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Psychiatry Research

journal homepage: www.elsevier.com/locate/psychres

Review article

PTSD symptoms in healthcare workers facing the three coronavirusoutbreaks: What can we expect after the COVID-19 pandemic

Claudia Carmassia, Claudia Foghia, Valerio Dell'Ostea,b,⁎, Annalisa Cordonea,Carlo Antonio Bertellonia, Eric Buic, Liliana Dell'Ossoa

a Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italyb Department of Biotechnology Chemistry and Pharmacy, University of Siena, Siena, Italyc Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

A R T I C L E I N F O

Keywords:CoronaMental healthNursesPhysiciansPsychological distressStress

A B S T R A C T

The COronaVIrus Disease-19 (COVID-19) pandemic has highlighted the critical need to focus on its impact onthe mental health of Healthcare Workers (HCWs) involved in the response to this emergency. It has been con-sistently shown that a high proportion of HCWs is at greater risk for developing Posttraumatic Stress Disorder(PTSD) and Posttraumatic Stress Symptoms (PTSS). The present study systematic reviewed studies conducted inthe context of the three major Coronavirus outbreaks of the last two decades to investigate risk and resiliencefactors for PTSD and PTSS in HCWs. Nineteen studies on the SARS 2003 outbreak, two on the MERS 2012outbreak and three on the COVID-19 ongoing outbreak were included. Some variables were found to be ofparticular relevance as risk factors as well as resilience factors, including exposure level, working role, years ofwork experience, social and work support, job organization, quarantine, age, gender, marital status, and copingstyles. It will be critical to account for these factors when planning effective intervention strategies, to enhancethe resilience and reduce the risk of adverse mental health outcomes among HCWs facing the current COVID-19pandemic.

1. Introduction

The outbreak of Corona Virus Disease-19 (COVID) that emerged inDecember 2019 in Wuhan (China), quickly spread outside of China,leading the World Health Organization (WHO) Emergency Committeeto declare a Public Health Emergency of International Concern (PHEIC)on January 30th 2020 (Nishiura, 2020), and a pandemic on March 11,2020. The SARS-CoV2 – the virus responsible for COVID-19 – wasisolated by 7th January 2020, and belongs to the same viral family asthe coronavirus syndrome (SARS-CoV) and the Middle East respiratorycoronavirus syndrome (MERS-CoV). Both of these coronavirus-basedrespiratory syndromes infected over 10,000 cases in the past two dec-ades, with overall mortality rates as high as 11% and 35%, respectively(Peeri et al., al.,2020; de Wit et al., 2016; Leung et al., 2004;WHO, 2004). Compared to the Severe Acute Respiratory Syndrome(SARS) and the Middle East Respiratory Syndrome (MERS), the CoronaVirus Disease-19 (COVID-19) has a greater transmission rate but alower, though still significant, fatality rate (Peeri et al., 2020;Huang et al., 2020). To date, with more than 14 million infectedworldwide and a spread that is far from being contained, investigating

the psychological impact of this pandemic on healthcare workers(HCWs) including physicians and nurses, has become increasingly im-portant.

In the last two decades, first responders’ mental health outcomes hasbeen the focus of increasing attention, particularly in the aftermath ofSeptember 11 2001, terrorist attacks that shed light on the risks theyare exposed to when operating in emergency settings, as they may beaffected by physical and mental disorders, such as burnout and post-traumatic stress disorder (PTSD) (Perlman et al., 2011; Carmassi et al.,2016, 2018; Martin et al., 2017). The DSM-5 (APA, 2013) indicates that"experiencing repeated or extreme exposure to aversive details of the trau-matic event(s)" can be considered as potentially traumatic events (cri-terion A4: e.g. first responders collecting human remains, police officersrepeatedly exposed to details of child abuse).

Healthcare Workers (HCWs) in emergency care settings are parti-cularly at risk for PTSD because of the highly stressful work-relatedsituations they are exposed to, that include: management of criticalmedical situations, caring for severely traumatized people, frequentwitnessing of death and trauma, operating in crowded settings, inter-rupted circadian rhythms due to shift work) (Figley, 1995; Crabbe et al.,

https://doi.org/10.1016/j.psychres.2020.113312Received 1 May 2020; Received in revised form 18 July 2020; Accepted 18 July 2020

⁎ Corresponding author at: Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56100 Pisa, Italy.E-mail address: [email protected] (V. Dell'Oste).

Psychiatry Research 292 (2020) 113312

Available online 20 July 20200165-1781/ © 2020 Elsevier B.V. All rights reserved.

T

2004; Cieslak et al., 2014; Berger et al., 2012; Hegg-Deloye et al., 2013;Garbern et al., 2016). PTSD rates have been reported to range from 10to about 20% (Grevin, 1996; Clohessy and Ehlers, 1999; Robertson andPerry, 2010; DeLucia et al., 2019), with even higher PTSD rates (8% to30%) among Intensive Care Unit (ICU) staff, (Mealer et al., 2009;Karanikola et al., 2015; Machado et al., 2018).

Although most individuals prove to be resilient after being exposedto a traumatic event (Bonanno et al., 2007), several risk factors maycompromise the effectiveness of adaptation, including prior psychiatrichistory, female sex, lack of social support (Brewin et al., 1999;Ozer et al., 2003; Carmassi et al., 2020a, 2020b), having young children(Yehuda et al., 2015; Bryant 2019); experiencing feelings of help-lessness during the trauma or intensity of emotions when exposed (i.e.,anger, peritraumatic distress) (Vance et al., 2018; Carmassi et al.,2017). On the other hand, resilience, defined as the capacity to react tostress in a healthy way through which goals are achieved at a minimalpsychological and physical cost (Epstein and Krasner, 2013), plays akey role in mitigating the impact of traumatic events and hence redu-cing PTSS, enhancing at the same time the quality of care (Wrenn et al.,2011; Ager et al., 2012; Haber et al., 2013; McGarry et al., 2013;Craun and Bourke, 2014; Hamid and Musa, 2017; Colville et al., 2017;Cleary et al., 2018; Winkel et al., 2019).

This interplay of risk and resilience factors becomes even morecomplex and challenging when applied in the context of an infectiousepidemic. This statement is first supported by the fact that, as previousstudies outlined, during epidemics a high percentage of HCWs, (up to 1in 6 of those providing care to affected patients), develops significantstress symptoms (Lu et al., 2006; McAlonan et al., 2007) It is worthconsidering that in epidemic contexts HCWs are first in line facing theclinical challenges intrinsically linked to the course of the disease whileunder the constant personal threat of being infected or representing asource of infection.

The current COVID-19 pandemic is characterized by some relevantfeatures that increase the risk for PTSD among HCWs addressing theemergency, such as the unprecedented numbers of critically ill patients,with an often unpredictable course of the disease, high mortality ratesand lack of effective treatment, or treatment guidelines (Wang, 2020;Peeri et al., 2020). Thus, the burden of the current outbreak onhealthcare providers deserves the closest attention, as it is extremelylikely that health care workers involved in the diagnosis, treatment andcare of patients with COVID-19 are at risk of developing psychologicaldistress and other mental health symptoms (Bao et al., 2020; Lai et al.,2020; Carmassi et al., 2020c)

The aim of the present paper is therefore to systematically reviewthe studies investigating the potential risk and resilience factors for thedevelopment of PTSD symptoms in HCWs who faced the two majorCoronavirus outbreaks that occurred worldwide in the last two decades,namely the SARS and the MERS, as well as the ongoing COVID-19pandemic, in order to outline effective measures to reduce the HCWs’psychiatric burden during the current crisis affecting healthcare sys-tems all over the world.

2. Methods

2.1. Search strategy

We reviewed articles indexed in the electronic database PubMeduntil 20th April 2020. No time limit was set in regard to the year ofpublication. The search terms were combined with the Boolean op-erator as follows: “(Post-traumatic stress OR Post-traumatic stress dis-order OR Post-traumatic stress symptoms OR PTSD OR PTSS) AND(Severe Acute Respiratory Syndrome OR SARS OR Middle EastRespiratory Syndrome OR MERS OR Corona Virus Disease 19 ORCOVID-19 OR Coronavirus)”. Furthermore, relevant articles were ex-tracted from the references section of the manuscripts found in theinitial search, to complete our search.

2.2. Eligibility criteria

We included articles that met the following inclusion criteria: ori-ginal studies on humans investigating possible risk and/or resiliencefactors for PTSD symptoms in HCWs facing the coronavirus outbreaksof SARS, MERS and COVID-19. Articles in print or published ahead ofprint were accepted. The exclusion criteria were: (a) studies involvinggeneral population samples that did not consider a sub-sample ofHCWs; (b) studies examining other mental health symptoms but notPTSS; (c) studies assessing PTSS but not considering potential risk andresilience factors; (d) literature reviews; (e) full text not available; (f)not available in English.

2.3. Study selection

The first author screened each study for eligibility by reading thetitle and abstract. Any uncertainties about eligibility were clarifiedthrough discussion among all authors. Decisions for inclusion or ex-clusion are summarized in a flowchart according to PRISMA re-commendations, usually used to conduct meta-analyses and systematicreviews of randomized clinical trials, but that have also been used forother types of systematic reviews such as our present one (Moher et al.,2009).

3. Results

3.1. Process of study selection

The study selection process is outlined in a flow-chart (Fig. 1). Theelectronic database search returned 263 publications. Following apreliminary screening of the titles and abstracts, 47 articles were con-sidered of potential relevance, their eligibility was assessed by means ofa full text examination. Twenty-four of these studies, published be-tween 2004 and 2020, were included in this review. The main reasonsfor study exclusion were: the absence of a HCW sample or sub-sample,the lack of data regarding PTSS and/or about possible risk or resiliencefactors related to psychopathology.

3.2. Characteristics of included studies

The key characteristics of the studies included are summarized inTable 1. All retrieved studies were published between January 2004and April 2020. Nineteen studies were on the SARS 2003 outbreak, twoon the MERS 2012 outbreak, and three on the ongoing Covid-19 out-break. Nine studies were on a mixed population in which HCWs re-presented a sub-sample (Bai et al., 2004; Chong et al., 2004;Kwek et al., 2006; Reynolds et al., 2007; Lancee et al., 2008; Wu et al.,2009; Mak et al., 2010; Wing and Leung, 2012; Li et al., 2020) while allother studies included HCWs only. Finally, five studies included spe-cifically survivors from the infection (Kwek et al., 2006; Lee et al.,2007; Mak et al., 2010; Wing and Leung, 2012; Ho et al., 2005).

3.3. PTSD and PTSS risk factors in HCWs facing the coronavirus outbreaks

3.3.1. Level of exposureTen studies (Chong et al., 2004; Maunder et al., 2004; Lin et al.,

2007; Su et al., 2007; Styra et al., 2008; Wu et al., 2009; Lee et al.,2018; Lai et al., 2020; Kang et al., 2020; Jung et al., 2020) highlightedthe role of exposure level, such as working in high-risk wards or infront-line settings during the Coronavirus outbreaks, as the major riskfactor for developing PTSS and PTSD. Particularly, they pointed out therelevance of perceived threat for health and life and the experiencedfeelings of vulnerability as mediating factors. Most of these studies re-ported on the 2003 SARS outbreak. Lin et al. (2007) showed higherrates of PTSD (21,7%) among 66 emergency department staff comparedto 26 HCWs of non-emergency departments (i.e., psychiatric ward,

C. Carmassi, et al. Psychiatry Research 292 (2020) 113312

2

13%). Wu et al. (2009) investigated a sample of 549 HCWs in Beijing(China), including administrative staff, finding 2 to 3 times higher PTSSrates among respondents who worked in high-risk locations and per-ceived high SARS-related risks, beside an increased risk for subsequentalcohol abuse/dependence. This latter resulted significantly relatedwith hyper-arousal symptoms. A further study in Toronto (Styra et al.,2008) confirmed the impact of operating in a high-risk unit, and firstreported that caring for only one SARS patient was related to a higherrisk than caring for multiple SARS patients. A recent study on 147nurses who worked in MERS units during the outbreak found higherPTSD rates among emergency HCWs than among non-emergency ones(Jung et al., 2020). To date, two studies have explored this issue in theCOVID-19 pandemic. Li et al. (2020) found among 526 nurses, thatthose who worked on the frontline appeared to be less prone to de-veloping PTSS compared to second-line ones; converselyKang et al. (2020) in a large study on 994 HCWs in Wuhan reported theexposure level to infected people, more broadly including colleagues,relatives or friends, to be a risk factor for mental health problems, in-cluding PTSS.

3.3.2. Occupational roleFive studies, four on the SARS epidemic and one on the COVID-19

pandemic, highlighted the occupational role as a major risk factor forPTSD or PTSS in Coronavirus outbreaks. Maunder et al. (2004) foundon a sample of 1557 HCWs collected in Toronto, higher PTSS ratesamong nurses and explained this finding by means of the longer contactand higher exposure to patients of the nursing staff. A study on 96emergency HCWs, assessed six months after the 2003 SARS outbreak,revealed a greater burden of PTSS among nurses than among physicians(Tham et al., 2004). A further study by Phua et al. (2005) confirmedthis finding in a sample of 99 HCWs. Finally, a most recent study on1257 hospital physicians and nurses caring for COVID-19 patientsreached the same conclusion (Lai et al., 2020).

3.3.3. Age and genderThree studies on the SARS outbreak and one on the COVID-19

pandemic reported that younger HCWs had a greater risk of developingPTSS (Sim et al., 2004; Su et al., 2007; Wu et al., 2009). From a widerperspective, further studies pointed out an association between feweryears of work experience and an increased PTSS risk in HCWs, as de-scribed in two SARS studies (Chong et al., 2004; Lancee et al., 2008)and in one COVID-19 study (Lai et al., 2020). As far as gender is

concerned, while one recent study on COVID-19 reported a higher riskfor the female HCWs, a previous study involving 1257 HCWs in a ter-tiary hospital affected by SARS found an increased risk of PTSS amongmales (Chong et al., 2004).

3.3.4. Marital statusThree studies focused on the relevance of marital status, two of

which referred to the SARS outbreaks and one to the current COVID-19pandemic. Chan and Huak (2004) in a study on 661 HCWs in Singaporeshowed that those who were not married were more adversely affectedthan married ones. In contrast, a further study in Singapore (Sim et al.,2004) found a positive association between post-traumatic morbiditiesand being married. Likewise, a recent case control study on HCWs fa-cing the COVID-19 pandemic showed that married, divorced or wi-dowed operators reported higher scores in vicarious traumatizationsymptoms compared to unmarried HCWs (Li et al., 2020).

3.3.5. Quarantine, isolation and stigmaThree SARS studies on Chinese hospital staff members (Bai et al.,

2004; Reynolds et al., 2007; Wu et al., 2009) and one on the MERSoutbreak (Lee et al., 2018) consistently reported high levels of PTSSamong HCWs who had been quarantined. More specifically,Bai et al. (2004) examining 338 HCWs in an East Taiwan hospital foundthat 5% of them suffered from acute stress disorder, with quarantinebeing the most frequently associated factor, and a further 20% feltstigmatized and rejected in their neighborhood because of their hospitalwork, with also 9% reporting reluctance to work and/or consideringquitting their job. Similar findings emerged from a Canadian SARSstudy on 1057 subjects (Reynolds et al., 2007), in which quarantinedHCWs reported more PTSS than non-HCWs quarantined individuals.Moreover, in a study on MERS outbreak, Lee et al. (2018) assessed PTSSexperienced by 359 university HCWs who cared for infected patients,observing that quarantined HCWs had a higher risk of developing PTSSwhich persisted over time, particularly sleep and numbness-relatedsymptoms. More in general, social isolation and separation from familywas found to be associated with higher rates of PTSS in SARS outbreak,as well as having friends or close relatives with the infection(Maunder et al., 2004; Chong et al., 2004; Wu et al., 2009).

3.3.6. Previous psychiatric disordersThree studies on SARS have stressed the presence of previous psy-

chiatric disorders as a risk factor for the development of PTSS

Fig. 1. PRISMA flowchart of studies selection process.

C. Carmassi, et al. Psychiatry Research 292 (2020) 113312

3

Tab

le1

Mainch

aracteristicsof

included

studies.

Study

Outbreak

Typ

eSa

mple

PTSS

/PTSD

measures

Mainge

neral

findings

Mainrisk

andresilien

cefactors

Bai

etal.(2004)

SARS

Cross-section

alstudy

557hospital

staff

mem

bers

(HCWsn=

402;ad

ministrative

personnel

n=

155)

SARS-relatedstress

reaction

squ

estion

naire

5%

acute

stress

disorder;

20%

stigmatized

;an

d9%

reluctan

ceto

workor

considered

resign

ation

Riskfactor:qu

aran

tine

Chan

andHuak

(2004)

SARS

Cross-section

alstudy

661HCWs(doc

tors

andnurses)

Impactof

Eve

nts

Scale

20%

IESscore>

30;

27%

psych

iatric

symptoms(35%

ofdoc

tors

and25%

ofnurses)

Resilience

factors:

Supportfrom

family/

supervisors/colleag

ues;workorga

nization

(clear

directive

s/precaution

arymeasures

from

man

agem

ent)

Chon

get

al.(2004)

SARS

naturalistic,

observational

study

1257hospital

staff

mem

bers

(nurses

n=

676;doc

tors

n=

139;healthad

ministrative

worke

rsn=

140;others

n=

302)

Impactof

Eve

ntScale

IESmeanscore=

34.8;

75.3%

psych

iatric

symptoms(anxietyan

dworrying,

dep

ressionan

dinterpersonal

diffi

culties,

somatic

problem

s)in

theinitialphaseof

theou

tbreak

Riskfactors:

male;

tech

nicians;

≤2ye

ars

workexperience;leve

lof

exposure

Mau

nder

etal.(2004)

SARS

cross-sectional

study

1557HCWs

Impactof

Eve

nts

Scale

Higher

Impactof

Eve

ntScalescores

arefoundin

nurses

andHCWshav

ingco

ntact

withSA

RSpatients.

Riskfactors:

leve

lof

exposure;nurses;

perceived

threat

fortheirhealth;social

isolation

Sim

etal.(2004)

SARS

cross-sectional

study

277HCWs

(doc

tors

n=

91;n

urses

n=

186)

Impactof

Eve

nts

Scale

9.4%

PTSS

;20.6%

psych

iatric

morbidity

Riskfactors:

younge

rag

e,be

ingmarried

,psych

iatric

morbidity,

less

venting,

less

humor,an

dless

acceptance.

Tham

etal.(2004)

SARS

cross-sectional

study

Emerge

ncy

HCWs

(doc

tors

n=

38;

nurses

n=

58)

Impactof

Eve

nts

Scale

IESscore≥

26in

13.2%

doc

tors

and20.7%

nurses;

Gen

eral

HealthQuestion

naire-28≥

5in

15.8%

doc

tors

and20.7%

nurses

Riskfactors:

nurses

Hoet

al.(2005)

SARS

cross-sectional

study

82HCWsnot

infected

and

97HCWswhoreco

veredfrom

SARS

Impactof

Eve

nts

Scale

(Chineseve

rsion)

HCWsreco

veredreportedhighPTSS

intrusion

symptoms

andmoreco

ncernsab

outother

healthproblem

san

ddiscrim

ination.

HCWsnot

infected

had

stronge

rfear

relatedto

infection

than

HCWsreco

vered;eq

ual

concern

abou

tinfecting

others(especiallyfamilymem

bers)than

beingself-

infected

emerge

d

Riskfactors:

beingHCWssurvivors

Phuaet

al.(2005)

SARS

cross-sectional

study

99HCVs

(doc

tors

n=

41;nursen=

58)

Impactof

Eve

nts

Scale

17.7%

IES>

26;

RiskFa

ctor:nurses

Resilience

factors:

positiveco

pingstyles

(humor

andplanning)

Kwek

etal.(2006)

SARS

cross-sectional

study

63HCWsSA

RSsurvivors

Impactof

Eve

nts

Scale

41%

scored

indicativeof

PTSD

;30%

like

lyan

xietyan

ddep

ression.

Riskfactor:be

ingHCW

survivors

Mau

nder

etal.(2006)

SARS

cross-sectional

study

769HCWs

(SARSan

dno-SA

RSunits)

Impactof

Eve

nts

Scale

SARSunitHCWsreportedhigher

PTSS

,bu

rnou

t,an

dpsych

olog

ical

distressrather

than

no-SA

RSunitHCWs.

SARSunitHCWsmorereducedpatient

contact

andworkhou

rs.

Riskfactors:

malad

aptive

copingstrategies

(avo

idan

ce,hostile

confron

tation

,an

dself-

blam

e).

Resilience

factors:

training,

Supportfrom

family/

supervisors/colleag

ues,work

orga

nization

Leeet

al.(2007)

SARS

cohortstudy

SARSsurvivors(non

–HCWs

n=

49;HCWsn=

30)

Impactof

Eve

ntScale–Rev

ised

Participan

tswithat

leastmod

eratePTSS

reported32.2%

Intrusion

,20.0%

Avo

idan

ce,an

d22.2%

Hyp

erarou

sal.

HCW

SARSsurvivorsweremoredistressedthan

non

–HCW

oneye

araftertheou

tbreak

.

Riskfactors:

beingHCW

survivors.

Linet

al.(2007)

SARS

cross-sectional

study

66em

erge

ncy

HCWsan

d26no-

emerge

ncy

HCWs

Dav

idsonTraumaScale-Chinese

version(D

TS-C)

Emerge

ncy

HCWsreported>

DTS-Cscores

than

no-

emerge

ncy

HCWs;21,7%

emerge

ncy

HCWsan

d13%

no-

emerge

ncy

HCWsreportedDTS-C>40(suspectedPTSD

).

Riskfactor:leve

lof

exposure

Rey

noldset

al.(2007)

SARS

cross-sectional

study

1057qu

aran

tined

subjects

(HCWsn=

269)

Impactof

Eve

nts

Scale–Rev

ised

14.6%

IES-R≥

20;qu

aran

tined

HCWsexperienced

greaterPTSS

than

quaran

tined

no-HCWs

Riskfactors:

quaran

tine

Suet

al.(2007)

SARS

prospective

and

periodic

follow

-up

study

102HCWs(70SA

RSan

d32no-

SARSHCWs)

Dav

idsonTraumaScale-Chinese

version(D

TS-C)

SARSunitHCWsreportedhigher

Dep

ression(38.5%

vs.

3.1%)insomnia

(37%

vs.9.7%)an

dPTSS

(33%

vs.

18.7%,bu

tnot

sign

ificant).

Riskfactors:

leve

lof

exposure

Lanceeet

al.(2008)

SARS

cross-sectional

study

139hospital

staff

(HCWs

n=

103;clerical

staff

n=

13;

Other

n=

21)

StructuredClinical

Interview

for

DSM

-IV;Clinician-Administered

PTSD

Scale

30%

lifetimepreva

lence

ofdep

ressive,

anxiety,

orsubstance

use

diagn

osis.

5%

new

psych

iatric

disordersafterou

tbreak

Riskfactors:

previou

spsych

iatric

disorder,

<ye

arsof

workexperience

(con

tinu

edon

next

page)

C. Carmassi, et al. Psychiatry Research 292 (2020) 113312

4

Tab

le1(con

tinu

ed)

Study

Outbreak

Typ

eSa

mple

PTSS

/PTSD

measures

Mainge

neral

findings

Mainrisk

andresilien

cefactors

Resilience

factors:

trainingan

dsupervisor/

colleagu

essupport.

Styraet

al.(2008)

SARS

cross-sectional

study

SARSunitsHCWs(n

=160)an

dno-SA

RSunitsHCWs(n

=88)

Impactof

Eve

ntScale—

Rev

ised

HCWstakingcare

ofon

lyon

eSA

RSpatienthad

higher

PTSS

leve

lsthan

thosetakingcare

ofnon

eor

morethan

twoSA

RSpatients

Riskfactor:leve

lof

exposure

Wuet

al.(2009)

SARS

cross-sectional

study

549hospital

staff

(21%

doc

tors,

38%

nurses,22%

tech

nicians;

20%

administrativean

dothers)

Impactof

Eve

ntScale—

Rev

ised

Abo

ut10%

IES-R≥

20.

Riskfactors:leve

lofexposure;y

ounge

rag

e;qu

aran

tine/isolation(quaran

tine,

hav

ing

friendsor

closerelative

sinfected

).Resilience

factor:co

pingstrategies

(altruisticacceptance

ofwork-relatedrisks)

Mak

etal.(2010)

SARS

retrospective

cohort

study

90SA

RSsurvivors(30%

HCWs)

StructuredClinical

Interview

for

theDSM

-IV;

Impactof

Eve

nts

Scale–Rev

ised

47.8%

PTSD

intheafterm

athof

SARS.

25.6%

stillsuffers

PTSD

30-m

onthspost-SA

RS

Riskfactors:

beingHCWssurvivors

(butlargeproportion

oftheHCWswere

female,

andthis

could

affectresults).

Wingan

dLe

ung(2012)

SARS

case-con

trol

study

233SA

RSsurvivors

Chinesebilingu

alve

rsionof

the

Semi-StructuredClinical

Interview

(SCID

-I)

Impactof

Eve

ntScale-revised

50%

SARSsurvivorsalifetimepsych

iatric

disorder

(dep

ression,PTSD

,somatoform

paindisorder,pan

icdisorder)

Riskfactor:be

ingHCWssurvivors

Leeet

al.(2018)

MERS

cohortstudy

359HCWs

(MERSan

dno-MERSunit)

Impactof

Eve

nts

Scale–Rev

ised

51%

HCWsreportedIES>

25

(MERSunits>

no-MERSunits)

inthefirstmon

thof

MERSou

tbreak

.After

onemon

th:qu

aran

tined

MERS

unitsHCWsshow

edhigher

sleepan

dnumbn

essscores;

MERSunitsHCWsshow

edhigher

intrusion

symptoms

Riskfactors:

leve

lof

exposure,qu

aran

tine

Junget

al.(2020)

MERS

cross-sectional

study

147HCWs(nurses

ofMERSunits)

Impactof

Eve

ntScale–Rev

ised

Koreanve

rsion

57.1%

PTSD

(25.1%

fullPTSD

and32.0%

partial

PTSD

).PTSD

was

associated

withturnov

erintention

Riskfactors:

leve

lof

exposure

(emerge

ncy

HCWs>

no-em

egen

cyHCWs),previou

spsych

iatric

disorders

Resilience

factor:supervisorsupport

Kan

get

al.(2020)

COVID

-19

cross-sectional

study

994Wuhan

HCWs(doc

tors

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C. Carmassi, et al. Psychiatry Research 292 (2020) 113312

5

(Sim et al., 2004; Su et al., 2007; Lancee et al., 2008). Accordingly,Su et al. (2007) on a sample of 70 nurses from two SARS units and 32nurses from two non-SARS units found highlighted a previous history ofmood disorders as a major risk factor for PTSS. One study on MERSoutbreak confirmed this finding (Jung et al., 2020).

3.4. PTSD and PTSS resilience factors of in HCWs facing the threecoronavirus outbreaks

3.4.1. Family and social supportTwo studies on the SARS outbreak highlighted the support of family

and friends as having a major role in protecting from PTSS development(Chan and Huak, 2004; Su et al., 2007). In particular, Su et al. (2007)investigating 102 nurses found that strong social and family supportprotected against acute stress, with a positive impact on their globalfunctioning as a function of time.

3.4.2. Supervisors and colleagues supportThree researches concerning the SARS outbreak (Chan and

Huak, 2004; Maunder et al., 2006; Lancee et al., 2008) and one on theMERS (Jung et al., 2020), reported a protective role of the support fromsupervisors/colleagues. Particularly, Lancee et al. (2008), in 139 HCWsin Canada, showed feeling well supported while working as a resiliencefactor also in the long-term. Jung et al. (2020) noticed that manage-ment strategies based on supervisors’ support proved helpful in order toreduce PTSS in 147 nurses in three isolation hospitals in South Koreaduring the MERS outbreak.

3.4.3. TrainingThe perception of being adequately trained was identified as a po-

tentially protective factor in two studies on the SARS (Maunder et al.,2006; Lancee et al., 2008)., Comparing 769 Canadian HCWs displacedin 9 hospitals that treated SARS patients and 4 hospitals that did not,from 13 to 26 months after the outbreak, Maunder et al. (2006) sug-gested the importance of supportive interventions in preventing PTSDand PTSS with particular impact on maladaptive coping styles.

3.4.4. Work organizationThe same authors reported that working in structured units and the

perceived safety of the working environment are further factors whichseem to enhance the resilience of HCWs, in line with findings of anotherstudy by Su et al., 2007). Moreover, it has also been observed that aclear communication of directives and precautionary measures to beadopted was related to a better outcome with regard to PTSS (Chan andHuak, 2004).

3.4.5. Coping strategiesIn five studies on the SARS outbreak (Chan and Huak 2004;

Sim et al., 2004; Phua et al., 2005; Su et al., 2007; Wu et al., 2009),positive coping strategies were reported to be a protective factor againstthe development of PTSD psychopathology. Particularly, in a studycarried out in Singapore on 41 physicians and 58 nurses,Phua et al. (2005) reported an association between the use of humorand planning as coping strategies, and lower rates of PTSD. Otherprotective coping styles included: the altruistic acceptance of work-re-lated risks (Wu et al., 2009), the ability to talk to someone about theirexperiences, and the presence of religious beliefs (Chan and Huak2004). Accordingly, Maunder et al. (2006) found that maladaptivecoping strategies, such as avoidance, hostile confrontation and self-blame, resulted in worse outcomes in terms of PTSS andSim et al. (2004) reported that less venting, humor and acceptance wereassociated to higher levels of PTSS. Consistently, positive coping stra-tegies, such as motivation to learning different skills, have been in-dicated as resilience factors also in HMWs dealing with the currentCOVID-19 pandemic (Kang et al., 2020).

3.5. HCWs survivors to coronavirus outbreaks

Five studies focusing on HCWs who survived the SARS infectionhighlighted this population as particularly “at risk” for PTSD.Kwek et al. (2006) in a sample of SARS survivors at 3 months post-discharge found that HCWs were more affected by PTSS than non-HCWs. Lee et al. (2007) examined a sample of 96 Hong Kong SARSsurvivors divided into sub-samples of HCWs and non-HCWs, found thatwhile PTSS levels were similar in the two sub-samples at the peak of theoutbreak, HCWs compared to non-HCWs, reported significantly higherPTSS one year after discharge, suggesting a lack of recovery as afunction of time, among HCW SARS survivors. In line with this, a laterstudy among 233 Chinese SARS survivors also reported a higher risk ofPTSD among HCW compared to non-HCW (Wing and Leung, 2012).Furthermore, a study conducted on a sample of 90 Hong Kong SARSsurvivors at 30 months after the outbreak (Mak et al., 2010) showedthat being a HCW was significantly associated with PTSD development,despite the authors hypothesizing that this finding could be gender-biased because the majority of the sample was made up of femaleHCWs. Finally, Ho et al. (2005) in 97 HCWs in Hong Kong found apositive correlation between the presence of pronounced SARS-relatedfears and PTSS burden, particularly intrusion symptoms; in additionHCWs who had recovered from SARS appeared to be more concernedabout death, discrimination and quarantine than those who had notbeen infected.

4. Discussion

To the best of our knowledge we conducted the first review ad-dressing PTSD and PTSS risk and resilience factors in HCWs who wereinvolved in the three major recent Coronavirus outbreaks, namely theSARS, the MERS and the current COVID-19, which have affected theworldwide population in the last two decades. Converging data suggesta high risk for PTSD development among emergency HCWs, with stu-dies consistently outlining several risk factors that are enhanced in thecase of these highly lethal outbreaks, such as: the frequent unpredict-ability of daily caseloads, having to frequently manage patients andtheir families’ expectations in unexpected critical cases/situations(Mealer et al., 2009; Czaja et al., 2012; Iranmanesh et al., 2013;Fjeldheim et al., 2014). In the context of an outbreak emergency such asthe COVID-19 crisis, difficulties are further heightened by the rapidlyincreasing flow of critical patients requiring increased medical atten-tion, the decision-making burden and high daily fatality rates, and theconstant updates of hospital procedures following advances in knowl-edge about the disease, that creates another burden for HCWs who needto keep up to date. Further, patients medical management requires tightphysical isolation, to protect patients and HCWs because of the ex-tremely high risk of contamination (Petrie et al., 2018; Berger et al.,2012; Brooks et al., 2019). Occupational role, marital status, age andgender, quarantine, stigma, previous psychiatric disorders, isolationand being survivors of the same outbreak also emerged as robust riskfactors for PTSS. In parallel, the literature highlighted a number ofresilience factors, such as support, training, prompt work organizationand good coping strategies.

The majority of studies included in our review focused on the 2003SARS outbreak; fewer data were available on the MERS, and the studieson COVID-19 are only emerging at the time of writing. All these studiesreported a high risk for adverse psychological reactions, particularlyPTSS and PTSD among HCWs, suggesting the proximity to “ground zero”as a primary risk factor (Kwek et al., 2006; Lee et al., 2018). HCWs’ fearof contagion and infection of their family, friends and colleagues,feelings of uncertainty, stigmatization and rejection in their neighbor-hood because of their hospital work were also reported. Studies alsoreported the reluctance to work and/or considering quitting their job,as well as high levels of stress, anxiety and depression symptoms, whichcould have long-term psychological implications (Maunder et al., 2003;

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Bai et al., 2004; Lee et al., 2007; Wu et al., 2009). The self-perceivedhigh risk for contagion might be the most important aspect related tothe front-line activities, with for example Su et al. (2007), failing to findany significant difference between HCWs in SARS vs. non-SARS units inPTSD prevalence rate. This suggests that not only HCWs working withinthe SARS units, but also those working outside them and facing un-certainty because of the displacement, might develop PTSS during theoutbreak. In this regard, in the ongoing COVID-19 pandemic, the lack ofpersonal protection devices represents a critical issue.

Interestingly, however, some authors found first-line exposure tohave a protective effect. Styra et al. (2008) reported that HCWs workingin SARS high risk units, as expected, experienced greater distress thanHCWs displaced in other departments such as the psychiatric one, butcontrary to expectations HCWs caring for many SARS patients whileworking in high-risk units emerged as being less distressed. This findingsuggests that experience in treating SARS patients may be a mediatingfactor that could be amenable to intervention in future outbreaks. Thisis in line with more recent findings from a COVID-19 study, accordingto which PTSS severity of non-front-line nurses was greater than that offront-line nurses, who showed stronger psychological endurance. Theauthors argue that this finding may be explained considering that front-line nurses were voluntarily selected and provided with sufficientpsychological preparation. Moreover, the selected front-line nurseswere mainly middle-level backbone staff with working experience andpsychological capacity (Li et al., 2020).

Hence, there is evidence that perceived adequacy of training re-presents a protective factor against adverse outcomes of traumatic ex-posure (Maunder et al., 2006; Lancee et al., 2008). Similarly, otherfactors concerning positive working organization, such as working instructured units, a sense of protection of environment (Maunder et al.,2006; Su et al., 2007) and clear communication of directives and ofprecautionary measures (Chan and Huak, 2004), have proven to beprotective factors against the development of PTSS in HCWs. In parti-cular, Chan and Huak (2004) explored the important role in preventingPTSS of clear and prompt communication of directives and informationabout the disease, of providing precautionary measures, such as Per-sonal Protective Equipment (PPE), and of the support of a supervisor/head of department, colleagues and family. The support from familyand friends as well as that from supervisors and colleagues has beenshown to represent an important resilience factor against the develop-ment of PTSS, as widely demonstrated in the literature (Chan andHuak, 2004; Maunder et al., 2006; Su et al., 2007; Lancee et al., 2008).Nevertheless, this matter deserves further consideration since in thispeculiar clinical setting the implications of the contagion risk often leadto self-isolation, with subsequent decreased social support.

Some important individual risk and resilience factors for PTSS havealso been reported among HCWs facing a coronavirus outbreak. First,female gender. Despite the fact that the majority of the studies corro-borate the preventive role of professional training as to PTSD onset upto the point of flattening of the gender gap which is commonly observedin PTSD reports, most of the studies on HCWs dealing with Coronavirusoutbreaks tend to show a higher incidence of PTSD among women.Females, in fact, were shown to be most affected by PTSS in three SARSstudies (Lee et al., 2007; Reynolds et al., 2007; Lai et al., 2020), as wellas younger HCWs or HCWs with fewer years of work experience(Reynolds et al., 2007; Lancee et al., 2008). Moreover, nurses proved tobe more affected by PTSS than other HCWs (Tham et al., 2004;Maunder et al., 2004). Although this has been explained as related tocloser contact with infected patients, we may also argue that often thenurse staff are mostly women. Further studies in this regard are thuswarranted. Outbreaks threatening family members’ well-being or af-fecting children's care, in fact, may constitute a burden for women(Carmassi et al., 2019). It is worthy of note that all these factors couldbe influenced by coping styles adopted by the HCWs to address thepsychic burden of the outbreak. Some studies focused on positivecoping styles that were associated to a better outcome (Phua et al.,

2005; Wu et al., 2009). Among these, Phua et al. (2005) found thatphysicians chose humor as a coping strategy more frequently thannurses, and this resulted in lower post-traumatic stress morbidity. Otherauthors stressed the effect of maladaptive coping styles in predictingPTSS, such as avoidance, hostile confrontation and self-blame(Maunder et al., 2006).

As previously highlighted, the sense of isolation was found to be animportant factor related to PTSS. Consequently, HCWs who had beenquarantined were shown to be at higher risk (Bai et al., 2004) as well asHCW survivors from the infection. These latter constitute a specialpopulation in which the impact of infectious disease, along with relatedfears for one's health and for the contagion of loved ones and the senseof isolation and the rejection due to the stigma, lead to a greater PTSSburden (Wing and Leung, 2012).

More recently, scientists, clinicians and the general public, in fact,have been increasingly referring to the current COVID-19 emergencyand its subsequent impact on health care systems, as the “9/11 of healthcare systems”. First studies reported high levels of psychopathologicalburden in HCWs dealing with the COVID-19 pandemic in China, in-cluding depression, anxiety, insomnia and PTSS (Huang et al., 2020;Kang et al., 2020; Lai et al., 2020). In particular, anxiety and PTSSsymptoms resulted higher in females, nurses and in HCWs with feweryears of work experience (Lai et al., 2020; Huang et al., 2020). HCWsare called to confront this new scenario under widespread media cov-erage and in a context of a persisting imbalance between needs andresources, increasing the decisional burden and the feelings of hope-lessness; they are also forced to deal with challenging expectations ofthe patients and their relatives in a framework characterized by unusualcommunicative constraints. Moreover, the fear of contagion is ampli-fied by the lack of personal protective equipment (PPE) and the highnumber of infected or deceased colleagues, and is associated to theconcern of representing a threat to family members: this often leads toself-isolation. As a consequence, loneliness, along with the risk of agrowing trend towards social stigmatization of HCWs as potential car-riers of infection (WHO, 2020) results in deprivation of social support,which is listed among the main factors of resilience.

Despite the slight decrease in the COVID-19 contagion rate, theimpact on HCWs mental health may produce enduring effects. Finally,some evidence revealed a significant time-effect on reducing PTSDsymptom ratings, as observed in a SARS study by Su et al. (2007), re-porting a 50% decrease after one month, no-one meeting the criteria forPTSD. Conversely, a MERS study by Lee et al. (2018) reported thatHCWs performing one month before MERS-related tasks were at higherrisk for symptoms of PTSD even after time had passed, and the risk wasincreased in sleep and numbness-related symptoms, in particular ifhome quarantine was implemented.

For all these reasons, providing a timely response to psychologicalpressure on HCWs in order to prevent negative mental health outcomesrequires the development of specific intervention strategies(Carmassi et al., 2020c). Such strategies cannot but be based on acareful survey of both risk and resilience factors that may be playing arole in this special working population and should take into accountwhat the studies conducted in the aftermath of the previous outbreaksreported.

When discussing our results some limitations should be considered.First, the lack of a quality assessment of the studies. Second, we con-sulted only one database for our search (PubMed). Third, most of theincluded articles (N = 16) adopted the Impact of Event Scale scores,which is a well-known rating scale that provides a subjective measureof perceived stress (Horowitz et al., 1979; Marziali and Pilkonis, 1986;Weiss et al., 1984), to detect PTSD or PTSS. Fourth, surveys give us alimited glimpse into a complex psychological dynamic that happenswith healthcare providers in isolation wards, because they rely on vo-luntary responses by the subjects, who may choose not to revisit atraumatic experience by participating in the survey, thus leading tounder-reporting the incidence of traumatic sequelae (Li et al., 2020).

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This is in line with Chen et al. (2020) who reported how the im-plementation of psychological intervention services in the COVID-19pandemic proved to be problematic, because medical staff were re-luctant to participate in the group or individual psychology interven-tions provided to them. Fifth, some studies reported that while quar-antined HCWs consistently showed more frequent adversepsychological impacts than non-HCWs, their experience was probablyinfluenced by their job-related experiences with SARS and not unique totheir HCW status (Reynolds et al., 2007). Finally, no information wasavailable on HCW family members, particularly on the possible impactof the presence of children as a possible PTSS risk factor(Carmassi et al., 2019).

We have examined studies carried out in the context of the threeCoronavirus outbreaks in order to outline PTSD and PTSS risk and re-silience factors impacting on HCWs and to consistently enhance theeffectiveness of intervention strategies. While the COVID-19 pandemicis straining healthcare systems all over the world, awareness of theimpact of the emergency on the HCWs’ mental health is rising, con-sistently with evidence of the high risk of them developing psycholo-gical distress, such as PTSD and PTSS, under similar circumstances. Todate, despite some recommendations released by international organi-zations (WHO, 2020; Inter-Agency Standing Committee (IASC) 2020;IFRC, 2020) and a variety of action proposals, a systematic approach isnot yet in place. Efficacious treatments for PTSD and PTSS exist(Lee and Bowles, 2020; Charney et al., 2018; Dell'Osso et al., 2015), andhealthcare systems should also focus on prepare to roll out thesetreatments among HCWs should prevention strategies fail to preventthe development of these conditions.

CRediT authorship contribution statement

Claudia Carmassi: Conceptualization, Methodology, Investigation,Writing – original draft, Writing – review & editing, Supervision.Claudia Foghi: Methodology, Investigation, Writing – original draft,Writing – review & editing. Valerio Dell'Oste: Conceptualization,Methodology, Investigation, Writing – original draft, Writing – review &editing. Annalisa Cordone: Investigation, Writing – original draft.Carlo Antonio Bertelloni: Investigation, Writing – original draft. EricBui: Conceptualization, Methodology, Writing – original draft, Writing -review & editing, Supervision. Liliana Dell'Osso: Conceptualization,Methodology, Writing – original draft, Supervision.

Declaration of Competing Interest

No conflict of interest. No disclosures to declare of any relationshipwith a commercial company that has a direct financial interest insubject matter or materials discussed in article or with a companymaking a competing product.

Financial support

This research did not receive any specific grant from fundingagencies in the public, commercial or not-for-profit sectors.

Ethical standards

Not applicable.

Acknowledgments

Dr. Julia Antonia Elizabeth Gray, native English speaker, revised theentire article.

Supplementary materials

Supplementary material associated with this article can be found, inthe online version, at doi:10.1016/j.psychres.2020.113312.

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