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.