Finding an article in the general media regarding PTSD. That is look in magazines, websites, newspapers and find a human interest

Contents lists available at ScienceDirect

Psychiatry Research

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

Review article

PTSD symptoms in healthcare workers facing the three coronavirus outbreaks: 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, Italy b Department of Biotechnology Chemistry and Pharmacy, University of Siena, Siena, Italy c Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

A R T I C L E I N F O

Keywords: Corona Mental health Nurses Physicians Psychological distress Stress

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 on the 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 in the context of the three major Coronavirus outbreaks of the last two decades to investigate risk and resilience factors for PTSD and PTSS in HCWs. Nineteen studies on the SARS 2003 outbreak, two on the MERS 2012 outbreak and three on the COVID-19 ongoing outbreak were included. Some variables were found to be of particular relevance as risk factors as well as resilience factors, including exposure level, working role, years of work experience, social and work support, job organization, quarantine, age, gender, marital status, and coping styles. It will be critical to account for these factors when planning effective intervention strategies, to enhance the resilience and reduce the risk of adverse mental health outcomes among HCWs facing the current COVID-19 pandemic.

1. Introduction

The outbreak of Corona Virus Disease-19 (COVID) that emerged in December 2019 in Wuhan (China), quickly spread outside of China, leading the World Health Organization (WHO) Emergency Committee to 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 – was isolated by 7th January 2020, and belongs to the same viral family as the coronavirus syndrome (SARS-CoV) and the Middle East respiratory coronavirus syndrome (MERS-CoV). Both of these coronavirus-based respiratory 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 Corona Virus Disease-19 (COVID-19) has a greater transmission rate but a lower, though still significant, fatality rate (Peeri et al., 2020; Huang et al., 2020). To date, with more than 14 million infected worldwide 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 has been the focus of increasing attention, particularly in the aftermath of September 11 2001, terrorist attacks that shed light on the risks they are exposed to when operating in emergency settings, as they may be affected 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 officers repeatedly 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-related situations they are exposed to, that include: management of critical medical situations, caring for severely traumatized people, frequent witnessing 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.2020.113312 Received 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 2020 0165-1781/ © 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 10 to about 20% (Grevin, 1996; Clohessy and Ehlers, 1999; Robertson and Perry, 2010; DeLucia et al., 2019), with even higher PTSD rates (8% to 30%) 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 exposed to a traumatic event (Bonanno et al., 2007), several risk factors may compromise the effectiveness of adaptation, including prior psychiatric history, 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 to stress in a healthy way through which goals are achieved at a minimal psychological and physical cost (Epstein and Krasner, 2013), plays a key 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 more complex and challenging when applied in the context of an infectious epidemic. This statement is first supported by the fact that, as previous studies outlined, during epidemics a high percentage of HCWs, (up to 1 in 6 of those providing care to affected patients), develops significant stress symptoms (Lu et al., 2006; McAlonan et al., 2007) It is worth considering that in epidemic contexts HCWs are first in line facing the clinical challenges intrinsically linked to the course of the disease while under the constant personal threat of being infected or representing a source of infection.

The current COVID-19 pandemic is characterized by some relevant features that increase the risk for PTSD among HCWs addressing the emergency, such as the unprecedented numbers of critically ill patients, with an often unpredictable course of the disease, high mortality rates and lack of effective treatment, or treatment guidelines (Wang, 2020; Peeri et al., 2020). Thus, the burden of the current outbreak on healthcare providers deserves the closest attention, as it is extremely likely that health care workers involved in the diagnosis, treatment and care of patients with COVID-19 are at risk of developing psychological distress 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 review the studies investigating the potential risk and resilience factors for the development of PTSD symptoms in HCWs who faced the two major Coronavirus outbreaks that occurred worldwide in the last two decades, namely the SARS and the MERS, as well as the ongoing COVID-19 pandemic, 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 PubMed until 20th April 2020. No time limit was set in regard to the year of publication. 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 East Respiratory Syndrome OR MERS OR Corona Virus Disease 19 OR COVID-19 OR Coronavirus)”. Furthermore, relevant articles were ex- tracted from the references section of the manuscripts found in the initial 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 resilience factors for PTSD symptoms in HCWs facing the coronavirus outbreaks of SARS, MERS and COVID-19. Articles in print or published ahead of print were accepted. The exclusion criteria were: (a) studies involving general population samples that did not consider a sub-sample of HCWs; (b) studies examining other mental health symptoms but not PTSS; (c) studies assessing PTSS but not considering potential risk and resilience 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 the title and abstract. Any uncertainties about eligibility were clarified through 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 systematic reviews of randomized clinical trials, but that have also been used for other 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). The electronic database search returned 263 publications. Following a preliminary screening of the titles and abstracts, 47 articles were con- sidered of potential relevance, their eligibility was assessed by means of a full text examination. Twenty-four of these studies, published be- tween 2004 and 2020, were included in this review. The main reasons for study exclusion were: the absence of a HCW sample or sub-sample, the lack of data regarding PTSS and/or about possible risk or resilience factors related to psychopathology.

3.2. Characteristics of included studies

The key characteristics of the studies included are summarized in Table 1. All retrieved studies were published between January 2004 and April 2020. Nineteen studies were on the SARS 2003 outbreak, two on 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 all other 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 exposure Ten 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) highlighted the role of exposure level, such as working in high-risk wards or in front-line settings during the Coronavirus outbreaks, as the major risk factor for developing PTSS and PTSD. Particularly, they pointed out the relevance of perceived threat for health and life and the experienced feelings of vulnerability as mediating factors. Most of these studies re- ported on the 2003 SARS outbreak. Lin et al. (2007) showed higher rates of PTSD (21,7%) among 66 emergency department staff compared to 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 PTSS rates among respondents who worked in high-risk locations and per- ceived high SARS-related risks, beside an increased risk for subsequent alcohol abuse/dependence. This latter resulted significantly related with hyper-arousal symptoms. A further study in Toronto (Styra et al., 2008) confirmed the impact of operating in a high-risk unit, and first reported that caring for only one SARS patient was related to a higher risk than caring for multiple SARS patients. A recent study on 147 nurses who worked in MERS units during the outbreak found higher PTSD rates among emergency HCWs than among non-emergency ones (Jung et al., 2020). To date, two studies have explored this issue in the COVID-19 pandemic. Li et al. (2020) found among 526 nurses, that those who worked on the frontline appeared to be less prone to de- veloping PTSS compared to second-line ones; conversely Kang et al. (2020) in a large study on 994 HCWs in Wuhan reported the exposure 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 role Five studies, four on the SARS epidemic and one on the COVID-19

pandemic, highlighted the occupational role as a major risk factor for PTSD or PTSS in Coronavirus outbreaks. Maunder et al. (2004) found on a sample of 1557 HCWs collected in Toronto, higher PTSS rates among nurses and explained this finding by means of the longer contact and higher exposure to patients of the nursing staff. A study on 96 emergency 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) confirmed this finding in a sample of 99 HCWs. Finally, a most recent study on 1257 hospital physicians and nurses caring for COVID-19 patients reached the same conclusion (Lai et al., 2020).

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

pandemic reported that younger HCWs had a greater risk of developing PTSS (Sim et al., 2004; Su et al., 2007; Wu et al., 2009). From a wider perspective, further studies pointed out an association between fewer years 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 risk for the female HCWs, a previous study involving 1257 HCWs in a ter- tiary hospital affected by SARS found an increased risk of PTSS among males (Chong et al., 2004).

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

which referred to the SARS outbreaks and one to the current COVID-19 pandemic. Chan and Huak (2004) in a study on 661 HCWs in Singapore showed that those who were not married were more adversely affected than married ones. In contrast, a further study in Singapore (Sim et al., 2004) found a positive association between post-traumatic morbidities and 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 traumatization symptoms compared to unmarried HCWs (Li et al., 2020).

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

2004; Reynolds et al., 2007; Wu et al., 2009) and one on the MERS outbreak (Lee et al., 2018) consistently reported high levels of PTSS among HCWs who had been quarantined. More specifically, Bai et al. (2004) examining 338 HCWs in an East Taiwan hospital found that 5% of them suffered from acute stress disorder, with quarantine being the most frequently associated factor, and a further 20% felt stigmatized and rejected in their neighborhood because of their hospital work, with also 9% reporting reluctance to work and/or considering quitting their job. Similar findings emerged from a Canadian SARS study on 1057 subjects (Reynolds et al., 2007), in which quarantined HCWs reported more PTSS than non-HCWs quarantined individuals. Moreover, in a study on MERS outbreak, Lee et al. (2018) assessed PTSS experienced by 359 university HCWs who cared for infected patients, observing that quarantined HCWs had a higher risk of developing PTSS which persisted over time, particularly sleep and numbness-related symptoms. More in general, social isolation and separation from family was 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 disorders Three 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

T ab

le 1

M ai n ch

ar ac te ri st ic s of

in cl u d ed

st u d ie s.

St u d y

O u tb re ak

T yp

e Sa

m p le

P T SS

/P T SD

m ea su re s

M ai n ge

n er al

fi n d in gs

M ai n ri sk

an d re si li en

ce fa ct or s

B ai

et al . (2 0 0 4 )

SA R S

C ro ss -s ec ti on

al st u d y

5 5 7 h os p it al

st aff

m em

be rs

(H C W s n =

4 0 2 ; ad

m in is tr at iv e

p er so n n el

n =

1 5 5 )

SA R S- re la te d st re ss

re ac ti on

s qu

es ti on

n ai re

5 %

ac u te

st re ss

d is or d er ;

2 0 %

st ig m at iz ed

; an

d 9 %

re lu ct an

ce to

w or k or

co n si d er ed

re si gn

at io n

R is k fa ct or : qu

ar an

ti n e

C h an

an d H u ak

(2 0 0 4 )

SA R S

C ro ss -s ec ti on

al st u d y

6 6 1 H C W s (d oc

to rs

an d n u rs es )

Im p ac t of

E ve

n ts

Sc al e

2 0 %

IE S sc or e >

3 0 ;

2 7 %

p sy ch

ia tr ic

sy m p to m s (3 5 %

of d oc

to rs

an d 2 5 %

of n u rs es )

R es il ie n ce

fa ct or s:

Su p p or t fr om

fa m il y/

su p er vi so rs /c ol le ag

u es ; w or k or ga

n iz at io n

(c le ar

d ir ec ti ve

s/ p re ca u ti on

ar y m ea su re s

fr om

m an

ag em

en t)

C h on

g et

al . (2 0 0 4 )

SA R S

n at u ra li st ic ,

ob se rv at io n al

st u d y

1 2 5 7 h os p it al

st aff

m em

be rs

(n u rs es

n =

6 7 6 ; d oc

to rs

n =

1 3 9 ; h ea lt h ad

m in is tr at iv e

w or ke

rs n =

1 4 0 ; ot h er s

n =

3 0 2 )

Im p ac t of

E ve

n t Sc al e

IE S m ea n sc or e=

3 4 .8 ;

7 5 .3 %

p sy ch

ia tr ic

sy m p to m s (a n xi et y an

d w or ry in g,

d ep

re ss io n an

d in te rp er so n al

d iffi

cu lt ie s,

so m at ic

p ro bl em

s) in

th e in it ia l p h as e of

th e ou

tb re ak

R is k fa ct or s:

m al e;

te ch

n ic ia n s;

≤ 2 ye

ar s

w or k ex p er ie n ce ; le ve

l of

ex p os u re

M au

n d er

et al . (2 0 0 4 )

SA R S

cr os s- se ct io n al

st u d y

1 5 5 7 H C W s

Im p ac t of

E ve

n ts

Sc al e

H ig h er

Im p ac t of

E ve

n t Sc al e sc or es

ar e fo u n d in

n u rs es

an d H C W s h av

in g co

n ta ct

w it h SA

R S p at ie n ts .

R is k fa ct or s:

le ve

l of

ex p os u re ; n u rs es ;

p er ce iv ed

th re at

fo r th ei r h ea lt h ; so ci al

is ol at io n

Si m

et al . (2 0 0 4 )

SA R S

cr os s- se ct io n al

st u d y

2 7 7 H C W s

(d oc

to rs

n =

9 1 ;n

u rs es

n =

1 8 6 )

Im p ac t of

E ve

n ts

Sc al e

9 .4 %

P T SS

; 2 0 .6 %

p sy ch

ia tr ic

m or bi d it y

R is k fa ct or s:

yo u n ge

r ag

e, be

in g m ar ri ed

, p sy ch

ia tr ic

m or bi d it y,

le ss

ve n ti n g,

le ss

h u m or , an

d le ss

ac ce p ta n ce .

T h am

et al . (2 0 0 4 )

SA R S

cr os s- se ct io n al

st u d y

E m er ge

n cy

H C W s

(d oc

to rs

n =

3 8 ;

n u rs es

n =

5 8 )

Im p ac t of

E ve

n ts

Sc al e

IE S sc or e ≥

2 6 in

1 3 .2 %

d oc

to rs

an d 2 0 .7 %

n u rs es ;

G en

er al

H ea lt h Q u es ti on

n ai re -2 8 ≥

5 in

1 5 .8 %

d oc

to rs

an d 2 0 .7 %

n u rs es

R is k fa ct or s:

n u rs es

H o et

al . (2 0 0 5 )

SA R S

cr os s- se ct io n al

st u d y

8 2 H C W s n ot

in fe ct ed

an d

9 7 H C W s w h o re co

ve re d fr om

SA R S

Im p ac t of

E ve

n ts

Sc al e

(C h in es e ve

rs io n )

H C W s re co

ve re d re p or te d h ig h P T SS

in tr u si on

sy m p to m s

an d m or e co

n ce rn s ab

ou t ot h er

h ea lt h p ro bl em

s an

d d is cr im

in at io n .

H C W s n ot

in fe ct ed

h ad

st ro n ge

r fe ar

re la te d to

in fe ct io n

th an

H C W s re co

ve re d ; eq

u al

co n ce rn

ab ou

t in fe ct in g

ot h er s (e sp ec ia ll y fa m il y m em

be rs ) th an

be in g se lf –

in fe ct ed

em er ge

d

R is k fa ct or s:

be in g H C W s su rv iv or s

P h u a et

al . (2 0 0 5 )

SA R S

cr os s- se ct io n al

st u d y

9 9 H C V s

(d oc

to rs

n =

4 1 ; n u rs e n =

5 8 )

Im p ac t of

E ve

n ts

Sc al e

1 7 .7 %

IE S >

2 6 ;

R is k Fa

ct or : n u rs es

R es il ie n ce

fa ct or s:

p os it iv e co

p in g st yl es

(h u m or

an d p la n n in g)

K w ek

et al . (2 0 0 6 )

SA R S

cr os s- se ct io n al

st u d y

6 3 H C W s SA

R S su rv iv or s

Im p ac t of

E ve

n ts

Sc al e

4 1 %

sc or ed

in d ic at iv e of

P T SD

; 3 0 %

li ke

ly an

xi et y an

d d ep

re ss io n .

R is k fa ct or : be

in g H C W

su rv iv or s

M au

n d er

et al . (2 0 0 6 )

SA R S

cr os s- se ct io n al

st u d y

7 6 9 H C W s

(S A R S an

d n o- SA

R S u n it s)

Im p ac t of

E ve

n ts

Sc al e

SA R S u n it H C W s re p or te d h ig h er

P T SS

, bu

rn ou

t, an

d p sy ch

ol og

ic al

d is tr es s ra th er

th an

n o- SA

R S u n it H C W s.

SA R S u n it H C W s m or e re d u ce d p at ie n t

co n ta ct

an d w or k h ou

rs .

R is k fa ct or s:

m al ad

ap ti ve

co p in g st ra te gi es

(a vo

id an

ce , h os ti le

co n fr on

ta ti on

, an

d se lf –

bl am

e) .

R es il ie n ce

fa ct or s:

tr ai n in g,

Su p p or t fr om

fa m il y/

su p er vi so rs /c ol le ag

u es , w or k

or ga

n iz at io n

Le e et

al . (2 0 0 7 )

SA R S

co h or t st u d y

SA R S su rv iv or s (n on

–H C W s

n =

4 9 ; H C W s n =

3 0 )

Im p ac t of

E ve

n t Sc al e– R ev

is ed

P ar ti ci p an

ts w it h at

le as t m od

er at e P T SS

re p or te d 3 2 .2 %

In tr u si on

, 2 0 .0 %

A vo

id an

ce , an

d 2 2 .2 %

H yp

er ar ou

sa l.

H C W

SA R S su rv iv or s w er e m or e d is tr es se d th an

n on

–H C W

on e ye

ar af te r th e ou

tb re ak

.

R is k fa ct or s:

be in g H C W

su rv iv or s.

Li n et

al . (2 0 0 7 )

SA R S

cr os s- se ct io n al

st u d y

6 6 em

er ge

n cy

H C W s an

d 2 6 n o-

em er ge

n cy

H C W s

D av

id so n T ra u m a Sc al e- C h in es e

ve rs io n (D

T S- C )

E m er ge

n cy

H C W s re p or te d >

D T S- C sc or es

th an

n o-

em er ge

n cy

H C W s; 2 1 ,7 %

em er ge

n cy

H C W s an

d 1 3 %

n o-

em er ge

n cy

H C W s re p or te d D T S- C > 4 0 (s u sp ec te d P T SD

).

R is k fa ct or : le ve

l of

ex p os u re

R ey

n ol d s et

al . (2 0 0 7 )

SA R S

cr os s- se ct io n al

st u d y

1 0 5 7 qu

ar an

ti n ed

su bj ec ts

(H C W s n =

2 6 9 )

Im p ac t of

E ve

n ts

Sc al e – R ev

is ed

1 4 .6 %

IE S- R ≥

2 0 ; qu

ar an

ti n ed

H C W s ex p er ie n ce d

gr ea te r P T SS

th an

qu ar an

ti n ed

n o- H C W s

R is k fa ct or s:

qu ar an

ti n e

Su et

al . (2 0 0 7 )

SA R S

p ro sp ec ti ve

an d

p er io d ic

fo ll ow

-u p

st u d y

1 0 2 H C W s (7 0 SA

R S an

d 3 2 n o-

SA R S H C W s)

D av

id so n T ra u m a Sc al e- C h in es e

ve rs io n (D

T S- C )

SA R S u n it H C W s re p or te d h ig h er

D ep

re ss io n (3 8 .5 %

vs .

3 .1 % ) in so m n ia

(3 7 %

vs . 9 .7 % ) an

d P T SS

(3 3 %

vs .

1 8 .7 % , bu

t n ot

si gn

ifi ca n t) .

R is k fa ct or s:

le ve

l of

ex p os u re

La n ce e et

al . (2 0 0 8 )

SA R S

cr os s- se ct io n al

st u d y

1 3 9 h os p it al

st aff

(H C W s

n =

1 0 3 ; cl er ic al

st aff

n =

1 3 ;

O th er

n =

2 1 )

St ru ct u re d C li n ic al

In te rv ie w

fo r

D SM

-I V ; C li n ic ia n -A d m in is te re d

P T SD

Sc al e

3 0 %

li fe ti m e p re va

le n ce

of d ep

re ss iv e,

an xi et y,

or su bs ta n ce

u se

d ia gn

os is .

5 %

n ew

p sy ch

ia tr ic

d is or d er s af te r ou

tb re ak

R is k fa ct or s:

p re vi ou

s p sy ch

ia tr ic

d is or d er ,

< ye

ar s of

w or k ex p er ie n ce

(c on

ti nu

ed on

ne xt

pa ge )

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

4

T ab

le 1 (c on

ti nu

ed )

St u d y

O u tb re ak

T yp

e Sa

m p le

P T SS

/P T SD

m ea su re s

M ai n ge

n er al

fi n d in gs

M ai n ri sk

an d re si li en

ce fa ct or s

R es il ie n ce

fa ct or s:

tr ai n in g an

d su p er vi so r/

co ll ea gu

es su p p or t.

St yr a et

al . (2 0 0 8 )

SA R S

cr os s- se ct io n al

st u d y

SA R S u n it s H C W s (n

= 1 6 0 ) an

d n o- SA

R S u n it s H C W s (n

= 8 8 )

Im p ac t of

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n t Sc al e—

R ev

is ed

H C W s ta ki n g ca re

of on

ly on

e SA

R S p at ie n t h ad

h ig h er

P T SS

le ve

ls th an

th os e ta ki n g ca re

of n on

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m or e th an

tw o SA

R S p at ie n ts

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