Effect of COVID-19 Pandemic on Mental Health in Patients with Kidney Transplantation

: Severe acute respiratory syndrome coronavirus-2 is the cause of coronavirus disease 2019 (COVID-19). The most effective method in controlling the disease is maintaining the distance between people and, if necessary, quarantine. Recent evidence suggests that people kept in isolation and quarantine experience significant anxiety, confusion, and stress levels. This study aims to investigate the effects of COVID-19 on mental health in kidney transplant recipients. In this cross-sectional study, all renal transplant patients who followed up in our transplantation clinic were evaluated to be included in the study. The Turkish version of the fear of COVID-19 scale, depression anxiety stress scale (DASS-21), and satisfaction with life scale (SWLS) were administered to the patients. Patients were interviewed face-to-face by the same physician. A total of 68 patients were included in the study: 29 (42.6 percent) women and 39 (57.4 percent) men. In the present study, we detected that DASS-21 anxiety, depression, stress, and total scores were higher in patients with a family history of psychiatric disease than without (p<0.05). We did not find any statistical differences between patients’ demographic characteristics and fear of COVID-19 scale, DASS-21 anxiety, depression, stress, and total scores except for family history of psychiatric disease. More extensive and multi-center studies are needed to determine these patients' anxiety and depression states in the future.


INTRODUCTION
Severe acute respiratory syndrome coronavirus-2 is the cause of coronavirus disease 2019 (COVID-19).The covid-19 infection has different clinical presentations ranging from asymptomatic or mild respiratory infection to acute respiratory distress 1 .Patients with kidney transplantation must use drugs that suppress their immune system to prevent organ rejection.This makes them prone to various infections, including COVID-19.The clinical presentation and severity of the COVID-19 disease in these patients' groups is still unknown.These patients are recommended not to enter closed environments and to be isolated.Recent evidence suggests that people kept in isolation and quarantine experience significant anxiety, confusion, and stress 2 .These can pose risks to the mental health of the individuals.
A few numbers of studies have investigated the effects of COVID-19 on mental health.Salari et 3 conducted a meta-analysis of studies investigating stress, depression, and anxiety in the general population during the covid-19 pandemic.They found that

RESULTS AND DISCUSSION
A total of 68 people was included in the study: 29 (42.6 percent) women and 39 (57.4 percent) men.Demographic characteristics of patients are summarized in Table 1.We compared the anxiety, depression, stress and total DASS 21 scores, fear of COVİD-19, and SWLS scores obtained as a result of the scales with the characteristics of the patients such as age over 65 and under, gender, education, marital status, educational status, economic status, job, smoking and alcohol use, quarantine history, presence of P a g e | 55 psychiatric diseases, family history of psychiatric disease.In the present study, we detected that DASS-21 anxiety, depression, stress, and total scores were higher in patients with a family history of psychiatric disease than without.No significant difference was present between scale scores and any of the parameters we compared.(p ≥ 0.05) (Table 2).
Covid-19 has affected the whole world in many aspects; socially, economically, and psychologically.This study is the first to investigate the effects of COVID-19 infection on the mental health of kidney transplant patients.In our patients, there was no difference in terms of anxiety levels between men and women, over and less than 65 years of age, those with high and low education levels, those who were married and single, those who used alcohol, and those who did not use alcohol.We found that only patients with a family history of psychiatric disease had high DASS-21 anxiety, depression, stress, and total scores (Table 2).Our knowledge about COVID-19 infection is limited; the contamination and mortality rates of the virus are high.Furthermore, COVID-19 infection can cause anxiety, panic attacks, and suicidal thought.A meta-analysis showed that the prevalence of stress, anxiety, and depression because of the COVID-19 pandemic in the general population, was 29.6, 31.9, and 33.7 percent, respectively 3 .The National Health Commission of China also released basic principles for emergency psychological crisis interventions for 2019-nCoV pneumonia on Jan 26, 2020 13 .Anxiety, when aboveaverage, weakens the immune system and increases the risk of infection.Previous research had shown that patients with chronic illnesses are more vulnerable to mental illnesses 14 .
Kidney transplantation patients are under immunosuppression at high risk of any infection.The progression of Covid-19 disease in kidney transplant recipients is not precisely known.Initially, it was thought that the risk of transmission was higher in kidney transplant recipients and that the disease would progress more severely.However, it was found that the prevalence of COVID-19 virus infection was 1.6-3 percent in kidney transplant recipients.Ozturk et al 15 .found that patients with kidney transplantation have an 11.1 percent mortality rate.Their patients adjusted mortality and combined outcomes (mortality and intensive care admission) did not differ from the control group.The uncertainty of the clinical progression of the disease may increase the anxiety and stress levels of kidney transplant patients.Although Karlıdag et al 4 .found a positive relationship between chronic diseases and fear of Covid-19 and anxiety, we did not find increased anxiety in kidney transplant recipients.

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We only found that patients with a family history of the psychiatric disease have high DASS-21 anxiety, depression, stress, and total scores.Karlıdağ et al 4 .also stated that patients with the psychiatric disorder had higher fear of COVID-19 scale, DASS-21 anxiety, and total scores than those without Since psychiatric disorders involve neurotransmitter abnormalities in the cerebrum, these patients seem to have poor control of anxiety and anger symptoms related to the emotional center 3,16 .We could not find any relationship with anxiety, depression, stress.We think it is because our patients with a history of psychiatric disorders number were minimal.Considering that most psychiatric diseases are genetically inherited, having a family history of the disease puts these patients at risk.
During this period, our patients reached us by all the communication ways and conveyed their problems.These results can be due to this.Physicians following kidney transplant patients should consider that patients may be under intense stress during this period, suppressing immunity.By providing patients with easy access to their physicians, patients' intense stress and anxiety can be reduced.Our limitation is sample size was small.Our study has some limitations.One of them is that the number of patients was small.The other one is that anxiety and stress levels of the patients evaluated through a questionnaire may not be compatible with the evaluation of psychologists and psychiatrists.

CONCLUSION
We aimed to study the effect of Covid-19 on kidney transplant recipients.We only have if patients have mental illness risk factors have more anxiety, depression, and stress during the pandemia.It can be expected that all types of psychiatric disorders may be negatively affected by the fear of COVID-19.Research with more sample size is needed for more complete results.

CONFLICT OF INTEREST
The author report no conflicts of interest and no funding resources in this study.

Table 1 .
Demographic Features of the Patients.

Table 2 .
The Results of Analysis of Comparison of Demographic Characteristics of Patients with the Anxiety, Depression, Stress and Total DASS 21 Scores, Fear of COVİD-19, and SWLS Scores.Whitney U test was used to compare two independent samples and Kruskal-Wallis test was used to compare more than two independent samples.The level of significance was set at P < .05. **The numerical values in the table are median (minimummaximum) values.