Spiritual Health Predicts Improved PHQ-9 During COVID Isolation in Extended Care Facility Patients.

To the Editor:

The COVID-19 pandemic is exacting a toll in terms of illness, death, and disruption, especially for residents of extended care facilities (ECFs), who are at very high risk of morbidity and mortality from the virus. For their own safety, when community transmission is high or when outbreaks occur in their facility, ECF residents are severely restricted from contact with the community, their families and friends, and from each other and staff.

In the ECF environment, COVID-19–related restrictions have the potential to cause even more isolation. Well-being declines when basic social needs are not met. Older people are particularly prone to social isolation, increasing their risk for decline in mental well-being.

People turn to spirituality in times of crisis and uncertainty as a coping mechanism. Compared with religious belief and practice, spirituality is a connection with the sacred, enhancing hope, peace, meaning, and purpose. It can provide a positive, hopeful worldview, offering indirect control over circumstances, thus reducing depression and anxiety.

Our preliminary study looked at whether spirituality offered protection from the psychological strains resulting from increased social isolation of ECF residents occasioned by COVID-19–related restrictions.

Methods

This project was approved by the Reid Health Institutional Review Board. The 124 residents of 2 extended care facilities were screened for eligibility to participate in the study by reviewing their latest documented Brief Interview for Mental Status (BIMS). Residents with BIMS scores greater than 12, indicating adequate cognitive capacity to consent, were invited to participate. , Two patients declined, and 1 was unable to participate, yielding n = 24 participants (13 female and 11 male; mean age = 74.9 years; 96% White). Each was met individually to explain the project and obtain consent.

For a pre-isolation assessment of emotional well-being, we used participants' Patient Health Questionnaire-9 (PHQ-9) scores obtained nearest in date prior to the initiation of the protective quarantine in March 2020. If admitted after that date, we used their admitting PHQ-9 score as the initial score. We used a second PHQ-9 score obtained within 30 days before commencement of the study (December 2020). We subtracted participants' second PHQ-9 (quarantine) score from their first PHQ-9 (prior to quarantine) score to obtain a measure of change in functioning (see Figure 1 ).

Fig. 1

Stronger spirituality predicts improved change in PHQ-9 (R2 = 0.18, P < .05). The larger data points in bold indicate participants with lower spiritual well-being. The smaller data points indicate participants with higher spiritual well-being. 0-28 = significant spiritual distress and despair; 29-36 = low spiritual well-being; 37-45 = average spiritual well-being; 46-48 = very high spiritual well-being.

To measure spirituality, we met with participants to complete the Functional Assessment of Chronic Illness Therapy–Spiritual Wellbeing–Non-Illness (FACIT-SP-NI). The FACIT-SP-NI Total score indicates overall spiritual well-being, with subscales for Meaning (eg, having a life purpose) and for Faith (eg, finding comfort in one's own faith).

We used Microsoft Excel (2016) to run descriptive statistics and simple linear regressions, with P < .05 significance.

Results

Change in PHQ-9 scores ranged from 7 points improved emotional well-being to 9 points worsened well-being during the quarantine isolation. Initial PHQ-9 predicted the subsequent PHQ-9 (R 2 = 0.60, P < .01).

Stronger spiritual well-being (Total FACIT-SP-NI score, R 2 = 0.18, P < .05), as well as stronger overall sense of meaning (Meaning subscale, R 2 = 0.16, P = .05), predicted improved PHQ-9 scores from prior to the quarantine isolation. Stronger faith was not statistically significant in predicting changes in PHQ-9.

Discussion

This preliminary study with residents of 2 extended care facilities found that stronger spirituality predicted improved PHQ-9 from March 2020 to December 2020, during quarantine precautions. Considering other research conducted during COVID-19, a Brazilian study found that adults who relied on their religion and spirituality experienced better mental health. A French study found lower scores on the 2-item French version of the PHQ-9 (HQP-2) for those with stronger spirituality, though this study did not look at changes in spirituality from before the pandemic. Taken together, these results point toward a more general finding well established before the conditions of the pandemic—spirituality is associated with better health outcomes. Our preliminary study suggests spirituality may help preserve residents of extended care facilities from the challenges of isolation during the COVID-19 pandemic.

Key limitations include the small sample size who met the criteria to participate and limitations to geographic, demographic, and racial diversity. Additionally, some of the participants were admitted to the facilities during the COVID-19 pandemic, so their initial PHQ-9 may have reflected their home circumstances during the quarantine. Therefore, our results should be validated by further study in a larger cohort of facilities with greater geographic and ethnic diversity, and in subjects with lower cognitive scores.

Even with these limitations, our results extend research supporting the positive impact of spirituality on health and resilience to health events before the end-of-life process.

Future research may explore whether interventions supporting spirituality reduce the negative impact of isolation and social curtailment.