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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 14-19

A study of assessment of depression, anxiety, and stress among coronavirus disease 2019 patients at tertiary hospital


Department of Psychiatry, Mamata Medical College, Khammam, Telangana, India

Date of Submission31-Mar-2021
Date of Decision23-May-2021
Date of Acceptance18-Jun-2021
Date of Web Publication30-May-2022

Correspondence Address:
Prashanth Challuri
Department of Psychiatry, Mamata General Hospital, Giriprasad Nagar, Khammam - 507 002, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjp.tjp_8_21

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  Abstract 


Introduction: The coronavirus disease 2019 (COVID-19) is not only causing physical illness but has also been causing psychological impact on human beings. Most people are aware of physical complications the disease causes, but now, they are learning psychological impact of the disease.
Aim: To estimate the level of depression, anxiety, and stress in general and with reference to age and sex among COVID-19 patients admitted at Mamata General Hospital, Khammam.
Materials and Methods: This study is a cross-sectional study with sample of 100 participants who were admitted at Mamata General Hospital, Khammam, Telangana. The samples were drawn by using convenience sampling method. DASS-21 was the tool used in this study.
Study Design: It is a cross-sectional study with a sample of 100 participants who were admitted at Mamata General Hospital, Khammam, Telangana. The samples were drawn by using convenience sampling method. Depression, anxiety, stress scale-21 was the tool used in this study.
Results: From a total of 100 patients, about 64% of the patients had varying degree of depression, 70% of the patients had anxiety, and 40% of the patients had various levels of stress. Furthermore, females in this survey were found to have higher level of depression, anxiety, and stress scores as compared to males.
Conclusion: Female patients require adequate psychiatric intervention in this COVID-19 pandemic to mitigate its psychological impact.

Keywords: Anxiety, coronavirus disease 2019 patients, depression, stress


How to cite this article:
Baothman AR, Challuri P, Ramana G, Macharapu R, Reddy M P. A study of assessment of depression, anxiety, and stress among coronavirus disease 2019 patients at tertiary hospital. Telangana J Psychiatry 2022;8:14-9

How to cite this URL:
Baothman AR, Challuri P, Ramana G, Macharapu R, Reddy M P. A study of assessment of depression, anxiety, and stress among coronavirus disease 2019 patients at tertiary hospital. Telangana J Psychiatry [serial online] 2022 [cited 2022 Jun 30];8:14-9. Available from: https://tjpipstsb.org/text.asp?2022/8/1/14/346242




  Introduction Top


Novel coronavirus disease 2019 (COVID-19) was declared as the public health emergency of international concern by the WHO, and on March 11, 2020, it was declared as pandemic.[1] The situation in the western countries, in initial days, were so grave that Lee and Morling urged for need of the public health involvement to contain the disease.[2] COVID-19 apart from being a challenge to human health also proved dangerous to the mental health of human being.[3] Fear of death from this contagious disease, death among close relatives, and anxiety about consequences combined with depression are some of the important effects that should be dealt appropriately.[4]

As on January 31, 2021, India reported about 10,746,183 cases with about 168,784 being active cases and 10,423,125 recovered and 154,274 succumbed to death and real-time data can be followed from the the Ministry of Health of India. Bao et al. found public panic and mental health stress among Chinese population in this COVID-19 pandemic as severe acute respiratory syndrome-coronavirus-2 (SARS-COV-2) virus posed potential threat to the health and life of patients themselves, as well as the surrounding population given its short incubation period, rapid onset, rapid change, and strong infectivity.[5],[6]

In spite of ampule acquisition of knowledge about SARS-CoV-2, its clinical picture, and diagnostic criteria, its definitive treatment is still in the pipeline.[7] Although previously we had extensive epidemics of acute respiratory illnesses such as SARS in 2003, that outbreak was aptly managed by quarantine measures. COVID-19 is consistently influencing all aspects of human beings ensuing social instability,[8],[9] people worldwide are experiencing tough emotions due to lockdown scenario which has discontinued daily life routine including schooling of children and business. A much more alarming situation may arise if people stop relying on availability of mental health services, due to exacerbation of anxiety and stress among them.[10]

The present research is hence pointed at the evaluation of level of depression, anxiety, and stress among COVID-19 patients admitted at Mamata General Hospital, Khammam. This study is to know the frequency psychological well-being of our community.

Aim

To estimate the level of depression, anxiety, and stress in general and with reference to age and sex among COVID-19 patients admitted at Mamata General Hospital, Khammam.


  Materials and Methods Top


Study design

A cross-sectional descriptive study was done during October 1–December 31, 2020, among COVID-19 patients admitted in Mamata General Hospital, Khammam, Telangana State. These were COVID 19 positive patients which were confirmed by RT-PCR test. To determine the level of depression, anxiety, and stress among COVID-19 patients, depression anxiety stress scale (DASS)-21 scale was used. Data relevant to age and gender were also collected in addition to data regarding scales of stress, anxiety, and depression. Informed consent was taken from all the respondents. The data were analyzed by means of SPPS version 20 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp).

Inclusion criteria

  1. Confirmed COVID-19 patients
  2. Conscious, coherent, and cooperative patients
  3. Patients oriented to time, place, and person
  4. Patients willing to participate with consent.


Exclusion criteria

  1. COVID-19–negative patients
  2. Unconscious, incoherent, and uncooperative
  3. Patient in delirium
  4. Patient requiring oxygen or ventilator support
  5. Patient not willing to give consent.


Size

One hundred COVID-19 patients admitted in Mamata Medical College, Khammam, Telangana.

Duration

October 1, 2020, to December 31, 2020.

Type of study

Cross-sectional prospective study.

Tools

To determine the level of depression, anxiety, and stress among COVID-19 patients, DASS-21 scale was used. DASS-21 scale is a 21-item brief version instrument, which is specifically made to ascertain three negative emotional states in a person, which include depression, anxiety, and stress.[11] It is proven to be extremely reliable with strong internal consistency.[12] It has been translated in number of different languages to make it utilizable by various ethnic groups.[13] We have interviewed the patients to fill this scale. Data relevant to age and gender were also collected in addition to data regarding scales of stress, anxiety, and depression. Informed consent was taken from all the respondents.

Statistical analysis

Statistical analysis was done with Statistical Package for the Social Sciences version 20 software (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp). Descriptive statistics were used to analyze socio-demographic data. One-way analysis of variance was applied to determine gender-based difference in depression, anxiety, and stress among COVID-19 patients for statistical significance. A P ≤ 0.05 was considered statistically significant. Prior approval for the study was taken from the Institutional Ethics Committee, Mamata Medical College and Hospital. Prior written informed consent was taken from the participants of the study.


  Results Top


The average age of COVID-19 patients in our study was 35.06 ± 16.12 years, with youngest being 20 years and oldest being 69 years, and out of 100 respondents, 68 were males while 32 were females. Sex of the respondents along with their age groups is depicted in [Figure 1]. Minimum education was 12th Class and maximum was postgraduation. About 38% were healthcare workers and 25% were students.
Figure 1: Sex-based distribution of coronavirus disease 2019 patients with respect to age (n = 100)

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In this study, there was no significant relationship between socioeconomic status and education with psychological impact which might be due to the fact that majority of the patients were healthcare workers. However, different studies show various relationships between socioeconomic status and education and mental health, with majority studies pointing inverse relationship.[14]

[Table 1] represents socio-economic data. There were 68percent males and 32% females in this study with age ranging from 20-70years. Majority of them were in their 20-30years group. About 44% were postgraduates in the education, 36% were graduates and 20% were educated till intermediate.
Table 1: Represents socioeconomic data which is as follows

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Majority of them, about 38% were from Health care profession followed by 25% of students, 15% homemakers and about 12% employees. About 48% were married among them and 28% were unmarried. About 24% were divorcee/widow/widower.

From a total of 100 patients, about 64% of the patients had varying degree of depression, 70% of the patients had anxiety, and 40% of the patients had various levels of stress. Of these, 38% of the patients had moderate to very severe depression, 66% of the patients had moderate to very severe anxiety and 32% patient had moderate to very severe stress. About 36% of cases had normal scores of depressions with majority of them being 20–30 years old, while 6% of respondents in the age group of 40 years and above had very severe depression amid COVID-19 pandemic as shown in [Table 2]. From [Table 2], it is clear that very severe depression was found to be much more in people with age group of 61–70 years (33.33, i.e., 4 out 12 patients) than 20–30 years age group (7.40%, i.e., 4 out of 54 patients).
Table 2: Levels of depression among different age groups of coronavirus disease-2019 patients (n=100)

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Furthermore, about 36% of our respondents had moderate anxiety scores with marginally high scores for group belonging to 20–30 years age group, while 10% and 20% reported to have severe and very severe anxiety scores, respectively, among COVID-19 patients during the pandemic as depicted in [Table 2]. From [Table 3], it is evident that very severe anxiety scores were very high among age group of 61–70 years (33.33%, i.e. 4 out of 12 patients) compared to 20–30 years group (14.81%, i.e. 8 out of 54 patients).
Table 3: Age-wise distribution of anxiety scores among coronavirus disease-2019 patients (n=100)

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Majority of the patients, about 60%, showed normal score of stress, particularly of age group 20–30 years, i.e. about 34 patients out of 54 patients, and this showed that many patients managed to cope up with stress in this COVID-19 pandemic. [Table 4] shows that two patients had very severe stress scores that too of 21–30 years age group patients. As evident from [Table 4], patients with age group of 40 and above managed to cope with stress.
Table 4: Stress among different age groups of coronavirus disease-2019 patients (n=100)

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From [Table 5], it is evident that female patients in our study were relatively more depressed and stressed on suffering from COVID-19 with statistical confirmation (P < 0.0001), and [Table 5] also shows that there was no statistical significance between males and females in anxiety subscale of DASS-21 scale (P = 0.07).
Table 5: Gender based comparison of depression, anxiety, and stress by using Depression Anxiety Stress Scales 21 Scale

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  Discussion Top


Because of high infectivity rate of COVID-19 and subsequent lockdown situations, mental health of the people is being drastically affected. Scientists across the globe are extensively researching for the genetics of the coronavirus, its epidemiological features, pathophysiology, and clinical manifestations, but the impact of COVID-19 pandemic on the mental health of people is a neglected facet and should be brought to the attention of stakeholders for timely intervention.[15]

In this study, we have evaluated the degree of depression, anxiety, and stress level among confirmed COVID 19 positive patients admitted at Mamata General Hospital, Khammam, Telangana State. The overall mean and standard deviation scores were found to be, in the decreasing order, as stress scale measuring as 12.96 ± 7.98, followed by depression score as 12.74 ± 8.95 and anxiety score as 11.69 ± 7.82.

From a total of 100 patients, about 64% of the patients had varying degree of depression, 70% of the patients had anxiety, and 40% of the patients had various levels of stress. Of the total sample, 38% of the patients had moderate to very severe depression, 66% of the patients had moderate to very severe anxiety, and 32% of the patients had moderate to very severe stress. About 40% of the patients had combined anxiety and depression, while about 32% had combined depression, anxiety, and stress. Zhou et al. found that combined anxiety and depression to be 31.3% among Chinese high school students during COVID-19 outbreak (Zhou SJ, Zhang LG, Wang LL, Guo ZC, Wang JQ, Chen JC, et al. Prevalence and socio-demographic correlates of psychological health problems in Chinese adolescents during the outbreak of COVID-19. Eur Child Adolesc Psychiatry 2020;29:749-58).

About 36% of all the patients were found to have normal score for depression and about 12% of patients revealed severe depression and 10% of the patients had very severe depression scores. About 30% of the patients had normal scores for anxiety and about 36% of the respondents had moderate anxiety scores and severe to very severe anxiety was reflected among 10% and 20% of the study subjects, respectively. While 60% of the respondents had normal scores for stress scale, only 2% of the respondents had very severe stress scores. On comparison with Chinese population, amid COVID-19 pandemic, DASS scale measured as the sample mean score of 20.16 ± 20.42. Around 69.7% of Chinese patients showed normal score of depression with only 4.3% having severe to very severe depression. Nearly 63.6% of Chinese population had normal score of anxiety with 8.2% people revealing scores for severe to very severe anxiety. Similarly, stress score among Chinese inhabitants was 67.9%, with only 2.6% depicting severe stress.[3]

On comparison with above study, higher frequency of depression, anxiety, and stress scores has been found among patients in Khammam, Telangana state. This difference is likely due to the small sample size. This aspect needs to be studied in depth to reach at the right conclusion.

When compared between male and female COVID-19 patients, female patients in this study were found to have higher score of depression and stress in comparison with those of males with P < 0.0001 and anxiety score was marginally higher in males than in females, but it was not statistically significant with P = 0.07. Similarly, females of Israel population displayed higher rates of fear associated with COVID-19.[16] One more study, which was done by Shahid et al., also reported that females had more psychological impact than males in COVID-19 pandemic with P < 0.05.[17] In another study, it was found that higher level of stress among female medical students which was also attributed to Middle East respiratory syndrome coronavirus epidemic during 2012,[18] which also belongs to Coronaviridae family of viruses.

Lim et al. described that a 54-year-old male patient in South Korea without any history of a physical and mental illness or substance use, when kept under isolation in hospital, had developed depression, stress, insomnia, and suicidal thoughts.[19] Quarantine has been associated with negative impact on mental health which might be attributed to long-term quarantine, insufficient information, frustration, and stigmatization. Hence, experts advised that quarantine should be for as short duration as possible and that appropriate education be provided.[20]

However, in the recent days, there has been relationship between respiratory virus infections and subsequent mood disorder. Okusaga et al. found the relationship between seropositivity for influenza virus and onset of mood disorder in some patients.[21] Hence, there might be biological relationship between COVID and mood disorder, but there is no definite conclusion and it requires extensive research.

Some studies have indicated high levels of anxiety, particularly those who were under isolation for COVID 19 treatment.[22] In our study, majority of the patients had some degree of anxiety and about 30% had severe to very severe anxiety. It was found that initially, there would mild anxiety symptoms which would worsen over the course in few days.[23] Because of severity of anxiety among hospitalized or isolated patients, it is advisable to have psychological and psychiatric counseling methods be used either in person or via online hospital systems. Some researchers have also recommended progressive muscle relaxation be used.[22]

However, Rosselli et al. found high level of anxiety and depression among hospitalized patients than other individuals and emphasized for screening for psychiatric distress during hospitalization in different hospital wards.[24] Lee et al. studied the stress and psychological stress levels of 79 and 96 patients in two different hospitals during the SARS outbreak and 1 year thereafter. They found high level of stress. Even after 1 year of outbreak, they showed worrying levels of depression, anxiety, and posttraumatic stress.[25] After 30 months of SARS outbreak, the SARS survivors showed cumulative incidence and prevalence of 58.9% and 33.3%, respectively, for any psychiatric disorders which include posttraumatic stress disorder and subsequent depressive disorders. Hence, researchers described SARS outbreak as mental health catastrophe. They also pointed out the need for identifying and treating psychiatric disorders during other infectious epidemics.[26] Since SARS outbreak and COVID-19 (SARS-CoV-2) belong to the same family, Coronaviridae, we should expect more or less same psychological impacts on the sample population.

From the discussion, it is very clear that there is need of counseling especially among females and old age patients who might be belonging to either general public group or from healthcare profession who all are having COVID-19 infection to reduce psychological impact, resulting from contagious disease among them. The impact of COVID-19 on mental health of these patients was reported to be around 30% which was severe to very severe enough to hamper their psychological condition. On the other hand, the severe psychological impact was determined which was about 54% among Chinese population out of about 1200 respondents amid COVID-19 pandemic.[3] The probable reason for this much difference in the results could be attributed to the large sample size of study population, which was enrolled in the research from China, and the other explanation could be the confirmed COVID-19 patients included in our research who were admitted and getting treatment in Mamata General Hospital, Khammam, which is not very populated city. Their level of satisfaction with regard to treatment and other facilities provided could also be assessed to rule out the cause for psychological impact of coronavirus infection among them as it might also have some impact on their mental health.

Limitation

  1. Small sample size
  2. Participants were restricted one hospital
  3. Survey was done for shorter period of time.



  Conclusion and Recommendations Top


Depression, anxiety, and stress were high among COVID-19 patients, particularly among old age patients and female patients. Voluminous sessions of counseling and psychotherapy for older and female COVID-19 patients are needed to normalize the psychological impact of the disease. Hence, there is need of participation of psychologists and psychiatrists for the same purpose at COVID-19 treating healthcare facilities. Moreover, all the frontline workers should be trained to screen for psychological stress or anxiety or any other mood symptoms among COVID-19 patients so that appropriate psychological and psychiatric intervention may be provided accordingly.

Acknowledgment

We are very much thankful to all the participants for their participation in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. WHO Director-General's Statement on IHR Emergency Committee on Novel Coronavirus (2019-nCoV). Geneva: World Health Organization; 2020.  Back to cited text no. 1
    
2.
Lee A, Morling J. COVID19: The need for public health in a time of emergency. Public Health 2020;182:188-9.  Back to cited text no. 2
    
3.
Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. International journal of environmental research and public health. 2020;17:1729.  Back to cited text no. 3
    
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Fardin MA. COVID-19 and anxiety: A review of psychological impacts of infectious disease outbreaks. Archives of clinical infectious diseases. 2020 Apr 1;15(COVID-19).  Back to cited text no. 4
    
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Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: Address mental health care to empower society. Lancet 2020;395:e37-8.  Back to cited text no. 5
    
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Yoo JH. The fight against the 2019-nCoV outbreak: An arduous march has just begun. J Korean Med Sci 2020;35:e56.  Back to cited text no. 6
    
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Chen C, Zhang XR, Ju ZY, He WF. Advances in the research of cytokine storm mechanism induced by corona virus disease 2019 and the corresponding immunotherapies. Zhonghua Shao Shang Za Zhi 2020;36:E005.  Back to cited text no. 8
    
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Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther 1995;33:335-43.  Back to cited text no. 11
    
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Silva HA, Passos MH, Oliveira VM, Palmeira AC, Pitangui AC, Araújo RC. Short version of the depression anxiety stress scale-21: Is it valid for Brazilian adolescents? Einstein (Sao Paulo) 2016;14:486-93.  Back to cited text no. 12
    
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Oei TP, Sawang S, Goh YW, Mukhtar F. Using the depression anxiety stress scale 21 (DASS-21) across cultures. Int J Psychol 2013;48:1018-29.  Back to cited text no. 13
    
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Lorant V, Deliège D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: A meta-analysis. Am J Epidemiol 2003;157:98-112.  Back to cited text no. 14
    
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Kluge H, Malik A, Nitzan D. Mental Health and Psychological Resilience during the COVID-19 Pandemic. World Health Organization; 2020.  Back to cited text no. 15
    
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Bitan DT, Grossman-Giron A, Bloch Y, Mayer Y, Shiffman N, Mendlovic S. Fear of COVID-19 scale: Psychometric characteristics, reliability and validity in the Israeli population. Psychiatry Res 2020;289:113100.  Back to cited text no. 16
    
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Shahid R, Raza MR, Umar M, Zeb S, Shehryar M, Ambreen S, et al. Assessment of depression, anxiety and stress among COVID-19 patients by using DASS 21 scales. Journal of Medical Case Reports and Reviews. 2020;3.  Back to cited text no. 17
    
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Al-Rabiaah A, Temsah MH, Al-Eyadhy AA, Hasan GM, Al-Zamil F, Al-Subaie S, et al. Middle East Respiratory Syndrome-Corona Virus (MERS-CoV) associated stress among medical students at a university teaching hospital in Saudi Arabia. J Infect Public Health 2020;13:687-91.  Back to cited text no. 18
    
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Lim J, Jeon S, Shin HY, Kim MJ, Seong YM, Lee WJ, et al. Case of the index patient who caused tertiary transmission of COVID-19 infection in Korea: The application of lopinavir/ritonavir for the treatment of COVID-19 infected pneumonia monitored by quantitative RT-PCR. J Korean Med Sci 2020;35:e79.  Back to cited text no. 19
    
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Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. Lancet 2020;395:912-20.  Back to cited text no. 20
    
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Okusaga O, Yolken RH, Langenberg P, Lapidus M, Arling TA, Dickerson FB, et al. Association of seropositivity for influenza and coronaviruses with history of mood disorders and suicide attempts. J Affect Disord 2011;130:220-5.  Back to cited text no. 21
    
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Liu K, Chen Y, Wu D, Lin R, Wang Z, Pan L. Effects of progressive muscle relaxation on anxiety and sleep quality in patients with COVID-19. Complement Ther Clin Pract 2020;39:101132.  Back to cited text no. 22
    
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Sartorious N. Comorbidity of mental and physical diseases: A main challenge for medicine of the 21st century. Shanghai Arch Psychiatry 2013;25:68-9.  Back to cited text no. 23
    
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Rosselli M, Salimbeni MV, Bessi C, Nesi E, Caruso S, Arboretti D, et al. Screening of distress among hospitalized patients in a department of internal medicine. Asian J Psychiatr 2015;18:91-6.  Back to cited text no. 24
    
25.
Lee AM, Wong JG, McAlonan GM, Cheung V, Cheung C, Sham PC, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. Can J Psychiatry 2007;52:233-40.  Back to cited text no. 25
    
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    Tables

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



 

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