Mental health consequences during alerting situations and recovering to a new normal of coronavirus epidemic in 2019: a cross-sectional study based on the affected population

The COVID-19 pandemic has had an unprecedented impact on all societies worldwide, and the World Health Organization (WHO) declared the COVID-19 outbreak an international public health emergency on January 30, 2020 [1]. The rapid spread of large-scale infectious diseases in a short period often generates fear among individuals and affects their mental health [2‐7]. Unlike the situation during the severe acute respiratory syndrome (SARS) outbreak in 2003, when communication technology was still in its infancy, the reach of communication technology at present is far greater. Data on daily number of cases and deaths, and real-time information from the frontlines regarding epidemic prevention contributed to the intensification and magnification of negative emotions regarding the novel coronavirus, such as fear and death anxiety, among people [2, 8, 9]. Continued exposure to an epidemic setting can induce an acute stress response or even post-traumatic stress response (PTSD).

Numerous studies have been conducted on the prevalence of PTSD after pandemics. However, the evolution of different stages (the initial stage, the lockdown stage, the mitigation stage) of PTSD remains controversial. During the initial stage, the 2019 coronavirus influenza pandemic caused prolonged exposure to stress, and the incidence of PTSD was associated with stress levels in different populations. Liang et al. assessed the mental health of adolescents in the early stages of the outbreak and found that 14.4% of young people had PTSD-related symptoms [10]. A study in China found that 9.8% of health workers had PTSD symptoms [11]. In the US, a survey of young people of age 18–30 years showed that 31.8% had symptoms of PTSD [12]. During the lockdown stage, governments required citizens to confine themselves to their homes and prohibited unnecessary travel in an effort to contain the outbreak. Passavanti et al., through a multicenter study, pointed out that more than half of the researchers reported PTSD [13]. An Indian study found that during the blockade, the incidence of mental illness increased by eight to ten times [14]. During the mitigation phase, as the severity of the outbreak lessened, several countries began to lift the mandatory lockdowns. In this regard, Eldhuis et al. found through follow-up observation that PTSD symptoms decreased with the remission of the epidemic19. However, Gonzalez-Sanguino et al. looked at 3480 ordinary Spaniards and found that the psychological effects of the epidemic, such as anxiety, were not relieved during the stable phase [15].

In addition, the 2019 coronavirus influenza pandemic led to the fear of death among people due to prolonged exposure to stress [2, 8, 9, 16, 17]. Death anxiety refers to the personal concern regarding existence and death in the face of threatening events, and it is a type of negative emotion [16, 18]. Curșeu et al. pointed out that death anxiety could be further aggravated in the presence of anxiety and negativity among the public in the face of an epidemic [16]. A survey conducted in Poland by Chodkiewicz et al. revealed that as a result of the epidemic, a large proportion of their respondents had symptoms such as anxiety and depression (40%) and suicidal thoughts (24%) [17]. Continued exposure to such conditions can induce an acute stress response or even post-traumatic stress response (PTSD) [16, 17].

It should be noted that most of these investigations have been conducted at a single point in time, with few studies investigating the evolution of the psychological and spiritual effects in the general population after deregulation in countries first affected by the COVID-19 pandemic. The current investigation is a cross-sectional study assessing the impact of the pandemic on the mental health of the general population at two points in time: 1 month after the outbreak and after the lifting of the lockdown (3 months after the outbreak). We analyzed the potential predictors of PTSD and the psychological effects of the epidemic the general population at different times. In addition, we developed a new mediation model to account for individual differences in sensitivity to the transition from past traumatic experience (PTE) to PTSD.

Ethical approval for the study protocol was provided by the Biomedical Ethics Review Committee of West China Hospital of Sichuan University, protocol number 2020(930). All participants provided informed consent prior to participation in this study.

This study aims to elucidate the evolution of the impact on the psychological and mental health of the general population at various stages in a country that was first affected by the COVID-19 outbreak. As the study was conducted 1 month (outbreak phase) and 3 months (work resumption phase) after the epidemic outbreak, the full impact of COVID-19 on the mental health at different times was captured. This implies that our sample population could serve as a strong representative of epidemic-affected populations.

The prevalence of PTSD and death anxiety in the general population in the first month of COVID-19 outbreak was 6.43 and 48.10%, respectively, which increased significantly to 8.60 and 53.20% at 3 months after the outbreak. Previous studies among the general population in China during the COVID-19 outbreak have shown trends in psychological impact at different stages that were not significant [27, 28]. This difference between our study and previous studies may be attributed to the differences in the measurement tools. The Impact of Event Scale-Revised (IES-R) was used by previous studies, which is different from the one used in this study [27, 28]. Another possible explanation is that prolonged lockdown has serious adverse effects on mental health [29]. In addition, PTSD is distinct from anxiety and depression, and these differences might reflect the variations between the acute and long-term psychological effects triggered by an outbreak, which may be more pronounced among healthcare workers [30, 31].

Medical workers are at high risk of exposure to COVID-19 as compared to non-medical workers and are faced with high levels of stress [31, 32]. Studies have shown that in major public health emergencies, health workers are the main responders to outbreaks and that they are often left with more lasting and more complex psychological damage [33, 34]. In our study, we found that compared to the outbreak stage, the stable stage of the epidemic had a significantly higher psychological impact in medical workers than in non-medical workers. This may be the response of healthcare workers to actual or possible threats after close clinical contact with infected patients during their involvement in disease control [4, 6]. In addition, stress associated with close clinical contact with infected patients increases the likelihood of the formation of trauma-related memories [11, 35]. The finding highlights some implications for public health. First, as the psychological impact of the 2019 coronavirus epidemic continues, it is necessary to prioritize offering the best possible support for health workers in the current crisis. Secondly, the existence of traumatic medical memory has a long-term impact on medical workers, and it would be worthwhile to identify measures to reduce the traumatic medical memory in rescue.

Our study also revealed some of the factors that make individuals most vulnerable to the psychological consequences of the COVID-19 outbreak. Consistent with recent studies exploring the effects of the COVID-19 pandemic, our study showed that older age was associated with more symptoms of post-traumatic stress [15, 36]. This increased vulnerability may have a negative effect of a higher risk of infection in older people, making them more vulnerable than younger people [37, 38]. In addition, and in line with the findings of previous studies, we found that traumatic stress responses were greater in individuals with poor self-reported physical health [15, 39]. It is possible that the pre-existing burden of disease may fuel fears of widespread susceptibility [36, 40]. Individuals with trauma have been reported to exhibit a higher prevalence of PTSD as compared to those who have not experienced highly traumatic events (Wald chi-square = 10.96, df = 1, P = 0.0009) [41, 42]. The risk of PTSD is influenced by the number and type(s) of traumatic events experienced (e.g., violence, loss of loved ones, and unrequited affection) [42]. In this study, we focused on two past experiences, namely the history of bereavement and the history of life-threatening events. Among them, the participant’s own PTE were found to be significantly associated with the development of PTSD. People who had been in contact with the COVID-19 outbreak also had a high risk of PTSD. This finding might suggest that even the acquaintance or contact with a COVID-19 patient may be viewed by individuals as personalized trauma [43].

Besides exploring socio-demographic and work-related factors associated with PTSD development among general population, the novel contribution of the present study the establishment of a prediction model between PTE and PTSD. Mediation analysis confirmed that death anxiety was a predictor of progression to PTSD from a PTE. Although characteristics of PTE have been shown to influence the risk of PTSD, studies indicate that 89.7% of Americans are exposed to a significant traumatic event over the course of their lifetime, and only a small percentage develop mental illness [11, 44, 45]. Several other factors are involved in an individual’s susceptibility towards PTSD following PTE, which include gender, neuroticism, and family history of mental illness; these data are consistent with findings from Comings, Fullerton, and Stein [44, 46, 47]. Therefore, it is important to identify individual differences that may contribute to the development of the more severe manifestations of psychopathology following trauma [44]. While mature and systematic mode of death education may be provided in foreign countries, Chinese people are restricted by the life and death culture of “avoiding death while living,” and the theory and practice of death education are still in exploratory stages [48, 49]. The health system may not provide psychological support in terms of life education after an individual experiences a life-threatening trauma, and fear of death may trigger a traumatic emotional reaction when the individual is faced with a life-threatening event again [50‐54]. In this study, the levels of death anxiety were found to be consistently high at both time points, with healthcare workers experiencing significantly higher levels of death anxiety 3 months after the outbreak than non-medical workers. This highlights the need to change the perception of death among the general population and provide them with effective life education. The more important message is that emergency plans for the improvement of psychological well-being, including life education, should be established for medical workers with traumatic experiences.

Our study has several limitations. First, the population surveyed in this study was not uniform and the baseline level of mental health of the participants before the survey was not accounted for. Second, when the content of the study was explained, some candidates refused participation because of the Chinese culture of avoiding the topic of death. It is unclear whether this rejection is in itself an indicator of higher levels of death anxiety. Finally, the participation rate of non-medical personnel was significantly lower than that of medical personnel, and again, we are unsure whether this lack of participation represents non-medical workers’ resistance to addressing the problem.

This study shows the long-term psychological impact of the COVID-19 pandemic on the general population in China. Despite the initial crisis being overcome and the relaxation of containment measures, the negative effects of the outbreak, such as death anxiety and PTSD, continue to rise. These results underscore the importance of continuous attention to mental health and reveal key variables such as history of life-threatening events and occupation. In addition, it is more important to pay attention to the moderating effect of death anxiety on PTE and PTSD. These new findings may be taken into consideration when formulating a plan for the management of the psychological effects of public health emergencies and thereby provide effective interventions for key populations.