Discussion
The COVID-19 has spread all over the world since the first quarter of
2020 and the uncertainty about the personal and global effects of
COVID-19 in addition to psychological effect of quarantine caused fear
and anxiety. Previous studies have suggested that the outbreaks can have
many psychological effects like anxiety and depression [20,21].
Although a number of studies evaluated psychological impact of COVID-19
pandemic in children and adults, data regarding the effect of pandemic
in patients with chronic disease is scarce [17].
In this study we evaluated the psychological reactions, family and peer
relations, self-care practises and coping methods of CF patients during
pandemic and compared with healthy controls. Symptoms of anxiety were
unexpectedly higher in controls compared to CF patients. Almost 50% of
the children in control group and 33% of the CF patients were feeling
anxious about the COVID-19 pandemic. Feeling upset for school closure,
worries for a family member having the risk of COVID-19 infection,
feeling sad, lonely or reluctant to have playful time, overthinking
about pandemic are all more common psychological reactions regarding
pandemic in control group compared to CF
patients.
Consistent to the results of current study, another study from Turkey,
Senkalfa et al also reported lower anxiety scores regarding COVID-19
pandemic in CF patients compared to age-matched healthy control group
[17]. Surprisingly lower anxiety scores in CF patients in both study
may be related with a number of factors.
Since the viral respiratory tract infections tend to be more severe in
CF patients with an increased risk of complications and a negative
impact on lung function, in the first days of pandemic, our patients and
their families were more concerned about the possible effect of COVID-19
infection. However until now, only few cases of COVID-19 infection in
people with CF were reported, which may probably related with the
efforts of families and patients to minimise social contacts [22].
It should also worthwhile to emphasize that reported cases are mainly
adult CF patients and COVID-19 infection does not have an apparent
effect on CF disease severity. It is not possible to identify protective
factors and we need more data in order to determine the impact of
COVID-19 on patients with CF. In cooperation with national registries,
European Cystic Fibrosis Society (ECFS) Patient Registry has established
an international dataset to identify factors that predict severity of
COVID-19. However we assume that low numbers and mild course of COVID-19
infection caused a relieve in CF patients, which may partly explain
lower anxiety levels in our patients.
During pandemic, consistent with international guidelines we recommended
self-isolation for our CF patients. Recommendations for preventive
measures such as using face masks and practising adequate hand hygiene
were reinforced. The CF team cancelled routine clinic appointments to
prevent unnecessary hospital visits and viral spread. Phone calls and
email contacts were used to monitor the clinical condition of patients
immediately after the lockdown. In a study from China, presence of
psychological problems were negatively associated with the level of
awareness of COVID-19 [14]. Wang et al revealed that wearing a mask
and practicing hand hygiene decreases the level of anxiety in children
older than 12 years old [10]. CF patients are used to follow
instructions for infection control guidelines’ including wearing masks
and avoiding close in-person contact with other CF patients. The
awareness regarding respiratory tract infections and familiarity to
infection control measurements might be factors which decrease the level
of anxiety in CF patients.
Psychosocial maladjustment might be another reason for lower anxiety
levels in CF patients. Children with chronic physical disorders have
twice the risk of psychosocial maladjustment compared with healthy
children [23]. This maladjustment phenomenon might be an explanation
for CF patients to give fewer psychological reactions in our study group
in the case of pandemic, as they are already having longer times at
home, mostly detached from the school or peer relations.
CF patients always facing with a serious health problem and associated
anxiety symptoms, hovewer, healthy peers has been encountered fear of
disease for the first time in their life during pandemic which can also
partly explain relatively lower levels of anxiety in CF patients
compared to healthy controls.
Although no significant difference was found between CF and control
groups regarding family environment and relations or self care and peer
relations, it is important to emphasize that almost half of the children
were having apetite changes in both groups and incidence of sleeping
problem were 10% in CF patients and 15% in control group. In our
country, during disease outbreak, right after the school closure and
home confinement, home schooling plan has been implemented. In addition
to academic learning, age appropriate and attractive videos may motivate
children to have a healthy lifestyle at home by increasing physical
activities, having a balanced diet, regular sleep pattern, and good
personal hygiene.
Althoug CF patients had a lower tendency to need psychological help
compared to control group, children in CF group had more anxiety
symptoms compared to adolescents and required more psychological help
than adolescents in both groups. During pandemic children are constantly
exposed to pandemic-related news, so having direct conversations with
children about these issues could alleviate their anxiety. Home
confinement, with the right parenting approaches could be a good
opportunity to enhance family interactions and improve their
self-sufficiency skills of children [24].
Resilience is the ability of properly adapt and react positively to
adversity, trauma, individual or society tragedies, including serious
health threats [25-26]. Coping responses mean the behaviours,
thoughts and feelings that individuals adopt to avoid being harmed by
life stressors [27]. In this study, we found that CF patients seem
more resilient and developed adaptive coping strategies with the
pandemic. Mental health of children and adolescents constitute
the basis for future adult mental health and related to quality of
life,
productivity, and well-being as well as compliance to treatment in the
presence of a chronic health condition. Therefore, it is a vital
effort
to understand the psychological reactions of CF patients during the
unusual period of pandemic, in addition to the chronic illness status.
Current study has a few limitations. First, although the CF and control
groups are aged-matched, they are not gender-matched. It has been shown
that girls experience more anxiety than boys in previous studies
[28-29]. Hovewer, since the anxiety levels of girls in our study
were similar in CF and control groups, we assumed that gender difference
has not been an important impact on our results.
Second, this was a phone survey and participants were recruited under
parental supervision. Since it was a self-report assessment, the
indicated levels of anxiety may not always be consistent with the
assessment of mental health by a professional.
Several studies reported increased anxiety and depression in CF pateints
compared to healthy controls and routine screening is strogly
recommended, [4-6]. In a recent unpublished study, before pandemic,
we revealed that moderate to severe depression and moderate anxiety was
peresent in 25.5% and 17.6% of 50 adolescent CF patients respectively
in our center [30].
Current study revealed that CF patients had lower anxiety symptoms and
they were more resilient in coping during pandemic than their healthy
peers.
In conclusion, although acute events such as pandemics may not seem to
increase baseline anxiety and not associated with an important
physcological impact in CF patients compared to heathy population, lack
of psychological support in routine care may lead to higher levels of
anxiety and depression in long term.