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

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

Summary

Post-traumatic stress disorder (PTSD) is a common mental disorder caused by major psychological trauma. It can cause severe distress and disability. Previous epidemic studies have reported a high prevalence among those exposed to trauma resulting from infectious disease outbreaks. While the control of the epidemic and care of COVID-19 patients remains a major challenge worldwide, this commentary calls for attention to early intervention and prevention of PTSD among the vast number of COVID-19 survivors, their families, health professionals, and other first-line helpers.

Keywords:

Coronavirus Disease 2019, Post Traumatic Stress Disorder, Prevention

Background

The World Health Organization has declared the 2019 outbreak of coronavirus disease (COVID-19) to be a pandemic. As of May 11, 2020, there have been 4, 006, 257, 278, and 892 deaths from COVID-19 reported to the World Health Organization (WHO)[1] in over 200 countries and territories. With the number of infections and deaths continuing to rise, it is still too early to predict the number of infections worldwide. Meanwhile, millions of people are fearful and even panicked about the potential loss of health, life, and wealth. Experiencing or witnessing distress associated with COVID-19 can lead to severe distress and disability among people with post-traumatic disorder (PTSD), survivors, family members, those providing initial assistance and care (medical and public health professionals, police officers, etc.), and even the general public
The high prevalence of mental disorders leading to serious distress and disability among survivors, family members, those providing initial assistance and care (medical and public health professionals, police, etc.), and the general public. While the control of the prevalence and care of patients with COVID-19 remains a major challenge worldwide, this commentary calls for attention to early intervention and prevention of PTSD in affected populations. PTSD is a common pathological outcome of a variety of traumatic events, ranging from war and disasters to individual events such as road traffic accidents and industrial accidents [2]. PTSD patients live under the shadow of past trauma. The primary symptoms of PTSD as defined by the American Psychiatric Association's fifth edition (DSM-5)[3] of Diagnosis and Statistics of Mental Disorders include persistent intrusive symptoms, persistent avoidance of stimuli, negative changes in cognition or mood, and marked changes in arousal and reactivity, all of which have been experienced
associated with the traumatic event. PTSD results in clinically significant distress or impairment in social, occupational, or other important areas of functioning. Epidemiologic data indicate that the median time to remission of PTSD is 36 months for those who sought help for mental health problems (not necessarily PTSD) and approximately 64 months for those who did not seek help for mental health problems. 4].

Infectious disease epidemic and PTSD

Exposure to an infectious disease epidemic results in specific types of psychological trauma, which fall into three groups. The first is the direct experience of and suffering from symptoms and psychological trauma treatment. For example, dyspnea, respiratory failure, ambulation, altered state of consciousness, threat of death, tracheostomy, etc. This is a serious trauma in a severely COVID-19 patient. Second, we see the patient suffering, struggling, fighting, and dying from an infection. Infections have a direct impact on other patients, patients' families, or those who directly provide assistance and care for the patient. Third, they experience real or unrealistic fears of infection, social isolation, exclusion, and prejudice. This directly affects patients, families, caregivers, help providers, and even the general public. Epidemiological studies have shown a substantial prevalence of mental health problems among survivors, families of victims, health care providers, and the general public following infectious disease outbreaks such as SARS, MERS, Ebola, influenza, and HIV/AIDS. While most of these mental health problems resolve after an epidemic, symptoms of PTSD can persist for long periods of time and result in severe distress and incapacity. A systematic review of psychological outcomes of infectious disease outbreaks (after the 2003 SARS outbreak, the 2009 H1N1 outbreak, and occupational exposure to HIV) indicates that the average prevalence of PTSD among health professionals is approximately 21% (range 10~33%), with 40% reporting persistent PTSD symptoms 3 years after exposure PTSD symptoms can also be a result of the exposure. PTSD symptoms were also significantly higher among exposed health care workers (health care workers) than non-exposed controls, particularly among relevant health care workers, followed by nurses and physicians [5]. A study of long-term psychiatric disorders among SARS survivors revealed PTSD to be the most prevalent long-term psychiatric disorder. The cumulative percentage of PTSD patients was 47.8%, but 25.5% continued to meet PTSD criteria at 30 months post-SARS [6]. Of the 116 people who survived Ebola in Liberia, 76 (66%) met DSM-IV diagnostic criteria for post-traumatic stress disorder 3 years after the outbreak (Nyanfor SS, Xiao SY: Psychological impact of Ebola in Survivors in Liberia: a backward cohort study submitted).

It appears to be a predictor. Most epidemiological studies indicate that survivors report the highest prevalence of PTSD, followed by family members of victims, health professionals providing care to infected patients, and others. Women, the elderly, children, and low-income populations with lower levels of education are more vulnerable to PTSD, while comorbidities such as chronic mental and physical disabilities, neurotic personality, lack of social connectedness, and social support possible risk factors, and early psychosocial interventions may be protective factors for PTSD [7].

PTSD prevention after an infectious disease outbreak

The importance of providing mental health services to those affected by infectious disease outbreaks is highly regarded by the academic community and the general public. In 2007, the Inter-Agency Standing Committee (IASC) published Guidelines for Mental Health and Psychosocial Support in Emergency Situations [8], which have been widely adapted to mental health services following disasters, including infectious disease outbreaks. The IASC guidelines are organized around a four-step intervention pimid: (1) restore basic services and safety to the affected population, (2) strengthen family and community networks, (3) provide psychosocial support to individuals who have suffered, and (4) provide specialized mental health interventions for severely affected individuals. Other strategies and intervention models have also been developed. Other strategies and intervention models have also been put into practice in different settings [9]. However, no systematic and appropriately designed intervention studies targeting the prevention of PTSD after disasters are available to date.

Conclusion.

Given the already large and growing number of people currently exposed to COVID-19, there is an urgent need to provide mental health services aimed at PTSD prevention to survivors and other populations exposed to COVID-19. Possible strategies include, but are not limited to, health education, psychosocial support and counseling services for the general population, and early interventions including psychosocial support, psychotherapy, and pharmacological treatment for vulnerable and high-risk groups. When possible, systematic and appropriately designed intervention trials with rigorous evaluation of outcomes can also shed light on the development of strategies and models for PTSD prevention in populations affected by other infectious disease outbreaks.

Abbreviation

COVID-19: Coronavirus Diseases 2019; WHO: World Health Organization; PTSD: Post-Traumatic Disorder; DSM-5: Diagnosis and Statistics of Mental Disorders,
5th Edition; SARS: severe acute respiratory syndrome; MERS: Middle East respiratory syndrome; HIV: human immunodeficiency virus; AIDS: acquired immunodeficiency syndrome; healthcare workers; IASC: Interagency Standing Committee

References

  1. World Health Organization: Coronavirus disease 2019 (COVID-19) Situation Report-112.
    https://www.who.int/emergencies/diseases/novel-coronavirus-2 019/situation-reports. Accessed 12 May 2020.
  2. Shalev AY, Marmar CR. Posttraumatic stress disorder. In: Sadock BJ, Sadock AV, Ruiz, editors. Kaplan and Sadock ’s
    comprehensive textbook of psychiatry. 10th ed. Philadelphia: Wolters Kluwer; 2017.
  3. American Psychiatric Association. Diagnostic and statistical manual of mental disorder, 5th edition (DSM-5). Washington: American Psychiatric Publishing; 2013.
  4. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617 –27.
  5. Vyas KJ, Delaney EM, Jennifer A, et al. Psychological impact of deploying in support of the U.S. response to Ebola: a systematic review and meta-analysis of past outbreaks. Mil Med. 2016;181(11):1515–31.
  6. Mak IWC, Chu CM, Pan PC, Yiu MGC, Chan VL. Long-term psychiatric morbidities among SARS survivors. Gen Hosp Psychiatry. 2009;31(4):318 –26.
  7. Mak IWC, Chu CM, Pan PC, Yiu MGC, Ho SC, Chan VL. Risk factors for chronic post-traumatic stress disorder (PTSD) in SARS survivors. Gen Hosp Psychiatry. 2010;32(6):590 –8.
  8. Inter-Agency Standing Committee. IASC guidelines on mental health and psychosocial support in emergency settings. Geneva: Inter-Agency Standing Committee; 2007.
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