studies took daily stress events equally research elements. These stress events are more moderate in intensity, longer in time, and less threatening. This is the biggest departure between daily stress events and the stress events of this epidemic and may be the master reason for the divergence in research results. This is the biggest divergence between daily stress events and stressful events in the context of this epidemic. This may too be the main reason for the divergence in inquiry results. Additionally, positive symptoms were reduced, while negative symptoms were increased during the study. An animal report showed that socially isolated mice exhibited schizophrenia-like behaviors, such equally a negative symptom phenotype (24). We speculated that the deterioration of negative symptoms in patients was the upshot of long severe social isolation and lack of adequate interpersonal communication caused by the COVID-nineteen.

This commodity also has certain deficiencies. Due to the need for epidemic prevention and control, the patients in the group were transferred to the designated place for further isolation and observation after reaching the discharge standard. Therefore, our ascertainment of the patients is short-lived, and the long-term impact of COVID-19 infection on schizophrenic patients needs further follow-upwards ascertainment. To prevent cross-infection, it is difficult to carry out a larger sample study at nowadays. A smaller sample size as well harms the statistical efficiency of the study.

In conclusion, hospitalized schizophrenia patients with COVID-19 had increased stress levels and negative symptoms but alleviated positive symptoms after medical isolated treatment. This suggests that effective measures should be taken to salvage the psychological force per unit area of exposing patients with schizophrenia during the outbreak of a major epidemic, and targeted relief of negative symptoms of the patients is needed after the epidemic.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving man participants were reviewed and approved by The Ethics Committee of Wuhan Mental Wellness Centre is affiliated to Wuhan Mental Health Center. The patients/participants provided their written informed consent to participate in this report.

Writer Contributions

LL and XL fabricated substantial contributions to formulation and design of the study. LZ and RL nerveless and collated the data. JM analyzed and interpreted data and drafted and revised the manuscript. JM and TJ were responsible for the evaluation of the scale. HH collected imaging data. 40 gave terminal approval of the version to be published. All authors contributed to the commodity and canonical the submitted version.

Funding

This study was funded by the Wuhan Health Commission (WX19Y12, JM, PI).

Conflict of Involvement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors express their heartfelt cheers for linguistic communication modification of this manuscript by Dr. Jing Chen from Wuhan Polytechnic University.

References

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