Prevalence and factors associated with post-traumatic stress disorder in healthcare workers exposed to COVID-19 in Wuhan, China: a cross-sectional survey

Coronavirus disease 2019 (COVID-19) is a highly contagious acute infectious respiratory disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) [1]. The outbreak of COVID-19 emerged in Wuhan (China) in the last month of 2019 and the subsequent spread outside of China led the World Health Organization (WHO) Emergency Committee to declare a Public Health Emergency of International Concern (PHEIC) on January 30, 2020, and a pandemic on March 11, 2020 [2]. The COVID-19 pandemic not only causes physical diseases, but also leads to great psychological distress, resulting in high level of anxiety, depression, burnout syndrome and PTSD [3‐5]. An important group experiencing severe distress consists of the doctors and nurses caring for COVID-19 patients, which is not surprising as several studies have reported that medical staff comprises one of the most vulnerable sectors in the population during global events [6‐8]. As of the writing (May 14, 2021), with more than 162 million detected infections worldwide and the pandemic far from being contained, investigating the psychological impact of this pandemic on healthcare workers (HCWs) has become increasingly important, especially the long-lasting impact on those working at the early stage of the pandemic. Post-traumatic stress disorder (PTSD) refers to an individual’s delayed appearance and long-lasting mental disorder caused by sudden, catastrophic or threatening life events [9, 10]. It is an emotional disorder dominated by fear and anxiety, which might lead to depression, helplessness, memory impairment, and decreased work quality [11]. Being isolated, working in high-risk positions, being nurses, and having contact with infected people are known risk factors for PTSD [3, 12]. The COVID-19 pandemic very likely also exerts a similar impact on HCWs. Indeed, several studies have reported that a proportion of first-line HCWs developed PTSD and that their work and life were affected significantly [13‐15]. A quantitative study indicated that the outbreak of COVID-19 in Wuhan had a clear impact on the mental health of local HCWs, with 22.4% reporting moderate and 6.2% severe disturbances [7]. Other studies have also investigated the PTSD status and risk factors of front-line HCWs [16‐18]. However, most of these studies investigated short-term PTSD symptoms soon after the outbreak, and any evidence of long-term PTSD related to COVID-19 is limited thus far. Therefore, in the present study, we aim to investigate the prevalence of PTSD and corresponding factors in HCWs exposed to COVID-19 8 months after the end of the outbreak in Wuhan.

The prevalence of PTSD in this study is 13.7% (90/659) which is lower than that reported in a recent study (61.8%) [27]. In that study, only front-line nurses were included and were all screened with PTSD immediately after having worked in COVID-19 units. Other studies have indicated that nurses were more vulnerable than other HCWs to PTSD [16, 28]. In our analysis, we also included other HCWs besides nurses; therefore, the impact of COVID-19 on HCWS can be more fully evaluated, although nurses still accounted for the majority of the participants (86.9%, 573/659). Furthermore, the time points of the PTSD screening were quite different. In the present study, all participants were screened 8 months after the exposure to COVID-19. The results of those previous studies, together with the results reported here, suggest that the incidence of COVID-19-related PTSD decreases over time. A similar decreasing trend was also reported in PTSD caused by a devastating earthquake, in which the PTSD rate was 8.4% 1 month after the earthquake, while decreasing to 4.3% 3 months later, and then dropping to 3.4% half a year later [29].

In terms of factors associated with PTSD, we identified that participants with a poorer score of family function, experienced social isolation and dissatisfaction with their job were at higher risk of developing PTSD, which highlighting the importance of support from supervisors, colleagues, family and society. This is in line with previous studies, as these factors were also frequently reported in HCWs exposed to SARS [30‐32]. In the present study, working in mobile cabin hospitals was identified as an independent protective factor of PTSD. Compared with other hospital departments, mobile cabin hospitals in China were well prepared with enough protective equipment, staff and well-organized infection prevention and control strategies, which increased the sense of security and hence decreased the extent of the impact of COVID-19 itself. Likewise, other studies have reported that a structured unit with perceived safety of the working environment enhanced the resilience against PTSD [30, 33]. Therefore, it is recommended to conduct workplace risk assessment and occupational health surveillance to establish the most effective preventive and protective measures in hospitals to eliminate risks of infection of COVID-19 among HCWs [34]. Interestingly, in our study, we found that chronic physical disease was associated with developing PTSD in HCWs, something that has not been reported before to our knowledge. As medical professionals, HCWs know that chronic diseases are independent risk factors for developing severe disease and would cause higher mortality in COVID-19. Therefore, this professional knowledge might cause the fear of developing the serious disease when infected with COVID-19 and subsequently cause higher stress than those without physical chronic diseases. Previous research has reported that psychiatric disorders are risk factors for developing PTSD in SARS and MERS [35, 36]. Therefore, both from a physical, as well as a psychological point of view, it is recommended to avoid deploying HCWs with chronic diseases to care for COVID-19 patients or other communicable diseases.

Regarding the impact of PTSD on daily life, although the frequency of panic did not show any statistically significant difference between participants with or without PTSD, those with PTSD did have a poorer score of quality of life, often feel lonely, and sleep less than that without PTSD. Strikingly, 44.4% of the participants with PTSD thought they were in need of psychological assistance. A study done immediately after the outbreak was brought under control in Wuhan demonstrated that of all HCWs caring for COVID-19 patients included, 36.3% had accessed psychological materials, 50.4% had accessed psychological resources available through media, and 17.5% had participated in counselling or psychotherapy [7]. As it was demonstrated that the workplace is a suitable arena for implementing mental health interventions to promote psychological resources and resilience and provide social and emotional support to HCWs [37], we recommend hospitals to allocate more resources to psychological assistance for staff that were directly or indirectly exposed to COVID-19. Moreover, the intention to resign in participants with PTSD was twice higher than those without PTSD in the present study, which is significantly consistent with the dimension of avoidance score. Combined with this evidence, it seems good if hospitals would offer opportunities to HCWs at risk for PTSD (or all, depending on capacity) to rotate to other positions for certain periods, to lower the prolonged fear related to caring for COVID-19 patients, as that was also suggested in a study on work-related PTSD [38].

The prevalence of PTSD was 13.7% among HCWs 8 months after the exposure of COVID-19. Suffering from chronic disease, the experience of social isolation, dissatisfied with the job were independent risk factors for PTSD, while obtaining COVID-19 related information at an appropriate frequency, good function of family, and working in the well-prepared mobile cabin hospitals were protective factors of developing PTSD. The impact of PTSD on HCWs was shorter sleeping time, feeling of loneliness, poorer quality of life and intention to resign.