J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website https://jocmr.elmerjournals.com

Original Article

Volume 18, Number 1, January 2026, pages 18-30

Long-Term Mental Health Evaluation After COVID-19: Insights From the CARDIO COVID 20–21 Registry

Figure 1. Flowchart of patient selection for the CARDIO COVID 20–21 psychiatric assessment. ACE-III: Addenbrooke’s Cognitive Examination; GAD-7: General Anxiety Disorder-7; ICU: intensive care unit; PHQ-9: Patient Health Questionnaire-9; PSS-14: Perceived Stress Scale-14.

Figure 2. Violin plots of psychiatric scales by sex and ICU admission: (a) GAD-7 scores; (b) PHQ-9 score; (c) PSS-14 score; (d) ACE-III score. Violins are stratified by sex (men and women), and split by ICU admission. Orange shading represents data on patients who did not require ICU admission, while green shading represents data on patients admitted to the ICU. ACE-III: Addenbrooke’s Cognitive Examination; GAD-7: General Anxiety Disorder-7; ICU: intensive care unit; PHQ-9: Patient Health Questionnaire-9; PSS-14: Perceived Stress Scale-14.

Figure 3. Four-dimensional Venn diagram demonstrating the co-occurrence of abnormal scores between scales. Percentages are calculated based on the total number of abnormal scores. ACE-III: Addenbrooke’s Cognitive Examination-III; GAD-7: General Anxiety Disorder-7; PHQ-9: Patient Health Questionnaire-9; PSS-14: Perceived Stress Scale-14.

**Table 1.** Psychiatric Scales Assessed
Scale	Use	Categories
ACE-III: Addenbrooke’s Cognitive Examination-III; GAD-7: General Anxiety Disorder-7; PHQ-9: Patient Health Questionnaire-9; PSS-14: Perceived Stress Scale-14.
GAD-7	A 7-item scale to screen for general anxiety disorder [20]. A cutoff point of 5 has shown a sensitivity of 94% and a specificity of 65% [21]. The version of this scale in Spanish has been previously validated in Colombia [22].	0–4: none to minimal anxiety; 5–9: mild anxiety; 10–14: moderate anxiety; ≥ 15: severe anxiety
PHQ-9	A 9-item scale validated for depression screening [23, 24]. A cutoff point of 5 has a sensitivity of 87% and a specificity of 80% [25]. The version of this scale in Spanish has been previously validated in Colombia [26].	0–4: none to minimal depression; 5–9: mild depression; 10–14: moderate depression; 15–19: fairly severe depression; ≥ 20: severe depression.
PSS-14	A 14-item questionnaire used to measure psychological stress [27]. The Spanish version of this scale has been previously validated [28].	0–13: Low perceived stress; 14–26: moderate perceived stress; 27–40: high perceived stress.
ACE-III	An extended cognitive assessment to screen for cognitive dysfunction. A cutoff score of 88 has a sensitivity of 100% and a specificity of 93% [29]. The Spanish version has been previously validated [30].	100–88: No cognitive dysfunction; 88–82: possible mild cognitive dysfunction; < 82 possible dementia.

Table 1. Psychiatric Scales Assessed

Scale

Use

Categories

ACE-III: Addenbrooke’s Cognitive Examination-III; GAD-7: General Anxiety Disorder-7; PHQ-9: Patient Health Questionnaire-9; PSS-14: Perceived Stress Scale-14.

GAD-7

A 7-item scale to screen for general anxiety disorder [20]. A cutoff point of 5 has shown a sensitivity of 94% and a specificity of 65% [21]. The version of this scale in Spanish has been previously validated in Colombia [22].

0–4: none to minimal anxiety; 5–9: mild anxiety; 10–14: moderate anxiety; ≥ 15: severe anxiety

PHQ-9

A 9-item scale validated for depression screening [23, 24]. A cutoff point of 5 has a sensitivity of 87% and a specificity of 80% [25]. The version of this scale in Spanish has been previously validated in Colombia [26].

0–4: none to minimal depression; 5–9: mild depression; 10–14: moderate depression; 15–19: fairly severe depression; ≥ 20: severe depression.

PSS-14

A 14-item questionnaire used to measure psychological stress [27]. The Spanish version of this scale has been previously validated [28].

0–13: Low perceived stress; 14–26: moderate perceived stress; 27–40: high perceived stress.

ACE-III

An extended cognitive assessment to screen for cognitive dysfunction. A cutoff score of 88 has a sensitivity of 100% and a specificity of 93% [29]. The Spanish version has been previously validated [30].

100–88: No cognitive dysfunction; 88–82: possible mild cognitive dysfunction; < 82 possible dementia.

**Table 2.** Baseline Characteristics Stratified by Sex and ICU Admission
Variable	All, N = 152	Sex	ICU admission
Statistical significance was evaluated using Fisher’s exact test, Pearson’s Chi-squared test, or Wilcoxon rank-sum test, as appropriate. ^aValues are presented as mean ± standard deviation. ^bIn Colombia, residential areas are classified into six socioeconomic strata (1–6) based on income levels. Stratum 1 represents the lowest-income areas receiving the greatest public utility subsidies, whereas Stratum 6 corresponds to the highest-income areas paying full rates without subsidies. ^cSmoking exposure refers to previous or current smoking. ARB: angiotensin receptor blocker; BMI: body mass index; DBP: diastolic blood pressure; ICU: intensive care unit; SBB: systolic blood pressure.
Demographics
Age, years^a	56 (14)	54 (16)	57 (12)	0.3	54 (16)	57 (13)	0.15
Years of education^a	10.7 (4.8)	10.7 (4.4)	10.6 (5.1)	0.8	11.7 (4.2)	9.9 (5.0)	0.012
Socioeconomic status^a,b	2.64 (1.37)	2.54 (1.39)	2.71 (1.36)	0.374	2.83 (1.55)	2.50 (1.21)	0.316
Follow-up duration (months)^a	24.5 (2.05)	24.4 (2.21)	24.6 (1.94)	0.7	24.8 (1.80)	24.4 (2.21)	0.3
Comorbidities
Overweight/obesity	74 (48%)	32 (50%)	42 (49%)	0.9	26 (41%)	48 (56%)	0.10
Hypertension	62 (40%)	26 (41%)	36 (40%)	> 0.9	26 (40%)	36 (40%)	> 0.9
Diabetes mellitus	26 (17%)	10 (16%)	16 (18%)	0.8	2 (3.2%)	24 (27%)	< 0.001
Pharmacological history
ARB	50 (33%)	20 (32%)	30 (34%)	0.80	22 (34%)	28 (32%)	0.74
Statins	34 (22%)	14 (22%)	20 (22%)	0.97	10 (16%)	24 (27%)	0.089
Hypoglycemic drugs	28 (18%)	13 (21%)	15 (17%)	0.55	5 (7.8%)	23 (26%)	0.004
Physical examination and lifestyle
SBP (mm Hg)^a	127 (15)	127 (15)	127 (16)	0.994	125 (16)	128 (15)	0.217
DBP (mm Hg)^a	78 (9)	77 (9)	79 (9)	0.108	79 (9)	78 (9)	0.833
Heart rate (bpm)^a	72 (12)	74 (12)	71 (11)	0.109	72 (11)	73 (12)	0.575
BMI (kg/m²)^a	28.5 (4.9)	29.1 (5.2)	28.2 (4.7)	0.426	27.5 (4.2)	29.3 (5.2)	0.029
Smoking exposure^c	21 (14%)	6 (9.5%)	15 (17%)	0.197	7 (11%)	14 (16%)	0.380

Table 2. Baseline Characteristics Stratified by Sex and ICU Admission

Variable

All, N = 152

Sex

ICU admission

Female, N = 63

Male, N = 89

P value

No, N = 64

Yes, N = 88

P value

Statistical significance was evaluated using Fisher’s exact test, Pearson’s Chi-squared test, or Wilcoxon rank-sum test, as appropriate. ^aValues are presented as mean ± standard deviation. ^bIn Colombia, residential areas are classified into six socioeconomic strata (1–6) based on income levels. Stratum 1 represents the lowest-income areas receiving the greatest public utility subsidies, whereas Stratum 6 corresponds to the highest-income areas paying full rates without subsidies. ^cSmoking exposure refers to previous or current smoking. ARB: angiotensin receptor blocker; BMI: body mass index; DBP: diastolic blood pressure; ICU: intensive care unit; SBB: systolic blood pressure.

Demographics

Age, years^a

56 (14)

54 (16)

57 (12)

0.3

54 (16)

57 (13)

0.15

Years of education^a

10.7 (4.8)

10.7 (4.4)

10.6 (5.1)

0.8

11.7 (4.2)

9.9 (5.0)

0.012

Socioeconomic status^a,b

2.64 (1.37)

2.54 (1.39)

2.71 (1.36)

0.374

2.83 (1.55)

2.50 (1.21)

0.316

Follow-up duration (months)^a

24.5 (2.05)

24.4 (2.21)

24.6 (1.94)

0.7

24.8 (1.80)

24.4 (2.21)

0.3

Comorbidities

Overweight/obesity

74 (48%)

32 (50%)

42 (49%)

0.9

26 (41%)

48 (56%)

0.10

Hypertension

62 (40%)

26 (41%)

36 (40%)

> 0.9

26 (40%)

36 (40%)

> 0.9

Diabetes mellitus

26 (17%)

10 (16%)

16 (18%)

0.8

2 (3.2%)

24 (27%)

< 0.001

Pharmacological history

ARB

50 (33%)

20 (32%)

30 (34%)

0.80

22 (34%)

28 (32%)

0.74

Statins

34 (22%)

14 (22%)

20 (22%)

0.97

10 (16%)

24 (27%)

0.089

Hypoglycemic drugs

28 (18%)

13 (21%)

15 (17%)

0.55

5 (7.8%)

23 (26%)

0.004

Physical examination and lifestyle

SBP (mm Hg)^a

127 (15)

127 (16)

0.994

125 (16)

128 (15)

0.217

DBP (mm Hg)^a

78 (9)

77 (9)

79 (9)

0.108

79 (9)

78 (9)

0.833

Heart rate (bpm)^a

72 (12)

74 (12)

71 (11)

0.109

72 (11)

73 (12)

0.575

BMI (kg/m²)^a

28.5 (4.9)

29.1 (5.2)

28.2 (4.7)

0.426

27.5 (4.2)

29.3 (5.2)

0.029

Smoking exposure^c

21 (14%)

6 (9.5%)

15 (17%)

0.197

7 (11%)

14 (16%)

0.380

**Table 3.** GAD-7, PHQ-9, PSS, and ACE-III by Sex and ICU Admission
Scale	All, N = 152	Sex	ICU admission
Statistical significance was evaluated using Wilcoxon rank sum test and Fisher’s exact test for count data; Fisher’s exact test for count data with simulated P-value (based on 2,000 replicates) was used. ACE-III: Addenbrooke’s Cognitive Examination; GAD-7: General Anxiety Disorder-7; ICU: intensive care unit; PHQ-9: Patient Health Questionnaire-9; PSS-14: Perceived Stress Scale-14.
GAD-7				0.052			0.7
No symptoms or minimal	102 (67%)	37 (59%)	65 (73%)		44 (69%)	58 (66%)
Mild symptoms	30 (20%)	14 (22%)	16 (18%)		10 (16%)	20 (23%)
Moderate symptoms	18 (12%)	12 (19%)	6 (6.7%)		9 (14%)	9 (10%)
Severe symptoms	2 (1.3%)	0 (0%)	2 (2.2%)		1 (1.6%)	1 (1.1%)
Abnormal (> 4)	50 (33%)	26 (41%)	24 (27%)	0.08	20 (31%)	30 (34%)	0.07
PHQ-9				0.02			0.8
None-minimal	78 (51%)	25 (40%)	53 (60%)		31 (48%)	47 (53%)
Mild	46 (30%)	21 (33%)	25 (28%)		21 (33%)	25 (28%)
Moderate	16 (11%)	8 (13%)	8 (8.9%)		7 (11%)	9 (10%)
Moderate-severe	11 (7.2%)	9 (14%)	2 (2.2%)		4 (6.3%)	7 (8%)
Severe	1 (0.7%)	0 (0%)	1 (1.1%)		1 (1.6%)	0 (0%)
Abnormal (> 4)	74 (49%)	38 (60%)	36 (40%)	0.021	33 (52%)	41 (47%)	0.6
PSS-14				0.011			0.5
Low perceived stress	136 (89%)	51 (81%)	85 (95.5%)		57 (89%)	79 (89.8%)
Moderate perceived stress	12 (7.9%)	9 (14%)	3 (3.4%)		6 (9.4%)	6 (6.8%)
High perceived stress	4 (2.6%)	3 (4.8%)	1 (1.1%)		1 (1.6%)	3 (3.4%)
Abnormal (> 13)	16 (11%)	12 (19%)	4 (4.5%)	0.006	7 (11%)	9 (10.2%)	> 0.9
ACE-III				0.018			0.007
No cognitive dysfunction	135 (89%)	52 (83%)	83 (93.3%)		63 (98.4%)	72 (82%)
Cognitive dysfunction (< 88)	17 (11%)	11 (17%)	6 (6.7%)	0.065	1 (1.6%)	16 (18%)	< 0.001

Table 3. GAD-7, PHQ-9, PSS, and ACE-III by Sex and ICU Admission

Scale

All, N = 152

Sex

ICU admission

Female, N = 63

Male, N = 89

P value

No, N = 64

Yes, N = 88

P value

Statistical significance was evaluated using Wilcoxon rank sum test and Fisher’s exact test for count data; Fisher’s exact test for count data with simulated P-value (based on 2,000 replicates) was used. ACE-III: Addenbrooke’s Cognitive Examination; GAD-7: General Anxiety Disorder-7; ICU: intensive care unit; PHQ-9: Patient Health Questionnaire-9; PSS-14: Perceived Stress Scale-14.

GAD-7

0.052

0.7

No symptoms or minimal

102 (67%)

37 (59%)

65 (73%)

44 (69%)

58 (66%)

Mild symptoms

30 (20%)

14 (22%)

16 (18%)

10 (16%)

20 (23%)

Moderate symptoms

18 (12%)

12 (19%)

6 (6.7%)

9 (14%)

9 (10%)

Severe symptoms

2 (1.3%)

0 (0%)

2 (2.2%)

1 (1.6%)

1 (1.1%)

Abnormal (> 4)

50 (33%)

26 (41%)

24 (27%)

0.08

20 (31%)

30 (34%)

0.07

PHQ-9

0.02

0.8

None-minimal

78 (51%)

25 (40%)

53 (60%)

31 (48%)

47 (53%)

Mild

46 (30%)

21 (33%)

25 (28%)

21 (33%)

25 (28%)

Moderate

16 (11%)

8 (13%)

8 (8.9%)

7 (11%)

9 (10%)

Moderate-severe

11 (7.2%)

9 (14%)

2 (2.2%)

4 (6.3%)

7 (8%)

Severe

1 (0.7%)

0 (0%)

1 (1.1%)

1 (1.6%)

0 (0%)

Abnormal (> 4)

74 (49%)

38 (60%)

36 (40%)

0.021

33 (52%)

41 (47%)

0.6

PSS-14

0.011

0.5

Low perceived stress

136 (89%)

51 (81%)

85 (95.5%)

57 (89%)

79 (89.8%)

Moderate perceived stress

12 (7.9%)

9 (14%)

3 (3.4%)

6 (9.4%)

6 (6.8%)

High perceived stress

4 (2.6%)

3 (4.8%)

1 (1.1%)

1 (1.6%)

3 (3.4%)

Abnormal (> 13)

16 (11%)

12 (19%)

4 (4.5%)

0.006

7 (11%)

9 (10.2%)

> 0.9

ACE-III

0.018

0.007

No cognitive dysfunction

135 (89%)

52 (83%)

83 (93.3%)

63 (98.4%)

72 (82%)

Cognitive dysfunction (< 88)

17 (11%)

11 (17%)

6 (6.7%)

0.065

1 (1.6%)

16 (18%)

< 0.001

**Table 4.** Univariable and Multivariable Linear Regression Analysis of ACE-III
Variable	Univariable	Multivariable
^aSmoking exposure refers to previous or current smoking. ^bSocioeconomic status was based on Colombia’s official residential socioeconomic strata classification, which categorizes households into six levels (1–6) according to housing and neighborhood characteristics. ACE-III: Addenbrooke’s Cognitive Examination III; BMI: body mass index; CI: confidence interval; ICU: intensive care unit.
Age	−0.05	−0.13, 0.03	0.23	−0.004	−0.10, 0.09	0.94
Male	2.96	0.65, 5.27	0.01	3.66	1.40, 5.93	0.002
Years of education	0.49	0.26, 0.72	< 0.001	0.47	0.20, 0.74	< 0.001
ICU admission	−3.10	−5.40, −0.80	0.01	−2.95	−5.37, −0.54	0.02
BMI (kg/m²)	−0.01	−0.25, 0.23	0.92	0.02	−0.21, 0.26	0.84
Smoking exposure^a	−1.51	−4.88, 1.85	0.38	−1.75	−5.04, 1.53	0.29
Hypertension	0.84	−1.49, 3.17	0.48	2.56	0.16, 4.96	0.04
Diabetes mellitus	−1.38	−4.01, 1.25	0.30	−0.87	−3.61, 1.86	0.53
Socioeconomic status	0.63	−0.22, 1.48	0.14	−0.10	−0.98, 0.77	0.82

Table 4. Univariable and Multivariable Linear Regression Analysis of ACE-III

Variable

Univariable

Multivariable

Beta

95% CI

P value

Beta

95% CI

P value

^aSmoking exposure refers to previous or current smoking. ^bSocioeconomic status was based on Colombia’s official residential socioeconomic strata classification, which categorizes households into six levels (1–6) according to housing and neighborhood characteristics. ACE-III: Addenbrooke’s Cognitive Examination III; BMI: body mass index; CI: confidence interval; ICU: intensive care unit.

Age

−0.05

−0.13, 0.03

0.23

−0.004

−0.10, 0.09

0.94

Male

2.96

0.65, 5.27

0.01

3.66

1.40, 5.93

0.002

Years of education

0.49

0.26, 0.72

< 0.001

0.47

0.20, 0.74

< 0.001

ICU admission

−3.10

−5.40, −0.80

0.01

−2.95

−5.37, −0.54

0.02

BMI (kg/m²)

−0.01

−0.25, 0.23

0.92

0.02

−0.21, 0.26

0.84

Smoking exposure^a

−1.51

−4.88, 1.85

0.38

−1.75

−5.04, 1.53

0.29

Hypertension

0.84

−1.49, 3.17

0.48

2.56

0.16, 4.96

0.04

Diabetes mellitus

−1.38

−4.01, 1.25

0.30

−0.87

−3.61, 1.86

0.53

Socioeconomic status

0.63

−0.22, 1.48

0.14

−0.10

−0.98, 0.77

0.82