Iran Journal of Nursing

Introduction
Immunosuppressive drugs are used to control inflammatory diseases, prevent transplanted organ rejection, and treatment of some autoimmune diseases. Despite their significant effects, their use is often associated with increased concern and fear of developing other diseases due to the weak immune system. This vulnerability can lead to the development of anxiety and depression in these patients and can cause post-traumatic stress disorder (PTSD). In this regard, this study aims to determine the anxiety, depression, and PTSD symptoms in individuals treated with immunosuppressive drugs during the COVID-19 pandemic.

Methods 
In this descriptive cross-sectional study, 330 patients with cancer, multiple sclerosis, myasthenia gravis, systemic lupus erythematosus, rheumatoid arthritis, organ transplantation, psoriasis, sarcoidosis, Behcet’s disease, pemphigus vulgaris, lichen planus, and inflammatory bowel diseases, who were admitted to the inpatient and outpatient departments of two teaching hospitals (Firouzgar and Rasoul-e-Akram) in Tehran, Iran, were included. Sampling was done from July 2022 to December 2022 using a continuous sampling method. 
Three questionnaires were used to collect data, including a demographic/disease-related questionnaire, the Hospital Anxiety and Depression Scale (HADS), and the Impact of Event Scale-Revised (IES-R). The demographic/disease-related questionnaire surveys age, gender, marital status, education level, type of disease, medication use, COVID-19 infection, and COVID-19 vaccinnation status. The anxiety and depression levels were categorized into normal (score 0-7), mild (score 8-10), moderate (score 11-14), and severe (score 15-21) based on the HADS score [21]. 
The IES-R, which does not have a defined cut-off point [24], has three sub-scales, including hyperarousal, intrusion, and avoidance. The higher score in this scale indicates a greater severity of PTSD symptoms [23]. The content validity of the questionnaires was confirmed by six experts and faculty members of the School of Nursing, Iran University of Medical Sciences, after applying their opinions. To measure the reliability of the questionnaires, they were sent to 20 eligible patients and were excluded from the study after completing questionnaires. 
The Chronbach’s alpha coefficient for the depression subscale of HDAS was 0.769 and for the anxiety subscale of HADS was 0.893. In the IES-R, the alpha coefficient was 0.866 for the intrusion subscale, 0.820 for the avoidance subscale, 0.751 for the hyperarousal subscale, and 0.864 for the total score.

Result 
In this study, the mean age of participants was 51.35±12.95 years, and 148 (44.8%) were female.The majority of participants were married (86.4%) and had a high school diploma or lower education (74.2%). Most of the participants had a history of COVID-19 infection (74.5%) and 169 had received three doses of the COVID-19 vaccine (51.2%). The majority of the participants had normal levels of anxiety and depression (91.2% and 92.1%, respectively). Regarding the PTSD symptoms, the mean scores of IES-R in the three subscales of arousal, avoidance, and intrusion were 8.14 out of 24, 10.25 out of 32, and 9.31 out of 32, respectively and the mean total score of IES-R was 27.71 out of 88. Moreover, the results showed that anxiety and depression had no significant correlation with any of the demographic, disease-related, and COVID-19 vaccine-related characteristics of the participants. A statistically significant correlation was found only between income level and the total score of IES-R (P=0.043).

Conclusion
In this study, the patients receiving immunosuppressive drugs, despite being susceptible to COVID-19 infection, did not show elevated levels of anxiety or depression and obtained lower than average scores in the IES-R. This finding may mitigate concerns regarding the psychological impact of COVID-19 and adverse mental effects of immunosuppressive drugs in these individuals. A qualitative study on the expriences of these patients during COVID-19 pandemic or using other questionnaires to measure anxiety, depression and PTSD symtoms can enrich these results. 

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1401.237).

Funding
This article was extracted from the master’s thesis of Amir Hojjat Abbasi in medical surgical nursing, which was funded by Iran University of Medical Sciences.

Authors' contributions
Conceptualization, methodology, and writing: Amirhojjat Abbasi and Maryam Ehsani; data collection: Amirhojjat Abbasi; supervision and validation: Naimeh Seyyed Fatemi; data analysis: Shima Haghanii and Amirhojjat Abbasi; editing and review: All authors.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to sincerely thank the personnel of Firouzgar and Rasoul-e Akram hospitals, the Deputy for Research of Iran University of Medical Sciences, and the patients participated in this research for their cooperation.


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