1. Introduction
Post-COVID-19 syndrome, also known as long COVID-19, is defined by the World Health Organization (WHO) as a condition where symptoms are present three months after SARS-CoV-2 infection and cannot be explained by alternative diagnoses [
1]. Fatigue, shortness of breath, sleep disorders, and cognitive dysfunction are the most common symptoms in patients with post-COVID-19 syndrome, while over 200 long-term different symptoms are identified in the literature [
2,
3]. A large proportion of COVID-19 patients also have post-COVID-19 syndrome. For example, according to a prediction model by the WHO, more than 17 million people across the WHO European Region may have experienced post-COVID-19 syndrome during the first two years of the pandemic [
4]. Moreover, a meta-analysis with a total of 1.2 million symptomatic COVID-19 cases found that the fatigue cluster of long COVID-19 occurred in 51.0% of cases, the respiratory cluster occurred in 60.4% of cases, and the cognitive cluster occurred in 35.4% of cases [
5]. Additionally, at >12-month follow-up, 41%, 31%, 30%, 22%, and 22% of confirmed SARS-CoV-2 cases continued to experience fatigue, dyspnea, sleep disorder, myalgia, and cognitive impairment, respectively [
3,
6].
The impact of post-COVID-19 syndrome on the mental health of patients is high. The European Centre for Disease Prevention and Control (ECDC) performed a meta-analysis and found that the prevalence of anxiety, depression, and post-traumatic stress disorder in patients with post-COVID-19 syndrome recruited in community settings was 17.2%, 17.3%, and 20.6%, respectively [
7]. The prevalence of mental health issues was even higher for patients recruited in hospital settings, i.e., the prevalence of anxiety was 27.5%, and that of depression was 23.3%. A similar systematic review found that anxiety (ranging from 6.5% to 63% across the studies), depression (ranging from 4% to 31%), and post-traumatic stress disorder (ranging from 12.1% to 46.9%) were the most common mental health issues in patients with post-COVID-19 syndrome [
8]. Even young people at 3 months post-COVID-19 showed emotional vulnerability in higher psychological distress (depression, anxiety, and stress) and dysphoria signs (irritability, discontent, interpersonal resentment, and feelings of renunciation/surrender) [
9].
Moreover, post-COVID-19 syndrome affects patients’ quality of life since a meta-analysis found that the prevalence of poor quality of life was 59% [
10]. Additionally, among patients with post-COVID-19 syndrome, 41.5% reported extreme pain/discomfort, 37.5% reported extreme anxiety/depression, 36% reported extreme problems with mobility, 28% reported extreme problems with usual activities, and 8% reported extreme problems with self-care [
10].
The positive impact of resilience and social support during the pandemic has already been proven. In particular, a meta-analysis found a significant negative relationship between resilience and psychological distress among COVID-19 patients [
11]. Moreover, a review including workers found that resilience was associated with lower levels of anxiety, depression, and burnout [
12]. Similarly, a systematic review found that resilience and social support among healthcare workers improved mental and psychological health outcomes [
13]. Additionally, low perceived social support was a risk factor for adverse psychological states in COVID-19 patients, such as stress, anxiety, and depression [
14]. Also, social support seemed very important during the first wave of the pandemic due to its negative correlation with psychological pressure, mental discomfort, and anxiety [
15].
Until now, research has only explored the relationship between a few demographic and clinical characteristics of patients with post-COVID-19 syndrome and mental health and quality of life. Greater anxiety and depression were reported in female patients, patients with a psychiatric history, and patients with intensive care unit admission [
8,
16]. Moreover, quality of life was lower among patients admitted to intensive care and patients with higher levels of fatigue [
10]. However, the available studies have not investigated the influence of psychosocial factors on patients’ lives. Thus, the aim of our study was to explore the impacts of resilience and social support on anxiety, depression, and quality of life among patients with post-COVID-19 syndrome.
4. Discussion
The impact of the COVID-19 pandemic on the mental health of citizens has been significant. Fear of infection, quarantine, disruption of the educational process, and teaching via e-learning were some of the factors that affected mental health, making it imperative to modify mental health services to meet the needs of patients. Patients who experienced long COVID-19 may have already had compromised mental health [
29,
30,
31]. However, the literature on factors that influence the mental health and quality of life in patients with post-COVID-19 syndrome is poor. The majority of studies focused only on the measurement of mental health and quality of life among patients. So far, a small number of demographic and clinical characteristics of patients have been studied. To the best of our knowledge, our study is the first that investigates the role of psychosocial factors on mental health and quality of life among patients with post-COVID-19 syndrome. In particular, we explored the relationship between resilience and social support, and mental health and quality of life in patients with post-COVID-19 syndrome.
Quality of life among patients with post-COVID-19 syndrome in our study was very poor. In our study, the EQ-5D-3L index value was 0.36, while the EQ-5D-3L index norm values based on the Greek value test were 0.916 in the 45–54 group, 0.739 in the ≥75 group, and 0.913 in all age groups [
32]. Moreover, the EQ-5D-3L VAS in our patients was 54.1, while the EQ-5D-3L VAS norm values were 78 in the 45–54 group, 54 in the ≥75 group, and 79 in all age groups [
28]. We compared our results with the 45–54 group since the mean age of our sample was 44.8 years. Thus, the quality of life of our patients was even worse than that of the Greek elderly over 75 years old. Additionally, similar studies in Spain, France, the USA, and China found that the EQ-5D-3L VAS among patients with post-COVID-19 syndrome ranged from 64 to 80, while the EQ-5D-3L index value ranged from 0.71 to 0.86 [
33,
34,
35].
Moreover, our patients experienced high levels of anxiety and depression. In particular, the proportion of our patients reporting possible major anxiety (60.7%) and depression disorder (69.7%) was much higher than that reported in a meta-analysis (the overall prevalence of anxiety was 23% and that of depression was 17%) [
36]. Additionally, another meta-analysis including only studies with low/moderate risk of bias found that the overall prevalence of depression among patients recruited in the community setting was 17.3%, while the prevalence of the disease among patients recruited in the hospital setting was 23.3% [
7]. Moreover, a systematic review found that the frequency of depressive symptoms ranged from 11 to 28%, while the frequency of clinically significant depression ranged from 3 to 12% [
16].
Our results show a significant negative relationship between resilience and anxiety and depression. In other words, the higher a patient’s resilience, the lower their anxiety and depression. Moreover, our multivariable model identified that resilience increased quality of life in our sample. The literature confirms the positive effect of resilience on individuals’ lives. In particular, a meta-analysis found a significant negative correlation between resilience and psychological distress in COVID-19 patients [
11]. Similarly, a meta-analysis including patients with a somatic illness or health problem found a negative relationship between resilience and anxiety and depression [
37]. Additionally, a meta-analysis including samples from the general population found a positive correlation between trait resilience and positive indicators of mental health, and a negative correlation between trait resilience and negative indicators of mental health [
38]. Moreover, it is well known that during the COVID-19 pandemic, resilience helped people, especially vulnerable groups (e.g., the elderly or patients), to maintain a good quality of life [
39,
40,
41,
42,
43].
Resilience is defined as an individual’s ability to withstand or recover quickly from difficult conditions [
38]. In other words, resilience can be described as a defense mechanism, which gives people the ability to cope successfully with stressful experiences and bounce back from negative experiences [
44]. Additionally, resilience implies the flexible use of emotional resources, such as flexibility, perseverance, balance, and self-reliance for adapting to adversity [
37,
45]. Therefore, resilience is crucial in promoting individuals’ positive mental health, especially during the COVID-19 pandemic where mental health was compromised in several ways (e.g., lockdowns, quarantine measures, social isolation, loneliness, etc.) [
46,
47,
48,
49]. Moreover, several studies showed that higher levels of resilience were associated with better mental health, not only in the general population but also in COVID-19 patients [
50,
51,
52,
53,
54]. Thus, higher levels of resilience among patients with post-COVID-19 syndrome can reduce negative consequences, protect patients against adverse events, and promote patients’ ability to cope with this condition. Patients with high resilience can have a stronger capacity for self-reflection and a better tolerance of negative feelings in order to better cope with anxiety, depression, and psychological distress [
55].
We found that social support reduced anxiety and depression among patients with post-COVID-19 syndrome. Also, our results show a significant positive relationship between social support and quality of life. A meta-analysis has already shown that post-COVID-19 syndrome reduces patients’ quality of life and maintains symptoms such as sleep disturbance, anxiety, depression, fatigue, and dyspnea [
10]. Cohort studies suggest that the negative consequences of post-COVID-19 syndrome on patients’ quality of life and mental health remain even a year after infection [
34,
56]. Several studies including COVID-19 patients found that high social support had a negative association with anxiety and depression symptoms [
57,
58,
59]. Moreover, social support positively affected COVID-19 patients’ quality of life during the COVID-19 pandemic [
60,
61]. Additionally, a systematic review confirmed the positive relationship between social support and people’s quality of life especially during the first wave of the pandemic [
15].
Social support, or a social network, characterizes the functioning of individuals among other people, e.g., family members, friends, significant others, and neighbors [
62]. During the pandemic, protective measures, such as quarantine, increased the loneliness of all citizens regardless of age group, with mental health consequences such as anxiety, depression, and suicide risk [
29]. Following disasters, social support plays an essential protective role in maintaining mental health [
63]. Similarly, several studies during the pandemic suggested that people could benefit from real-life and online social support [
62,
64,
65,
66]. Social support increased belongingness and community attachment during the pandemic and that resulted in reduced anxiety and depressive symptoms [
67]. Additionally, peer and community support groups reduced psychological distress in the era of the pandemic [
68]. Moreover, social support positively affected individuals’ self-efficacy during the pandemic, improving their ability to cope successfully with stressful experiences, such as compliance with quarantine and isolation measures [
69,
70,
71]. Therefore, social support is an essential psychological resource that can improve mental health and quality of life in patients with post-COVID-19 syndrome, allowing them to successfully deal with the long-term psychological consequences of the disease.
Our study had several limitations. First, we used a convenience sample, which is not representative of the population of patients with post-COVID-19 syndrome in Greece. For example, most of our patients were females, while only a few had been hospitalized in a COVID-19 intensive care unit. Moreover, our sample was obtained from the long COVID Greece patient society. Thus, patients who did not belong to this society did not have the chance to participate in our study. Although we achieved the required sample size, further studies with random and bigger samples can add valuable information. Second, we used self-reported tools to measure resilience, social support, anxiety, depression, and quality of life in our patients. Thus, information bias is probable in our study. Especially for anxiety and depression, we need to use valid diagnostic criteria in order to obtain more robust results. In that case, longitudinal studies can be very helpful. Third, we assessed the independent effects of resilience and social support, eliminating some confounders, but other factors could also be possible confounders, e.g., socioeconomic status, educational level, family status, etc. Fourth, we performed a cross-sectional study measuring the variables at a specific time. Thus, a causal effect relationship between resilience and social support, and anxiety, depression, and quality of life cannot be established. Follow-up studies measuring changes over time could provide more valid results. Finally, we measured the impacts of two psychological factors (i.e., resilience and social support) on patients’ lives. Several other psychological variables (e.g., self-efficacy, mindfulness, optimism, loneliness, social integration, etc.) could affect patients’ mental health and quality of life. Thus, further studies should be performed in order to expand our knowledge in this field.
5. Conclusions
Our study identified a worrying proportion of patients with post-COVID-19 syndrome with anxiety and depression symptoms. Moreover, the quality of life among these patients was very poor. However, resilience and social support can be protective by reducing anxiety and depression and improving quality of life among patients with post-COVID-19 syndrome. The prevalence of psychological problems among patients with post-COVID-19 syndrome seems to be high. Since we are dealing with a new condition, our knowledge is very limited. Thus, the identification of factors that influence patients’ lives is crucial to reducing negative outcomes and improving quality of life.
Psychological resources, such as resilience and social support, are important for promoting positive adaptation in case of post-COVID-19 syndrome and reducing negative symptomatology. There is a need to provide on-time and updated psychological care services for patients with post-COVID-19 syndrome. Moreover, we should follow up on these patients for a longer period since post-COVID-19 syndrome can last for more than a year.
Patients with post-COVID-19 syndrome need time to adapt to their condition both physically and mentally. Since it is a new and unknown condition, patients should develop resilience over time in order to deal effectively with post-COVID-19 syndrome. Also, policymakers should develop and implement healthcare management programs to provide psychological support to patients.
Healthcare workers, especially clinical psychiatrists and psychologists, should be aware of the psychological needs of patients with post-COVID-19 syndrome in order to improve their mental health and quality of life. Moreover, healthcare professionals should carry out regular follow-up observations to assess the long-term effects of post-COVID-19 syndrome.