[Paper] COVID-19 survivors are at higher risk of post-traumatic stress disorder

Summary

Post-Traumatic Stress Disorder (PTSD) is a common psychiatric disorder triggered by major psychological trauma, which can cause severe distress and impairment. Previous epidemic studies have reported high prevalence rates among individuals exposed to trauma associated with infectious disease outbreaks. While the COVID-19 pandemic and management of patient care remain significant challenges worldwide, this commentary emphasizes the need for early intervention and PTSD prevention among a vast number of COVID-19 survivors, their families, healthcare professionals, and other frontline helpers.

Keywords:

COVID-19, Post-Traumatic Stress Disorder, prevention

Background

The World Health Organization declared the outbreak of coronavirus disease (COVID-19) in 2019 as a pandemic. As of May 11, 2020, there have been 4,006,257 reported deaths due to COVID-19 in over 200 countries and territories [1]. Predicting the number of infections and deaths worldwide remains premature as these figures continue to rise. Meanwhile, millions of people fear the potential loss of health, life, and livelihood, leading to widespread panic. Experiencing or witnessing the suffering associated with COVID-19 can result in high prevalence rates of psychiatric disorders such as Post-Traumatic Stress Disorder (PTSD) among survivors, their families, early responders, and caregivers (including healthcare and public health professionals, police officers, etc.), as well as the general public.

While the pandemic and control of COVID-19 patient care remain major global challenges, this commentary calls for early intervention and prevention of PTSD in affected populations. PTSD is a common pathological outcome of various traumatic events, ranging from wars and disasters to individual incidents like road traffic accidents and workplace injuries [2]. PTSD patients live under the shadow of past traumas. Defined by the American Psychiatric Association's DSM-5 [3], major symptoms of PTSD include persistent intrusive symptoms, sustained avoidance of stimuli, negative changes in cognition or mood, and marked alterations in arousal and reactivity, all associated with experienced traumatic events.

PTSD significantly impairs social, occupational, or other important areas of functioning. Epidemiological data suggests that the median time to remission for PTSD (not necessarily all mental health issues) is approximately 36 months for those seeking assistance and about 64 months for those not seeking assistance for mental health issues. About one-third of patients diagnosed with PTSD experience a chronic course [4].

Infectious Disease Outbreaks and PTSD

Exposure to infectious disease outbreaks results in specific types of psychological trauma, classified into three groups. Firstly, experiencing and suffering directly from symptoms and psychological trauma treatments, such as respiratory distress, respiratory failure, ambulation, changes in consciousness, threats of death, and tracheostomy, are significant traumas for severe COVID-19 patients. Secondly, witnessing patients suffering from infections, struggling, and dying directly impacts other patients, their families, or caregivers providing assistance and care. Thirdly, experiencing realistic or unrealistic fears of infection, social isolation, exclusion, and prejudice directly affects patients, families, caregivers, help providers, and the general public.

Epidemiological studies have shown significantly high prevalence rates of mental health issues among survivors, victim families, healthcare professionals, and the general public following infectious disease outbreaks such as SARS, MERS, Ebola hemorrhagic fever, influenza, and HIV/AIDS. While most of these mental health issues tend to dissipate after outbreaks, PTSD symptoms can persist long-term, causing severe distress and disability. Systematic reviews of psychological outcomes from infectious disease outbreaks (e.g., SARS in 2003, H1N1 in 2009, and occupational exposure to HIV) indicate an average PTSD prevalence rate of approximately 21% (range 10-33%) among healthcare professionals, with 40% reporting persistently high PTSD symptoms three years post-exposure. PTSD symptoms were significantly higher among exposed healthcare workers, especially nurses and physicians, compared to unexposed controls [5]. Long-term studies on mental health disorders among SARS survivors revealed PTSD to be the most prevalent long-term psychiatric disorder, with a cumulative incidence of 47.8%, and 25.5% still meeting PTSD criteria 30 months post-SARS [6]. Among 116 survivors who overcame Ebola hemorrhagic fever in Liberia, 76 (66%) met DSM-IV diagnostic criteria for PTSD three years after the outbreak [7].

Most epidemiological studies report survivors having the highest prevalence of PTSD, followed by victim families, healthcare professionals caring for infectious disease patients, and others. Factors such as being female, elderly, children, low educational attainment, and low-income vulnerability to PTSD, along with comorbidities like chronic mental disorders, physical disabilities, neurotic personality, lack of social connections, and social support, are considered risk factors. Early psychosocial interventions are potential protective factors against PTSD.

Preventing PTSD after Infectious Disease Outbreaks

The importance of providing mental health services to individuals affected by infectious disease outbreaks has been widely recognized by academic circles and the general public. In 2007, the Inter-Agency Standing Committee (IASC) published guidelines on mental health and psychosocial support in emergencies [8], which have been broadly applied to mental health services after disasters, including infectious disease outbreaks. The IASC guidelines are organized based on a four-tiered intervention pyramid: (1) providing basic services and safety to affected populations, (2) strengthening family and community networks, (3) offering psychosocial support to individuals suffering, and (4) delivering specialized mental health interventions to severely affected individuals. Other strategies and intervention models are also practiced in various contexts [9]. However, systematically designed interventions aimed at preventing PTSD after disasters are currently not available.

Conclusion

Given the current and anticipated increase in the number of people exposed to COVID-19, it is considered urgent to provide mental health services aimed at preventing PTSD among survivors and others exposed to COVID-19. Possible strategies include health education, psychosocial support and counseling services for the general population, and early interventions that encompass psychosocial support, psychotherapy, and pharmacological treatment for vulnerable and high-risk groups, among others. Ideally, systematically designed intervention trials rigorously evaluating outcomes could shed light on developing strategies and models for preventing PTSD in people affected by other infectious disease outbreaks as well.

Abbreviations

COVID-19: Coronavirus Disease 2019

WHO: World Health Organization

PTSD: Post-Traumatic Stress Disorder

DSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

SARS: Severe Acute Respiratory Syndrome

MERS: Middle East Respiratory Syndrome

HIV: Human Immunodeficiency Virus

AIDS: Acquired Immunodeficiency Syndrome

Healthcare Workers

IASC: Inter-Agency Standing Committee

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