With the coronavirus disease 2019 (COVID-19) pandemic outbreak at the end of 2019, the disease rapidly spread worldwide. In the initial period, China was the most impacted by this pandemic, and there was an accompanying epidemic of anxiety and depression nationwide (1–3). People experienced numerous inconveniences due to the implementation of home quarantine policies (4, 5). Additionally, hospitals admitted large numbers of COVID-19 patients, and the shortage of frontline medical staff resulted in limited follow-up for postoperative patients (6, 7). Postoperative thyroid patients require close monitoring and treatment, and the majority of these patients are also cancer patients, who may be more vulnerable to negative emotions that could lead to psychological problems (8–10).

Several studies have explored anxiety, depression, and quality of life during the COVID-19 pandemic in a variety of populations, including the general population (1, 2, 11), health care workers (12–14), medical students (15, 16), cancer patients (17–19), and postoperative surgical patients (20, 21). The majority of these study populations experienced negative emotional states during the pandemic; however, to date, no studies have focused on the mental health of patients after thyroid surgery (22). While thyroid cancer is one of the more inert cancers with a relatively good prognosis, a diagnosis of thyroid nodules, especially thyroid cancer, would affect a patient’s postoperative psychological status. And several studies have reported similar or greater mental burden in thyroid patients (23, 24). The prevalence of thyroid cancer has increased every year, as has the volume of thyroid surgery (25–27), and the quality of life for postoperative thyroid patients has been of great concern to researchers (28, 29). However, during the COVID-19 pandemic, postoperative thyroid patients did not receive attention commensurate with their numbers.

The current study employed 4 validated psychological scales to assess symptoms of insomnia, anxiety, depression, and posttraumatic stress symptoms (PTSS) in postoperative thyroid patients during the peak of the COVID-19 pandemic in China and to investigate factors associated with these psychological symptoms. The goal of our study was to report the mental health status of postoperative thyroid patients and provide a reference for conducting thyroid surgery and perioperative patient education during the COVID-19 outbreak based on the potential influencing factors.

The psychological and emotional issues in numerous populations during the COVID-19 pandemic have received increasing attention (11–21). While psychological symptoms such as insomnia, anxiety, depression, and reduced quality of life after thyroid surgery have been reported by patients (34–36), the mental health of postoperative thyroid patients during the pandemic and the factors affecting it remain relatively unknown (37). To our knowledge, this current study is the first investigating mental health and influencing factors during the peak of the COVID-19 pandemic.

Our study found that a significant proportion of postoperative thyroid patients experienced insomnia, anxiety, depression, and PTSS, mostly to a mild degree. Age, marital status, education level, annual family income, number of comorbidities, time since surgery, the patients’ knowledge of their condition, disruption to follow-up during the COVID-19 pandemic, and coping strategies were associated with one or more of the psychological symptoms of insomnia, anxiety, depression, and PTSS.

Overall, we found that during the COVID-19 pandemic, postoperative thyroid patients reported more symptoms of insomnia, anxiety, depression, and PTSS than the normal population and worse psychological status than postoperative thyroid patients before COVID-19 (1, 11, 36); however, these patients had better mental health than postoperative patients with other types of cancers (18).

Consistent with previous studies, we found that single/divorced/widowed patients were at a higher risk of psychological symptoms than married since they received more emotional support (36, 38). Higher education levels and higher annual family income were associated with lower psychological symptoms, consistent with the literature (11, 36), possibly because patients with higher education levels usually have more comprehensive information about both their condition and the COVID-19 pandemic. Moreover, higher income suggests higher risk tolerance. Together, these factors may support patients in coping with negative emotions and prevent the development of psychological disorders.

As shown in Table 1 , almost a third of the patients underwent thyroid surgery more than 12 months before enrollment, and we set time since surgery as a variable for analysis. Notably, we found that it was an independent factor related to insomnia and depression and had nonsignificant but similar associations with anxiety and PTSS scores. Interestingly, patients who had undergone surgery within the past 6 months reported the most severe psychological symptoms, followed by those who underwent surgery more than 12 months ago, while patients who had surgery between 6 and 12 months ago had the best mental health. Chen et al. have shown that symptoms of anxiety and depression in patients become milder within 1 year after surgery (39), similar to our results. A possible explanation is that patients’ lives gradually return to normal after surgery. However, our results are novel in that patient mental health symptoms worsened again 1 year after surgery; this unanticipated result could stem from an increase in fear of recurrence after 1 year had elapsed (40–42).

According to the multivariable linear regression model, we found a significant association between the number of comorbidities and all 4 mental health symptoms: having 2 comorbidities was an independent risk factor for PTSS. Surprisingly, however, patients with one comorbidity reported the lowest scores on the psychological scales, i.e., had better mental health than that patients without comorbidities. This result has not been previously reported and is contrary to our expectations; therefore, it should be treated with caution. It is difficult to explain this observation, but it might be related to fatigue due to comorbidity (43). Another possible explanation is that patients with one comorbidity tend to be more conscious and well informed about their physical health and therefore experienced fewer mood fluctuations due to the COVID-19 pandemic than patients without comorbidities, whereas the poor mental health of patients with two or more comorbidities may be due to their poorer general condition (44).

Another interesting finding was that proactive search of COVID-19-related information and medical guidance from social media was associated with higher levels of anxiety and PTSS and was an independent risk factor for PTSS. This is consistent with the findings of previous studies (45–48). Potentially, information overload on social media makes it difficult for people with insufficient expertise to distinguish between truths and falsehoods. Especially for patients who are worried about their condition and those who cannot visit hospitals due to the pandemic, information overload increases their anxiety and PTSS about COVID-19 (17, 45, 49).

Our study is the first to report on the mental health of postoperative thyroid patients during the peak of the COVID-19 pandemic and the potential factors that influenced mental health. However, some possible limitations should be noted. First, we did not enroll a control group, although we made comparisons to previous studies. Second, this was a single-center study, and our patients were all from nearby areas; the hospital was far from Wuhan, the center of the epidemic in China. In addition, there was no specific preoperative mental assessment to determine the potential impact of thyroid function on their psychological status, which may influence postoperative mental health.

According to our findings, patients who were older, single/divorced/widowed, less educated, had lower annual income, in poor general health, had undergone surgery within the past six months, had disrupted access to postoperative follow-up, and actively searched social media for COVID-19-related information were more likely to develop mental health problems. These findings suggest that older, single/divorced/widowed patients should be encouraged to reach out more to friends and seek emotional support. Additionally, patients with lower levels of education, lower income, more comorbidities, and those who have undergone surgery within the past 6 months are at higher risk of developing mental health problems and need to be promptly identified to provide more psychological support and intervention.

In addition, the mental health of patients might be improved by enhancing patient education and improving their understanding of their condition. Providing postoperative patients with medical care during the COVID-19 pandemic, such as educating patients to correctly identify medical information on social media, providing psychological counseling services for patients during special periods, offering special online consultation section, and organizing inter-patient support to alleviate patients’ anxiety and PTSS.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Ethics Committee of Peking Union Medical College Hospital. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

SY data analysis, data interpretation, original manuscript drafting; XX: study concept and design, data collection, data interpretation, original manuscript drafting and editing. All authors contributed to the article and approved the submitted version.

This study is supported by the National Natural Science Foundation of China (32071436) and the Beijing Municipal Natural Science Foundation (7222127).

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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