PTSD Associated with COVID-19 

The COVID-19 pandemic has taken a large toll on mental health throughout the global population. This public health crisis has upended lives over the past 2.5 years in a number of distinct ways, from deadly waves of infection and overburdened healthcare systems, to lockdowns and general societal disruptions (1, 2). The ongoing, often intense stress caused by COVID-19 has led to increases in depression and anxiety, as well as post-traumatic stress disorder (PTSD) (1-4, 7). PTSD is a disorder that develops after a traumatic experience that can involve flashbacks, changes in mood, dissociative symptoms, and cognitive symptoms. In the long term, it is associated with substance abuse, mood disorders, suicidality, and a number of physical health conditions (3). It is therefore crucial to understand the risk factors for PTSD due to COVID-19 and develop strategies to accommodate current and future healthcare needs in this area. 

Early studies highlighted the stress placed on healthcare workers (HCWs), especially those in critical care and emergency care settings who are already at higher risk of PTSD (1). A study during the spring of 2020 surveyed frontline HCWs in 21 ICUs in France. The prevalence of symptoms of anxiety, depression, and peritraumatic dissociation was 50.4%, 30.4%, and 32%, respectively. Researchers identified six key concerns that were associated with symptoms: fear of being infected, inability to rest, inability to care for family, struggling with difficult emotions, regret about the restrictions in visitation policies, and witnessing hasty end-of-life decisions (4). Another group of researchers investigated risk factors and resilience factors based on literature from the SARS 2003, MERS 2012, and COVID-19 outbreaks. This review similarly concluded that emergency HCWs were at high risk due to the nature of their roles, as well as that a sense of isolation contributed to symptoms (1). These concerning patterns are likely to have significant impacts on the healthcare system; already, data show high rates of burnout and of HCWs exiting the field. 

Unsurprisingly, patients who are infected with COVID-19, especially those who require critical care, are also at risk of developing PTSD symptoms. One study followed up with survivors 3 months after they had been discharged from the hospital. 10.4% of the group received a diagnosis of PTSD, while another 8.6% presented with subthreshold PTSD. A surprising risk factor identified in the analysis was obesity, which may reflect greater stress in patients with obesity due to the known link between the condition and poorer outcomes (3). 

The general population has also been greatly affected by the pandemic. Researchers have been particularly concerned about its effect on children and young adults, whose minds are still developing and who are more vulnerable to the effects of upheavals. Disrupted learning, social isolation, and loss of employment all have negative impacts on mental health. In addition to an increased prevalence of depression and anxiety, research shows that young adults have also experienced high levels of PTSD symptoms. High levels of loneliness, high levels of COVID-19-specific worry, and low distress tolerance were significantly associated with clinical levels of depression, anxiety, and PTSD symptoms (2). 

Further research has also focused on how family members of COVID-19 patients are affected. It is well-established that the families of critical care patients often experience adverse psychological outcomes, including PTSD symptoms (5, 6). The need for infected patients to be isolated may exacerbate this phenomenon – studies show that being able to be involved in a patient’s ICU care is associated with reduced PTSD symptoms in family members (6). A prospective study found that over 60% of the family members of COVID-19 ICU patients displayed significant levels of PTSD symptoms. Female respondents and Hispanic respondents had greater symptoms on average. In addition, those with higher scores exhibited more distrust of providers (7). 

References 

1. Carmassi, C., Foghi, C., Dell’Oste, V., et al. PTSD symptoms in healthcare workers facing the three coronavirus outbreaks: What can we expect after the COVID-19 pandemic?. Psychiatry Research, 2020;292:113312. DOI: 10.1016/j.psychres.2020.113312 

2. Liu, C. H., Zhang, E., Wong, G. T. F., Hyun, S., & Hahm, C. Factors associated with depression, anxiety, and PTSD symptomatology during the COVID-19 pandemic: Clinical implications for U.S. young adult mental health. Psychiatry Research, 2020;290: 113172. DOI: 10.1016/j.psychres.2020.113172 http://dx.doi.org/10.1016/j.psychres.2020.113172

3. Tarsitani, L., Vassalini, P., Koukopoulos, A., et al. Post-traumatic Stress Disorder Among COVID-19 Survivors at 3-Month Follow-up After Hospital Discharge. Journal of General Internal Medicine, 2021; 36(6): 1702–1707. DOI: 10.1007/s11606-021-06731-7 

4. Azoulay, E., Cariou, A., Bruneel, F., et al. Symptoms of Anxiety, Depression, and Peritraumatic Dissociation in Critical Care Clinicians Managing Patients with COVID-19. A Cross-Sectional Study. American Journal of Respiratory and Critical Care Medicine, 2020;202(10). DOI: 10.1164/rccm.202006-2568OC   

5. Davidson, J. E., Jones, C., & Bienvenu, O. J. (2012). Family response to critical illness. Critical Care Medicine, 40(2), 618–624. doi:10.1097/ccm.0b013e318236ebf9  

6. Amass, T. H., Villa, G., OMahony, S., Badger, J. M., McFadden, R., Walsh, T., … Levy, M. M. (2019). Family Care Rituals in the ICU to Reduce Symptoms of Post-Traumatic Stress Disorder in Family Members—A Multicenter, Multinational, Before-and-After Intervention Trial. Critical Care Medicine, 1. doi:10.1097/ccm.0000000000004113 

7. Amass, T., Scoy, L. J. D., Hua, M., et al. Stress-Related Disorders of Family Members of Patients Admitted to the Intensive Care Unit With COVID-19. JAMA Internal Medicine, 2022 (online). DOI: 10.1001/jamainternmed.2022.1118