Prevalence of post-traumatic stress disorders and associated factors one month after the outbreak of the COVID-19 among the public in southwestern China: a cross-sectional study

COVID-19 has totally affected people’s life. The most direct impact was social isolation and the panic of being infected, and a series of indirect effects followed by. The citizens were encouraged by policy to self-quarantine at home in order to minimize the risk of viral spreading. So, the people who should have been reunited with their family during the Spring Festival, which is the most important one, was failed. Some people even didn’t have the last chance to meet their loved ones. Many industries such as catering, entertainment and tourism were facing the challenge of survival. The confirmed or suspected COVID-19 patients were in danger of losing life. Healthcare professionals rushed to fight with the virus, and countless community workers and volunteers were also in the front line of the epidemic. Information about COVID-19 pandemic have been updated daily for the public through a variety of medium. At the beginning of the COVID-19 outbreak, the lack of specific treatments, limited knowledge of the virus and increasing death rates had further tensing the nervous of the society.

Post-traumatic stress disorder (PTSD) is a psychiatric syndrome that is developed by exposing to an extremely threatening or horrific event or series of events according to International Classification of Diseases,11th Revision (ICD-11) [1].COVID-19 pandemic unlike the normal natural disaster such as earthquake, hurricane and flood had the enormous power to threaten people’s lives immediately, but a substantial, potential and prolonged stressors with uncertain threat of health and life, unprecedented restrictions on movement and devastating economic consequences. The previous studies also mentioned that similar immense epidemics promoted development of PTSD [2‐6]. A study of severe acute respiratory syndrome (SARS) showed that being infected or the threat of being infected can be a potentially traumatic event and elevates risk of developing PTSD [2, 5, 6]. After a year of the outbreak of the Ebola virus in Sierra Leone, among 27% of the participant met levels of clinical apprehension for PTSD and 16% met levels of possible PTSD [3]. In the Republic of Korea, 42.9% of survivors reported PTSD after 12 months of Middle East Respiratory Syndrome (MERS) [4].Kalin [7] enumerated several reasons to explain why the COVID-19 pandemic represents the perfect storm of stressors and traumatic events:1) a sense of uncontrollability and a sense of uncertainty about the future,2) concerns about contracting COVID-19, becoming gravely ill, and dying,3) worries about losing loved ones and friends, and the grief associated with real losses,4) prolonged physical separation and social isolation from family and friends,5) disruption of regular routines, including work and school for children,6) losses of jobs, business failures, and the profound economic consequences,7) lack of trust in leadership to effectively deal with the crisis. Thus, through this lens, the COVID-19 pandemic may be viewed as a valid traumatic event according to ICD-11.

PTSD is considered by some psychologists as a secondary consequence of the SARS-Cov-2 pandemic no matter for patients, healthcare professionals or general population [8]. Different populations may be disproportionately affected by COVID-19 pandemic both in terms of the level of exposure, as well as the amount and type of stressors they experience [9]. In a sample of Chinese healthcare professionals,40.2% indicated positive screens for significant PTSD symptoms from Feb 23 to March 5, 2020 [10]. The prevalence of clinically-relevant PTSD was 30.8% in a 2500 invited Chinese university students in a survey between Feb 12 and 17, 2020 [11],and 25.2% of confirmed COVID-19 patients were reported symptoms of posttraumatic stress in a Jianghan Fangcang shelter of Wuhan city from Feb 15 to 22,2020 [12]. A study reported that 44.5% of people who were geographically located in Wuhan were associated with severe symptoms of PTSD among 9225 participants after 1 month of COVID-19 outbreak in Hubei province [13]. At present, most of the study mentioned above focused on exploring the psychological state of healthcare professionals, patients and people near by the hotspots, the mental health condition of every ordinary person under the epidemic is still worthy of attention. In addition, at present, older age, male, having been isolated, knowing people who had been isolated, people who had recent epidemic area contact history, those at high risk of infection or with poor sleep quality were reported associated with higher prevalence of PTSD during the COVID-19 outbreak [11, 14‐16].PTSD has brought about substantial medical and economic burden [17],and high suicide rates [18]. Under the epidemic situation of COVID-19, PTSD was not only reported to exacerbate and deteriorate of pre-existent mental symptoms [19],but people with mental diseases were more likely to develop PTSD [20]. Therefore, understanding and intervention of PTSD is highly essential as soon as possible.

Currently, control of the epidemic is still the dominant task across the world, and it seems that humanity will coexist with COVID-19 for a long time in the future. In order to a full understanding of the psychosocial responses induced by such infectious diseases from different aspects, to conduct an investigation in southwestern China, which hosts a population of over 160 million, is important. Hence, this study aimed to evaluate the prevalence of post-traumatic stress disorders (PTSD) in the general people of southwestern China and associated factors 1 month after the outbreak of the COVID-19.

To the best of our knowledge, this is the first study to investigate the prevalence and associated factors of PTSD among general population in southwestern China in about 1 month after the COVID-19 outbreak in China. The prevalence of PTSD was 25.2% from the result of this study. The current study with showed that males, adults less than 30 age, and health care workers were in the risk of developing higher PTSD. High level of exposure to COVID-19 were also found to be significantly associated with higher PTSD. Unexpected, there was a significant correlation between higher PTSD and that not worried about being infected and no damage to the property.

The prevalence of PTSD was 25.2% in our study. Before COVID-19 pandemic, a survey showed the weighted life-time prevalence of any mental disorders (excluding dementia) was 16.6% in China [23],and another research reported that 11.8% of adult survivors from 2008 Wenchuan Earthquake in southwestern China had probable PTSD after 8 years of the earthquake [24]. Comparing the PTSD prevalence rate before and after the pandemic, the obvious increase of this rate after the pandemic indicates a positive correlation between the pandemic and PTSD, and it is reasonable to assume that COVID-19 pandemic can be highly traumatic experiences. A recently study based on resting-state functional connectivity MRI (rs-fcMRI) also showed that COVID-19 pandemic was a crucial stressor to bring risks developing PTSD symptom [25]. The underlined result was consistent with the results of several recently published systematic review and meta-analyses. Surapon [26] searched articles including information from 32 different countries and 398,771 participants (general population) published from Jan 1, 2020, to Jun 16, 2020, and this period was the initial stage of global epidemic. Their results showed that the global prevalence estimate was 24.1% for post-traumatic stress symptoms. Another similar articles reported the pooled prevalence of post-traumatic stress symptoms was 28.34% [14] and 21.94% [27]. The research mentioned above showed that under the epidemic situation, the general population were at a high level of PTSD across countries and regions, suggesting the attention to PTSD related to COVID-19 should be increased globally and identifying related risk factors in terms of reducing the mental health burden of COVID-19 is crucial.

Under the COVID pandemic, some reports revealed a higher percentage of PTSD compared to the present study. Despite the different methodological methods used, our findings show that the pooled prevalence of PTSD is higher. Such as in the Italian population the PTSD prevalence was reported at around 29% in two weeks instantly post COVID-19 outbreak (from March 18 to 31,2020) [28]. Another report of the Chinese general population revealed that PTSD was significantly prevalent in 67.09% of the participants (self-reported) at the end of March 2020 [29]. Some reports revealed a lower percentage of PTSD percentage than the results obtained from the present study, such as the rate of COVID-19-associated PTSD was 17.7% in the Irish general population (the underlined survey was completed on April 52,020.) [30]. A study reported that COVID-19-associated PTSD symptoms were prevalent in a sample of adults living in Wuhan and surrounding cities in China and the underlined study also revealed that 7% of participators met the diagnostic criteria for PTSD between January 30 and February 8, 2020 [31]. In a sample of the Spanish population, PTSD symptoms were observed in 15.8% of participants (from March 21 to 28, 2020) [32]. Moreover, various races and cultural backgrounds, various cut-off points, different measurement, and past traumatic experience of individuals leads to the variations in the PTSD prevalence. The PTSD prevalence was significantly associated with the duration of the COVID-19 outbreak at which the survey was performed. In fact, PTSD symptoms usually appear months after the traumatic experience [33]. For example, in SARS the mental health was significantly impaired after the acute outbreak than in the initial phases [34], and after the SARS outbreak in 2003, the PTSD prevalence in survivors of SARS was 9.79% in their initial stage of recovery [35] and 25.6% at 30-months after SARS assessment [5]. So, with the development of the pandemic, how the prevalence of PTSD will change will become the next question for us to explore.

In the present study, the rate of PTSD prevalence was found to be higher in males relative to the female which showed consistency with the report in the Irish general population [30]. On the contrary, many studies evaluated the traumatic effects of COVID-19 and revealed that the females were at higher risk to develop PTSD symptoms [31, 32, 36]. Earlier reports on the outbreak revealed that the rate of PTSD prevalence was13.0–20.4% and 6.2–8.2% for women and men, respectively [37, 38] which shows that the chances of females developing PTSD were two times higher in comparison with males [39]. But in the condition of isolation and quarantine, men usually cannot express their feelings that may result in highly negative emotions.

In the present study, the PTSD prevalence is 29.5% in younger people (< 30 age) and the underlined result has been consistent with the results of PTSD (31.8%) in young adults (18–30 years) of U. S during the COVID-19 pandemic [40]. The present study revealed that in the < 30 age group the PTSD was significantly higher, as compared to the 40 ~ 49 years age group. The obtained results showed consistency with the reported study which revealed that younger age groups were more likely to develop psychological distress [41],and the diagnostic requirement for COVID-19-associated PTSD showed a significant correlation with younger age group [30] because young people have less life experience than middle-aged people, and it is difficult to deal with personal problems, such as completing school on time or finding a suitable job. In addition, young people use more social networking software and are exposed to more information related to the pandemic which may elevate the psychological burden of young people to a certain extent. Huang and Ni results also showed consistency with the underlined reports [42, 43].

Post outbreak, health care workers are fighting on the front line of protest, while students are strictly protected and isolated and are not allowed to go side and our obtained results revealed that health care workers are at higher risk of developing PTSD than students. A study has reported that the prevalence of PTSD was 2.7% in a sample of Chinese university students (home quarantined), and in this study, around 89.7% of students were quarantined at home [44]. The outbreak of the pandemic has put tremendous pressure on the medical system around the world. The front-line health workers who directly or indirectly deal with COVID-19 patients bear more risks and workload. Furthermore, the medical staff needs more attention and professional guidelines because of the lack of PPE at the beginning of the outbreak, working for long hours, at risk of been infected, the unknown future of the pandemic, separation from the family, and the psychological burden of staff in the medical system. A systematic review did not evaluate statistically considerable variations in PTSD and occupational stress of health care workers, as compared with none-health care workers until May 02, 2020 [45], and in the present study, the obtained results revealed that no considerable variation has been found in PTSD prevalence between health care workers and non-healthcare workers excepted for students.

Earlier studies have been revealed that worry about infection has been positively correlated with PTSD [30, 41, 46, 47]. But our finding revealed that a large number of participants were developing PTSD that was not worried about being infected, as compared to those who are little and more worried about being infected which might be due to limited information regarding COVID-19 in the initial phase of the outbreak and the risks may not be recognized. In addition, when a major traumatic event or loss occurs, people’s first reaction is to escape and not to believe that their lives will change, they tend not willing to admit that they are worried about being infected by SARS-CoV-2.

For ordinary people, that themselves, their family members, and someone they used to know had been confirmed/suspected with COVID-19 or nobody around them has been confirmed/suspected with COVID-19 are at different levels of developing PTSD. Among the participants, the PTSD prevalence was significantly elevated (80.0%) in participants who had experienced confirmed or suspected COVID-19. Another reported study revealed that in China the symptoms of post-traumatic stress were significantly prevalent in clinically stable patients (COVID-19 affected) i.e., 96.2% [48]. The PTSD was significantly higher among individuals who were significantly exposed to COVID-19. Our obtained results show consistency with other results, for example, Sun et al. reported the study in which survey data was collected from a general sample of adults in the Chinese mainland, and the obtained data revealed that 4.6% of the participants showed symptoms suggesting more likely to develop PTSD. Moreover, the chances of PTSD prevalence was considerably elevated (18.4%) in a subsample of participants that were greatly exposed to COVID-19 (suspected or confirmed COVID-19) and also those who had close contact with a person infected with COVID-19 [49]. Recently, another report revealed that the participants that are significantly exposed to COVID-19 have a considerable correlation with moderately or severe symptoms of PTSD such as those participants that are the friend or family member of a health-care professional or a person having confirmed COVID-19 or having family member or friends that visited Wuhan [50]. So, in the present study, it has been suggested that in the early phase of the outbreak, different levels of psychological support should be provided to the people based on the level of exposure to COVID-19.

The results of this study provide the first data about the PTSD under the initial stage of COVID-19 carried out in southwestern China. Our findings highlight that a positive correlation between the pandemic and PTSD, and the high level of exposure, males, adults less than 30 age, and health care workers were more likely to report elevated PTSD. This found helps in the identification of the target population in the early phase of the pandemic. It is urgent to build a screening and prevention systems for the population who are significantly exposed to COVID-19, and underscore the need to provide different psychological intervention strategies for different groups of people according to their characteristics. Simultaneously, the results obtained in the present study could be combined with future studies for the comparison of PTSD prevalence during different periods, and assist to establish standard intervention strategy for mental disorder in a potential pandemic outbreak in the future.