Background
Coronavirus disease 2019 (COVID-19) has affected more than 5 million people and caused more than 300,000 deaths worldwide in just a few months. The World Health Organization (WHO) declared the outbreak a pandemic in March 2020 and stated that the world was facing a global health crisis [
1]. To date, most studies have focused on mental health problems in medical staff and the general population [
2‐
4], and research involving hospitalized patients with COVID-19 has focused on treatments for the disease [
5]. As observed during the epidemics of severe acute respiratory syndrome (SARS), novel influenza A (H1N1), Ebola virus disease (EVD) and Middle East respiratory syndrome (MERS), patients experience serious psychological problems in the acute phase of the disease and in the long term after an epidemic [
6‐
10]. Therefore, the mental health problems experienced by hospitalized patients with COVID-19 must be detected and treated promptly. This issue deserves global attention. However, no detailed study on the mental health status of patients during the pandemic has been conducted to date.
According to previous studies, the onset of a sudden and immediately life-threatening illness can lead to posttraumatic stress disorder (PTSD) [
11]. The psychological pressure on COVID-19 patients due to isolation treatment and other reasons may be far greater than that of the general public, and the situations they face during hospitalization also produce potential trauma [
12]. According to past experiences of epidemics, more than 40% of SARS survivors experienced posttraumatic stress symptoms at some time during the outbreak [
10,
13]. In addition to PTSD, depression and anxiety are common mental health problems in patients with infectious diseases. Kim et al. [
7] investigated patients with suspected and confirmed MERS who were isolated in hospitals and found that the prevalence of depression was 40.7%. Wu et al. [
14] reported that 14% of SARS patients reported anxiety 1 month after they were discharged from the hospital. Consequently, PTSD, depression and anxiety in patients during the COVID-19 outbreak should be afforded more attention.
Moreover, PTSD commonly co-occurs with other psychiatric disorders over a range of populations and trauma types [
15]. Among subjects with PTSD, the rates of comorbid depression and anxiety range from 21 to 94% and from 39 to 97%, respectively [
16]. Previous studies showed that 10 to 35% of SARS survivors reported symptoms of depression, anxiety or both during the early recovery phase [
14,
17]. Compared with PTSD alone, PTSD combined with other psychiatric diseases is more difficult to treat [
18]. Therefore, it is very important to identify psychiatric comorbidities of PTSD in hospitalized patients with COVID-19 to enable the implementation of interventions as soon as possible. In addition, it is critical to determine the factors that are predictive of these comorbidities.
Evidence has shown that when PTSD and other psychiatric disorders co-occur in populations who have experienced trauma, a combined stress model with shared vulnerabilities and similar risk factors might be involved [
18]. Therefore, it is important to identify risk factors for not only the psychiatric disorders of interest but also comorbid disorders. North et al. [
19] systematically analyzed the factors predictive of mental health problems in survivors of 10 disasters. Their review noted that the research findings to date collectively indicate that the risk of mental health problems following disasters is generally associated with female sex, young age, minority ethnicity, lower socioeconomic status, higher education level, marital status (married for women and unmarried for men), predisaster psychiatric illness, greater exposure to the disaster, and lack of perceived and actual social support. Focusing on the differences in demographic variables between individuals with relatively high and low scores for PTSD, depression and anxiety helps to predict the populations at high risk for these disorders. This study focuses on sex, age, educational background and socioeconomic status. The degree of trauma exposure is a direct inducer of the posttraumatic psychological response [
20]. Trauma exposure refers to objective factors such as the degree of injury to oneself, relatives and friends and subjective experiences such as worrying about the safety of oneself and important others [
21]. Studies have found that media exposure during critical public events may cause additional psychological trauma and anxiety, indicating that the vicarious traumatization effect may play an important role in the development of psychological disorders [
22,
23]. Hence, exposure to news reports related to the pandemic is considered a candidate risk factor.
In addition, resilience and perceived social support are considered protective factors against an adverse psychological response. Resilience is the ability to maintain relatively stable, healthy levels of psychological and physical functioning in the context of adversity, stress or trauma [
24]. After patients have been diagnosed with COVID-19, resilience enables them to cope with the stressful event through the interaction of external resources and internal potential [
25]. Perceived social support has been identified as a strong external resource [
26]. According to Cohen and Wills [
27] and Goyne and Downey [
28], there are two models to explain the role of social support in the posttraumatic psychological response. The direct effect model suggests that social support can directly promote individual posttraumatic adaptation by improving an individual’s healthy behavior and reducing the negative psychological response after the traumatic event. The buffering effect model of social support holds that providing resources for individuals to use when coping with traumatic events helps to alleviate the negative impact of these events on individuals.
This study was performed to provide information about the prevalence rates of PTSD, depression, and anxiety among COVID-19 patients in China and to explore the associated risk factors. The related factors examined were demographic variables, trauma exposure and psychosocial variables.
Discussion
To the best of our knowledge, this is the first study to investigate the prevalence and predictors of psychiatric symptoms among hospitalized COVID-19 patients during the acute treatment period. The current study showed that the prevalence rates of PTSD, depression and anxiety among hospitalized patients with COVID-19 were high and that these disorders often co-occurred. Negative media reports, exposure to trauma and perceived social support were shared risk and protective factors of PTSD, anxiety and depression. Resilience was a protective factor only for depression.
Prevalence of and differences in PTSD, depression and anxiety among hospitalized patients with COVID-19
In this study, the prevalence of PTSD, depression and anxiety among hospitalized patients with COVID-19 was 13.2, 21.0 and 16.4%, respectively. The prevalence of PTSD was lower than the prevalence in previous studies with patients with similar infectious diseases [
10,
13] but higher than those in other groups, such as general residents and medical staff, during the COVID-19 pandemic [
2‐
4]. The prevalence of depression and anxiety was higher than in previous studies on infectious diseases [
7,
14] and studies involving residents [
4] and medical workers [
2] in Wuhan during the COVID-19 outbreak. The results indicate that hospitalized patients who have contracted COVID-19 may have the most serious mental health problems during this pandemic. The possible causes are related to the virus itself, the use of corticosteroids or hydroxychloroquine, or pandemic-related stress. First, the virus that causes COVID-19 might infect the brain or trigger immune responses that have additional adverse effects on brain function and mental health in patients with COVID-19 [
41,
42]. Second, corticosteroids may induce affective psychosis, and hydroxychloroquine use has been related to agitation, emotional lability and irritability [
43,
44]. Third, the psychological pressure on COVID-19 patients due to isolation treatment may be far greater than that of medical workers and general residents [
12]. Additionally, patients have a greater risk of death.
The study showed that PTSD, depression and anxiety are often comorbid. PTSD, depression, and generalized anxiety disorder (GAD) are all thought to stem from high levels of general distress in the acute stage of trauma and are likely to become a symptom network [
45]. A network analysis study showed that symptoms of GAD (inability to relax) and PTSD (restricted or diminished positive emotion) were identified as key hub symptoms for the network of PTSD, depression and anxiety. Symptoms of depression and GAD are highly interrelated [
46]. A previous study has shown that the association of anxiety and depression during the COVID-19 pandemic can be attributed to the strong connection among impaired motor skills, restlessness, and inability to relax [
47]. During treatment for COVID-19, patients may develop multiple related psychiatric diseases that form a mutually influential symptom network. Therefore, mental illness intervention from the perspective of symptoms (e.g., impaired motor skills or inability to relax) rather than mental illness as a whole (e.g., PTSD or depression) may be a better choice for mental health interventions for patients. In particular, the relationship between symptoms in the context of COVID-19 needs to be studied further.
Effects of trauma exposure, resilience and perceived social support on PTSD, depression and anxiety
This study found that negative media reports, trauma exposure and perceived social support were shared risk and protective factors of PTSD, anxiety and depression. Resilience was a protective factor only for depression. First, infection with an unknown virus for which there are no known treatments increases patients’ perception of a threat to their lives, which in turn can lead to the development of mental disorders. Second, as one aspect of trauma exposure, the degree of subjective fear plays an important role in inpatients’ susceptibility to mental health problems. Previous studies have reported that the subjective experience of fear is more strongly related to PTSD than objective exposure alone [
48]. As evidenced in past epidemics [
49], the perception of personal risk, rather than not only actual exposure, can confer considerable susceptibility to mental health disorders. Negative news reports and the severity of the disease can affect an individual’s subjective experience of fear. Sensational media reports may stimulate the subconscious perception of threat and induce fear [
50], and fear has been shown to be associated with a considerable risk of the new onset and recurrence of mental health disorders [
51]. Moreover, heightened distress responses to media reports of collective crises may have long-term physical health repercussions [
22]. However, the positive impacts of media reports were not found to alleviate psychiatric disorders in this study.
In addition, resilience was a protective factor against depression, and perceived social support was a protective factor against PTSD, depression and anxiety. A possible reason is that external resources are more important than internal resources for patients infected with COVID-19. Social support can not only affect individuals directly by improving their health behaviors but can also affect individuals indirectly by providing resources to individuals [
27,
28]. Resilience is a personality trait. In the face of life-threatening events such as COVID-19 infection, patients need to deal with their physical health rather than their mental health. However, according to previous studies, resilience plays an important role in the long-term mental health recovery of patients [
11].
Limitations and implications
There are some limitations of this study. First, our participants were a convenience sample mainly recruited from hospitals in Wuhan. It is uncertain whether our findings can be generalized to all patients during this pandemic. Second, the data used in this study came from patients’ self-reported questionnaires. In the future, clinical diagnoses of PTSD, depression and anxiety should be used. Third, this was a cross-sectional study. Directionality cannot be determined between the “predictors” (e.g., resilience, perceived social support) and mental health symptoms. The pattern and long-term clinical course of the psychiatric effects of COVID-19 should continue to be investigated, and there should be widespread awareness of the possible psychiatric impacts of a future reemergence of COVID-19. Future studies should exploit existing datasets and ongoing longitudinal studies in addition to establishing new cohorts to collect detailed information on psychological factors.
The findings of this study indicate that timely integrated mental health interventions are warranted for patients during the acute treatment phase of COVID-19. First, health authorities need to identify high-risk groups based on sociodemographic information and implement early psychological interventions. Females, elderly patients, patients with lower levels of education, and patients with lower socioeconomic status are target populations. Second, reducing news reports during the pandemic and disseminating accurate scientific information will help patients understand this novel virus, thereby alleviating their fear and reducing their perception of COVID-19 as a threat. Third, providing a supportive hospitalization environment will help foster resilience, enabling hospitalized patients to maintain relatively stable, healthy levels of psychological and physical functioning.
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