PTSD, depression and anxiety in Ebola virus disease survivors in Beni town, Democratic Republic of the Congo

The 10th Ebola Virus disease (EVD) outbreak, declared in the North- Kivu and Ituri provinces, Democratic Republic of the Congo, on 1 August 2018, was the second largest in the world after the one that affected Western Africa between 2013 and 2016 [1, 2]. By the time it was declared over, on 25 June, 2020, it had affected 3470 and killed 2287 people, with 1171 survivors (https://​www.​who.​int/​news-room/​detail/​25-06-2020-10th-ebola-outbreak-in-the-democratic-republic-of-the-congo-declared-over-vigilance-against-flare-ups-and-support-for-survivors-must-continue). It was particularly challenging to manage this outbreak as it took place in an area where long-lasting conflict among countless armed groups is ongoing (https://​www.​who.​int/​news-room/​detail/​25-06-2020-10th-ebola-outbreak-in-the-democratic-republic-of-the-congo-declared-over-vigilance-against-flare-ups-and-support-for-survivors-must-continue) [3, 4]. This unstable situation affects the mental health of those living in these provinces, [5] which also lack proper mental health services [6, 7]. Previous studies suggest that EVD survivors are likely to present with neuropsychological disorders and posttraumatic stress reactions [8‐10].

This study therefore aimed to determine the prevalence of depression, anxiety and post-traumatic stress disorder among EVD survivors. In addition, it sought to assess the relationship between these psychiatric disorders and other comorbidities among EVD survivors.

Over the period of this study, 179 EVD survivors were evaluated by the psychosocial care team. A total of 144 (80.4%) aged 18 years or more were enrolled in this study.

This study sought to determine the prevalence of PTSD, depression and anxiety among EVD survivors. Moreover it looked to assess the relationship between these psychiatric disorders and other comorbidities among EVD survivors. Symptoms consistent with PTSD, depression and anxiety were found among 24.3%, 24. 3% and 33. 3% of EVD survivors respectively.

It has been shown that understanding psychological reactions among EVD survivors can give opportunity to provide important data about post-treatment Ebola psychological preventative measures [10].

In the cultural context of the studied epidemic, it is quite possible that most EVD survivors did not have sufficient health literacy to easily understand what EVD is, how to avoid it, and how to reach the nearest ETU when their first symptoms appeared, because of their high rate of illiteracy (40.3% had never been to school). This study revealed also that 45.1% EDV survivors had lost loved ones because of EVD, and may have thought they were dying themselves. Many of them did not have an opportunity to mourn with their families or communities. During their hospitalization, they were mostly cared for by foreigners (infectious disease specialists and epidemiologists, who were often expatriate or from other provinces) with whom they did not share the same culture or language. This situation could contribute to psychological distress, during their ETU admission and following discharge. Data collected in Liberia through focus group discussions among EVD survivors revealed that they generally felt stigmatized. The stigma began in the ETU and continued afterwards in the family, community, workplace and even in places of worship [10, 15‐17].. Furthermore, some survivors experienced ongoing physical symptoms, which might be a further source of psychological stress. All these stressors are likely to have triggered and maintained PTSD, anxiety and depression symptoms among survivors.

In Sierra Leone, 21% of EVD survivors reported clinically important post traumatic reactions between 3 and 4 weeks post discharge, and these reactions predicted later development of post-traumatic stress disorder [10]. In Guinea, three out of 33 EVD survivors in follow-up program had PTSD symptoms [18]. The psychological impact of EVD is such that it affects even those who have not suffered from it. According to a community based study carried out in Sierra Leone among the general population [19], 16% (95% CI 14.7 to 17.1%) had levels of symptoms consistent with a probable PTSD diagnosis, although the definition and measurement of these symptoms in each study differed.

In this study, factors associated with higher reporting of PTSD symptoms included loss of a family member, persistent headache (those with headache being twice as likely to have PTSD compared to headache-free survivors), and being female. Human gender differences in anxiety and emotional disorder has been reported, with studies generally concluding that women are more likely than men to develop acute stress disorder or PTSD [20, 21]. Some arguments have been made that the increased PTSD prevalence among women is due to a reporting bias because men tend to under-report and women over-report symptoms of PTSD [22], while other authors suggest that this high prevalence is probably due to social expectations related to the male and female gender role; with women expected to be vulnerable, men expected to be tough and more resilient to trauma [23].

Having persistent headaches and losing a loved one could be considered as a cumulative exposure to potentially traumatic experiences, and previous research has elucidated causal links between stress exposure and the development of anxiety disorders [24].

This study showed that the younger the EVD survivor was (18–24 years), the greater was the risk for them to suffer from PTSD. Creamer and Parslow [25] also found that the risk of PTSD was highest between the age of 18 and 24 years for both men and women. Despite what we have found, Norrid et all [26] examined the effects of age on PTSD in a cultural context and compared the effects of of age after similar disaster in three different parts of the world and concluded that PTSD depended upon the social, economic, cultural and historical context of the disaster- stricken-setting, more than it depended on age.

More than one-third of our survivors had persistent headaches and nearly a quarter had short-term memory impairment (STMI). Beni town, where this study was performed, is also an active conflict zone. As discussed before, numerous stressful factors associated with life in the province are probably more likely to trigger anxiety and depression, where there is also an acute mental health services shortage [6].

In this study, symptoms consistent with depression and anxiety were found among 24.3 and 33.3% of EVD survivors respectively. Unsurprisingly, we’ve found that factors associated with higher reporting of anxiety-depression symptoms included STMI and persistent headache (twice more likely to exhibit anxiety-depression symptoms). It is possible that suffering from physical symptoms that some authors consider a « post-Ebola syndrome » - such as STMI and headaches – [27] interferes with daily life and delays social reintegration, in a situation already made tough by stigma [16]. This may then in turn contribute to the development of anxiety and depressive symptoms. Depression is also known to be a common comorbidity of persistent headaches in other populations [28, 29]. As mentioned above, women seem to be more vulnerable to stress- and fear-based disorders, such as anxiety and post-traumatic stress disorder. It has been reported that women are two to three times more likely than men to suffer from generalized anxiety disorders and have higher self-reported anxiety scores [30, 31].

In the same way, anxiety symptoms were mostly reported by female survivors in this study. Since previous research describes existing gender differences in anxiety disorders, in animals models it has been suggested that a conflict anxiety-related serotonergic region that may be particularly vulnerable in females is the midbrain [32]; a role for gonadal hormones, and estrogen in particular, has also been reported [33].

Due to the high illiteracy rate (40.3% EVD survivors had never been to school), EVD survivors needed help in completing the tools used in this study (Posttraumatic Checklist Scale (PCLS) and Hospital Anxiety and Depression Scale (HADS), even though other study populations have successfully self-completed them in numerous previous studies. Some more difficult-to-understand items were translated by the neuropsychiatrist into Swahili, another commonly used language in the area the study was conducted, to aid understanding. Given the health emergency conditions in which this study was done, it was not possible to conduct a full cross-cultural validation of these scales and the effects of translation upon them.

Furthermore, in the literature, the diagnostic thresholds proposed by various authors were different depending on the populations studied. For this study, we chose a threshold of 44 for PTSD screening and of 8 for the diagnosis of anxiety-depressive disorders as proposed by Bjelland et al. [34]. This PTSD cut-off score is higher than some others proposed, and could have helped to minimize false positive cases [35]. However, to overcome the weakness of this questionnaire, it is often advisable to have more than one structured clinical face-to-face interviews with the patient in order to make an accurate diagnosis. This was not possible in the context of carrying out this work. Patients often had to travel significant distances to meet with health care workers in this program and additional visits were thus not practical.

It also must be mentioned that this cross-sectional study was conducted from October 26 to November 13, 2019 while the EVD outbreak went on up to the April 2020. These results should therefore not be generalized for all EVD survivors.

Finally, this study was conducted in an area where armed conflicts, and their impacts on psychological health, have been ongoing for more than two decades. Some of our patients may have already had PTSD before they suffered from EVD and this was revealed by our screening. Thus our results on psychological trauma may not be fully generalizable to other EVD survivor populations from different contexts.

Ebola Virus Disease (EVD) is a deadly and feared infectious disease, which can be responsible of debilitating physical and psychological sequelae in survivors including depression and anxiety disorders. Survivors have often seen their loved ones die, and have been confronted with corpses and death. After leaving the hospital, they have to deal with the difficulties of family and socio-professional integration because of stigma associated with the disease. Many also suffer from post-ebola syndromes (headaches, memory disorder, physical pain etc.). These potent psychological and physical stressors may trigger high rates of anxiety disorders and depression, as detected in this study. Surviving EVD is therefore not synonymous with being free from the consequences of the disease, due to this accumulation of stress. This may be even more marked in DRC as the EVD outbreak was declared in areas affected by long lasting armed conflicts.

Implementation of specialized, culturally contextualised programs to sustain psychiatric and psychological care in the Eastern part of the Democratic Republic of Congo should be prioritized by health services battling EVD in the DRC and further research is needed to show how this major burden of physical and psychiatric comorbidity following EVD may be overcome [36, 37].