Coronavirus disease 2019 (COVID-19) can be considered as a situation of acute stress, especially for people who were affected in wave 1, as they required hospitalization, and had to cope with a very demanding and unpredictable situation (e.g., lack of communication with their family members at hospital; Whitehead and Torossian, 2021). Given the nature of this dramatic situation it is not surprising that different studies have shown important negative consequences for the physical and emotional health (e.g., depression) of the people affected by it (e.g., Huang et al, 2021). In order to analyze the inherent impact of situations of natural disasters and pandemics, results of previous studies suggest that the variability between the different reactions to the pandemic found in the population depend on factors such as perceived health, previous mental health, level of social support, coping strategies and socioeconomic context, among others (Cedeño et al, 2020). The difficulty of having family visits at the hospitals, and the uncertainty of knowing the evolution and impact of COVID-19 on patients and their relatives, may have led to feelings social isolation and loneliness, variables strongly associated with negative consequences for mental health (e.g., depression; Jurblum et al, 2020).

However, most of the existing literature about the impact of COVID-19 on mental health has been conducted with non-hospitalized patients and using cross-sectional study designs. In the scarce number of existing longitudinal studies about COVID-19, most of them have focused on analyzing the prevalence rates of emotional symptoms (e.g., Cénat et al, 2022; Houben-Wilke et al, 2022), with studies showing that 26% of hospital survivors with COVID-19 reported anxiety or depressive symptoms one year later (Huang et al, 2021), although information about predictors of this distress remains scarce. A recent systematic review, conducted in long COVID patients or with persistent symptoms after 4 weeks from recovery, suggested that the most common emotional symptoms found in these patients were depression, posttraumatic stress and, specially, anxiety (Marchi et al, 2023). Although evidence suggests, about depression and anxiety, to be a co-occurring phenomenon and predictive factors of long COVID (Engelmann et al, 2024), the exploration of predictors of these long-term impacts, particularly in hospitalized populations, remains underdeveloped. Moreover, understanding the role of modifiable factors, such as family communication during hospitalization, perceived social support and loneliness, which are well-known risk factors of emotional distress in other populations (Wang et al, 2018), could allow researchers to developed targeted interventions for at-risk hospitalized populations.

Among the existing studies on risk factors associated with suffering a high psychological impact derived from the pandemic, a few stand out: being female, younger, having a low educational level, the existence of previous psychological disorders, loneliness, negative perception of one’s own health, living alone and working in healthcare (Broche-Pérez et al, 2021; Cortés Zamora et al, 2022; MacDonald et al, 2022). Another factor that frequently modulates the psychological impact of stressful situations, such as the COVID-19 pandemic, on emotional distress (e.g., anxiety) is social connections and support (Xu et al, 2020). However, the longitudinal role of predictors of emotional distress in hospital survivors who suffered from severe COVID-19 in Wave 1 have been scarcely studied. Within the general population, studies have highlighted the importance of social support (Jónsdóttir et al, 2025), as well as psychological variables such as psychological flexibility (Sebastião and Neto, 2025), in predicting better long-term mental health outcomes. Among the limited longitudinal studies conducted with survivors of severe COVID-19, the use of invasive mechanical ventilation has been identified as a significant predictor of both depression and post-traumatic stress symptoms (Navarra-Ventura et al, 2024). Yet, no studies to date have specifically focused on analyzing psychosocial predictors of emotional distress in this high-risk population. Exploring these predictors on severe patients hospitalized during the COVID-19 pandemic, may be of several importance, not only for those who still experience the consequences of the pandemic (i.e., long COVID, or COVID survivors who still experiences emotional consequences of the disease process), but for other kinds of hospitalized patients with similar conditions of uncertainty. Loneliness and lack of social support are common problems in various patient groups, such as those in intensive care units’ patients, or with complex chronic illnesses, who often required hospitalizations (e.g., Christiansen et al, 2021). By exploring the longitudinal relationships between these uncovering risk and protective factors and mental health outcomes, research may contribute to a better understanding of the psychosocial support needs of vulnerable populations during and after hospitalization. Identifying these modifiable key factors enables the creation of prevention initiatives (e.g., fostering family communication during hospitalization) or interventions that could prevent long-term emotional distress and improve the quality of life of different types of patients.

Therefore, this study aimed to analyze the role of quality of family communication during hospitalization, perceived loneliness and social relationships on emotional distress (depression and anxiety symptoms) in survivors of bilateral pneumonia and respiratory failure in Wave 1 of COVID-19 in a two-year longitudinal study. We hypothesized that lower loneliness, having higher quality of family communication during hospitalization and presenting better social relationships would predict lower emotional distress.

The aim of this study was to analyze longitudinally if psychosocial variables (loneliness, social relationships, and quality of family communication during hospitalization) were associated with emotional distress (depression and anxiety symptoms) in patients of severe COVID-19 in the first Wave 1 of pandemic, two years after being hospitalized, after controlling for gender, age, perceived health as well as for emotional symptoms at baseline. This study adds to previous literature, mostly focused on analyzing the physical and psychological impact of the COVID-19 pandemic cross-sectionally (Cortés Zamora et al, 2022; Huang et al, 2021), we have aimed to increase the knowledge regarding potential psychosocial predictors of emotional health outcomes longitudinally in survivors of severe COVID-19 in Wave 1. To our knowledge no studies have focused on the role of risk factors on emotional health in hospitalized patients with severe COVID-19 two years after being hospitalized, being, at this moment, only one study available that has a one year follow up (Cortés Zamora et al, 2022; Méndez et al, 2022). Specifically, results of our study suggest that higher levels of loneliness and a lower number of social relationships predict higher levels of depressive symptoms two years after being hospitalized, which is consistent with previous cross-sectional studies (e.g., Meyer et al, 2020) and longitudinal studies in non-hospitalized population (e.g., MacDonald et al, 2022), as loneliness and social support are well-documented risk factors for depression across diverse populations and contexts (Cacioppo et al, 2006). Results also suggest that, in the context of COVID-19, the prolonged social restrictions and high level of physical limitations, either during and after hospitalization, may likely exacerbate feelings of loneliness, which may increase vulnerability to develop depression two years later. Prolonged isolation during hospitalization for COVID-19 survivors, coupled with the challenges of re-establishing social connections post-discharge, likely amplifies emotional vulnerability. Our findings highlighted the need for comprehensive psychosocial assessments as part of post-hospitalization care, particularly for those recovering from severe illnesses like COVID-19, specially addressing loneliness and social support during critical transitions from hospital to home. Assessing and designing strategies targeting loneliness and social support may be useful for enhancing long-term emotional distress in patients recovering from severe illnesses.

In addition, patients who had worse quality of communication with their relatives (measured as lower levels of family communication) while being hospitalized presented higher levels of depression longitudinally, which suggests that a better quality in family communication may play a relevant role in explaining emotional discomfort, having practical suggestions for the humanization of care. These results are consistent with studies in other populations that highlight the relevant role that social support and family communication variables have on explaining depression (Curran and Allen, 2017). These results suggest that encouraging a better quality of family communication during hospitalization (e.g., face to face) may be a modifiable and a key target in preventing depression symptoms, an outcome which has been associated longitudinally with poor functional recovery in hospitalized COVID-19 survivors (Lorent et al, 2022). The inclusion of family cohesion as a protective factor to buffer effects of stress and to explain health outcomes has been previously addressed (Fosco et al, 2023; Montirosso et al, 2021). Although previous studies have examined the effects of the type of communication (e.g., digital communication such as the use of social media) when face-to-face interaction was limited in the first wave of COVID-19 (e.g., Nguyen et al, 2022), as well as the impact of the type of communication in physician-patient interactions (Hammersley et al, 2019), until now, no study had explored how the mode of communication between a hospitalized patient and his relatives during admission for a severe contagious illness, relates to adverse emotional outcomes such as long-term depression two years later. Results of this study suggest that patients who were able to maintain better communication with family members during hospitalization exhibited significantly lower levels of anxiety and depression two years later. These results suggest that fostering effective family communication during critical care not only humanizes the healthcare process but also may serve as a preventive measure against future emotional distress.

Also, our results suggest that reporting a worse perceived health longitudinally predicts a higher level of depressive symptoms which is consistent with other studies (Sullivan et al, 2017). This finding has potential clinical implications, as previous studies have shown that depressive symptoms are associated with hospital readmissions (Cancino et al, 2014), and targeting psychological correlates of depression such as encouraging family communication at hospitals and social support may reduce perceived loneliness in patients, which could prevent clinically depressive symptoms over time.

Regarding anxiety symptoms, results of this study show that worse perceived health and low social support significantly predicted higher levels of anxiety symptoms 2 years after being hospitalized. In this line, it has been found that higher emotional support from healthcare workers during hospitalization is a protective factor for posttraumatic stress symptoms one-month post-discharge in COVID-19 survivors (Ju et al, 2021).

In addition, results of this study suggest that being a female survivor patient significantly predict anxiety symptoms in long term, which is consistent with previous literature, as women may often being exposed to more caregiving roles, influenced by societal and cultural expectations (Matud and García, 2019). It is important to acknowledge that the small sample size of female participants constitute a limitation of the study. It would be interesting to analyze gender differences in the associations between psychosocial variables and emotional health in future studies to identify the specific needs of people of different genders. Previous studies highlighted the important role of social support on the association between gender and emotional outcomes (Swickert and Hittner, 2009), suggesting that emotional social support predict psychological distress specially in women (Matud and García, 2019). The design of future studies with gender stratification is recommended.

This study presents some limitations. First, the small sample size of the study limits the generalizability of the conclusions, although this is the first exploratory study that analyzes predictors of longitudinal emotional consequences in a specific profile of participants, patients with severe COVID-19 disease who were hospitalization during Wave 1 of the pandemic. Future studies with larger samples and a priori power analyses would be crucial to confirm and extend our preliminary findings. Due to the pilot nature and time constraints of this longitudinal study with post-pandemic survivors, telephone interviews were conducted using self-reported measures with ad hoc items to measure some key variables (e.g., quality of family communication and perceived loneliness), rather than established, validated scales, which constitute an important limitation of this study. Consequently, it was not possible to report the psychometric properties of these variables, which represents an additional limitation. This could potentially compromise the generalizability and reliability of our findings. Future research should prioritize the development and utilization of well-validated, comprehensive scales to quantify these constructs accurately, particularly considering both frequency of and quality of family communication during hospitalization (e.g., Wongpakaran et al, 2020). Although this is a longitudinal study, this does not allow us to infer causal relationships between the variables of the study. In addition, future research should consider also the differences between those patients reporting any of these kinds of family communication and those who did not having any kind of communication at all during their hospital stay. These analyses were not possible to be considered for the present study, due to the small number (n = 4, 5.9% of the total sample) of participants who did not report any kind of family communication during their stay. Therefore, future studies with larger sample sizes should try analyzing these different groups, in order to stablish clearer associations between family communication and psychological well-being in hospitalized patients. Moreover, an important limitation of the present study is the absence of objective measures of the participants’ physical health status, as well as the lack of information regarding any psychological or psychiatric treatment received during the two years following hospitalization. These variables could have significantly contributed to explaining the current emotional distress and should therefore be considered in future longitudinal studies. Finally, another limitation of this study is the absence of intermediate assessments (e.g., a one-year follow-up) between baseline and the two-year follow-up. The two-point assessment design may have missed potential fluctuations or changes in the variables of interest over time. Future studies would benefit from incorporating multiple time points to better understand the trajectories and dynamics of emotional distress in patients following hospitalization. Given the mentioned limitations, it is important to be cautious when generalizing the conclusions of this study. In spite of these limitations, this study adds to previous longitudinal studies in hospitalized patients with severe COVID, which found negative consequences of COVID-19 for depression and anxiety symptoms (e.g., Huang et al, 2021). We highlight the important role of psychosocial predictors (loneliness, social support and quality of family communication during hospitalization) on these outcomes.

Although our conclusions may not be directly applicable to the current situation of the COVID-19 pandemic, since it has ended, we consider that our preliminary findings, highlighting the potential significant role of social factors and family communication in explaining emotional distress over time, may have implications for understanding and addressing the needs of patients with symptom persistent COVID-19 or other populations who have experienced critical illness, such as intensive care unit (ICU) survivors. These individuals may often face similar challenges related to physical and psychological recovery, and our research suggests that high social support, low perceived loneliness and an effective family communication during hospitalizations could play a crucial role in their well-being.

Therefore, this study may present important clinical implications for the humanization of care. First, preliminary results suggest that perceived loneliness and presenting better quality of communication with relatives during hospitalization, which is a very critical and uncertain situation, may contribute to longitudinally explain consequences on emotional distress. It would be useful to foster and promote communication with family members and social connections as key components during critical care and hospitalization processes, as this may prevent the development of future emotional distress problems in patients. These results may be applied to other clinical populations (e.g. intensive care units or complex chronic diseases) which have important clinical implications for social and public health systems.

The preliminary findings obtained in this study may contribute to understanding the long-term emotional impact on patients hospitalized for severe COVID-19, as well as clinical implications to identify populations at risk in which it would be important to implement prevention strategies and treatments from a multidisciplinary approach. To continue studying the long-term emotional, physical, and comorbid consequences and their predictors in these patients, in order to provide them with the necessary psychological support, should be greatly encouraged.

The authors had full control of all the primary data and the datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

RRM designed and supervised the study, performed the analyses, and wrote the first draft of the manuscript. YCV and PVL collected the data, provided resources, and contributed to manuscript revision. CVG contributed to study design, methodology, and manuscript writing. LMG and MCMA collected data and contributed to manuscript revision. MAF and AVC contributed to methodology, formal analysis, and manuscript revision. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

The study was carried out in accordance with the guidelines of the Declaration of Helsinki, and the study protocol was approved by the Ethics Committee of the Hospital Universitario Severo Ochoa (approval number: 0820). All participants gave their informed consent for inclusion before they participated in the study.

This research received no external funding.

The authors declare no conflict of interest.