Post-traumatic stress symptoms among an Egyptian sample of post-remission COVID-19 survivors: prevalence and sociodemographic and clinical correlates

Background Given its global spread, the COVID-19 virus infection itself may be experienced as a traumatic and stressful event among survivors. The post-traumatic stress symptoms (PTSS) among those surviving the disease were under evaluated. This study aimed to identify and compare PTSS and associated correlates among COVID-19 survivors and control subjects. A cross-sectional design with a convenience sampling included a total of 85 adults who survived COVID-19 virus infection and 85 control subjects (matched for age, sex, education, and socioeconomic level) who were recruited from Zagazig University Hospitals, Sharkia Province, Egypt. The participants were interviewed using a semistructured demographic and clinical checklist, Structured Clinical Interview for DSM-5 Axis I Disorders (SCID-5), the Impact of Event Scale-Revised (IES-R), and the Hospital Anxiety Depression Scale (HADS). Results Approximately, 72% of COVID-19 survivors experienced moderate-to-severe PTSS (compared to 53% of control subjects). Individuals who survived the COVID-19 virus infection were more likely to have intensified hyperarousal symptoms (OR: 2.7, 95% CI: 1.7–4.4), with higher total IES-R scoring (OR: 1.03, 95% CI: 1.01–1.05). Among COVID-19 survivors, those who reported moderate-to-severe PTSS were likely to experience severe COVID-19 symptoms during their illness (OR: 4.1, 95% CI: 1.4–11.9). Conclusions PTSS was prevalent among COVID-19 survivors in Egypt. The hyperarousal symptoms were the most experienced ones. The symptom severity of COVID-19 virus infection predicted PTSS in COVID-19 survivors.


Background
Patients who experience post-traumatic stress symptoms (PTSS) live under the shadow of past traumatic accidents. According to the Diagnostic and Statistics of Mental Disorders, the fifth edition (DSM-5), the symptoms include persistence of intrusive thoughts, avoidance of trauma-related cues, and dysregulation in mood and cognitive functions with obvious changes in arousal level. These symptoms are associated and complicated with interpersonal and occupational dysfunctions [1]. In December 2019, a novel coronavirus disease  emerged in Wuhan, China, and by May 18, 2020, the outbreak has catastrophically spread resulting in around 5 million confirmed cases of COVID-19 affections worldwide [2]. With the increased COVID-19 related morbidity and mortality, individuals started to experience extensive illness-related fears, and higher levels of anxiety and depression, with increased susceptibility to physical and psychological distress [3,4].
The nature and severity of the traumatic event are considered the most robust predictor of PTSS during and after an epidemic. Most epidemiological studies stated that the survivors, followed by their families and health care providers, were more likely to experience PTSS [5]. Survivors of severe COVID-19 symptoms frequently suffer, during their illness, from intense respiratory symptoms which may progress to respiratory failure [6]. Moreover, patients may be subject to physical pain from interventions such as endotracheal intubation, and extreme stressors owing to fear of death from a fatal illness, inability to communicate, and feelings of loss of control. Survivors may be also traumatized after witnessing the death of their family members [7][8][9]. Therefore, surviving COVID-19 illness would represent near-death or fatal illness experiences, that would be sufficient to develop PTSS.
It is, also, claimed that most individuals diagnosed with COVID-19 have to isolate themselves, which is associated with the development of various psychological symptoms, including PTSS [10]. There are various stressors associated with isolation, which are associated with increased risk of developing psychological disturbances: (i) apprehensions about own health or fears of infecting their families; (ii) feelings of frustration, boredom, and a sense of isolation or even rejection from others; (iii) improper or inaccurate information from the official authorities regarding the nature and severity of the pandemic, or the instructions and actions to take; (iv) lack of basic resources like nutrition, clothes, or accommodation; and (v) financial and socioeconomic problems [10,11].
All these aforementioned factors seem to apply to the current pandemic. Therefore, determining the psychological impact of COVID-19, particularly PTSS, among individuals who survived the outbreak, would be an essential step for implementing early interventions, aiming to reduce the possibility of further irrational behaviors and helping those populations return to their normal life. So, this study aimed to identify and compare the PTSS and their associated correlates among individuals who survived the COVID-19 outbreak and their control counterparts.

Subjects and study design
This study was a comparative cross-sectional study. Data, utilized in this study, were collected by nonprobability convenience sampling method encompassing a total of 85 COVID-19 survivors who were consecutively enrolled according to the WHO discharge criteria adopted by the Zagazig University isolation hospitals, Zagazig City, Egypt. The inclusion criteria for the COVID-19 survivors included adults of both sexes who were previously diagnosed as COVID-19 positive ones according to their presenting symptoms, and their nasopharyngeal swab confirmed the presence of the offending viral nucleic acid. The COVID-19 survivors were interviewed provided that they were recovered from their COVID-19 infection, and at least one month had been elapsed since completeness of their home isolation or being discharged from hospitalization with stabilization of their general medical condition). An equal number of non-COVID-19 control subjects were also recruited. They were matched for age, sex, and educational level. They were first-degree relatives never diagnosed as positive COVID-19 patients and were chosen to differentiate between the shared environmental and genetic factors and the potential COVID-19-related effects on their mental health status. The sample size was calculated using Epi Info 6.0, at 80% power of the study, 95% confidence level [12]. Exclusion criteria for both groups included individuals younger than 18 or older than 60 years, those who had current comorbid physical or psychiatric disorders, illiterate, and those who refused to participate. All data were collected during the period from September 1 to November 29, 2020.

Data collection and measures
A semi-structured sheet was designed to collect relevant demographic and clinical data from all participants. It encompassed questions about age, gender, marital status, residence, level of education, residence, occupation, and history of psychiatric and medical illnesses.

Structured Clinical Interview for DSM-5 Axis I Disorders (SCID-5)
It is a semi-structured interview utilized to help the examiner confirm or exclude the presence of current major primary mental illnesses [13]. Several studies had established the validity and reliability of this procedure [14,15].

Impact of Events Scale-Revised (IES-R)
It is a 22-item self-report tool utilized to measure the subjective distress associated with traumatic events [16]. The overall score was categorized into normal (0-17), PTSD-like symptoms (18)(19)(20)(21)(22)(23), and diagnosis of PTSD (above 24). Its three subscales, namely, intrusion, avoidance, and hyperarousal are closely representatives of the PTSD symptoms. A cut-off score of 2 or more, for each subscale, implies a moderate level of distress. An Arabic validated version of the IES-R scale was previously used among Egyptians from various populations (during the COVID-19 outbreak) [17]. In this study, the Arabic version with good validity and reliability was applied [18].

Hospital Anxiety and Depression scale (HADS)
Depressive and anxiety symptoms were considered as potential covariates in this study. HADS is a self-report rating scale used for assessing the associated symptoms of anxiety and depression among participants [19]. It is comprised of 14 items (7 items for each subscale) on a 4-point Likert scale calculated from 0 to 3. The overall score for each subscale, representing the sum of each subscale's 7 items, ranges from 0 to 21. The Arabic version of this scale, utilized in this study, was previously examined for its reliability and validity [20], and previously applied among the Egyptian populations [4].

Statistical analyses
The collected data were analyzed using the Statistical Package for the Social Sciences software version 16.0. For categorical variables, the chi-square test was used, while the continuous variables were compared using the independent sample t test, and a nonparametric test (Mann-Whitney U) for data not normally distributed. To obtain odds ratios (OR) and 95% confidence intervals (CI) of PTSS among COVID-19 survivors and control subjects, the logistic regression analysis was used to adjust for associated anxiety and depressive symptoms. All results were statistically significant when their significant probability was less than 5% (p < 0.05).

Discussion
The current study would be one of the few and earliest studies, if any, to present data on the post-discharge mental health consequences of the COVID-19 outbreak among survivors. Data from previous outbreaks, including severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS), would explain the increased likelihood of psychiatric symptoms and disorders in COVID-19 survivors [5,21,22].
The main finding in this study is that the majority of COVID-19 survivors experienced PTSS. Moreover, compared to the control subjects, the COVID-19 survivors were more likely to suffer from avoidance, intrusion, and hyperarousal symptoms. These findings were consistent with the results from previous outbreak studies. For example, 42% and 27% of MERS survivors experienced symptoms of PTSD at 1 year and 18 months after the outbreak, respectively [23]. Similarly, previous studies found that PTSD symptoms were reported in nearly 39% and 25% of SARS survivors at 12 months and 30 months after discharge, respectively [24,25].
The results for COVID-19 survivors are much higher than those for control subjects and even for SARS and MERS survivors. These findings would be attributed to several reasons. First, the nature of the COVID-19 virus, being more contagious, with lack of specific antiviral drugs with definite efficacy, and floods of misleading information result in widespread extensive fears and horrors with increased propensity to develop PTSS [26][27][28]. Second, the separation from family members and close friends is possibly associated with feelings of loneliness and helplessness [29]. Third, the financial burden of the COVID-19 epidemic can add to psychological distress [30].
It would be, however, claimed that the potential neuro-immunological attributes of the COVID-19 virus itself might have additional effects, so that the survivors' psychological symptoms, as the findings in this study found, would exceed those of normal people sharing the   neurovirulent properties of the virus itself, neuroinflammation, the increased numbers of severe COVID-19 patients who are older adults, and ICU-related causes such as oversedation, prolonged isolation, and interventions like endotracheal intubation and mechanical ventilation [34,35]. In this study, following logistic regression analysis, the only variable that would predict the severity of PTSS was the history of COVID-19 symptom severity in COVID-19 survivors. Consistent with this finding, Patel and his colleagues found that PTSS had been developed in ICU survivors [36]. In Wuhan, where the COVID-19 outbreak first raised, nearly 3% of COVID-19 patients were intubated with invasive ventilation [37]. Invasive ventilation and prolonged mechanical ventilation were found to be associated with an increased risk for PTSS [38]. Also, it was documented that once the physical illness itself had been more severe, the mental health was more negatively affected [39]. It was claimed that severe complications of the medical illnesses with direct and serious threats to life, with the resultant hospitalization associated with comprehensive medical or invasive interventions to maintain or restore vital functions, would increase the likelihood of developing PTSD symptoms [40,41].
Finally, despite being lower than that of COVID-19 survivors, the prevalence of moderate-to-severe PTSD symptoms among control subjects, in the current study, was unpredictably high (53%). The control subjects were never hospitalized nor infected with the COVID-19 virus. However, this finding would be explained as those individuals would be subject to a various array of stressors like social restrictions and isolation, financial troubles related to the lockdown regulations, or even worries and fears of being infected themselves or their close relatives and beloved persons, which would have a negative impact on their psychological well-being and quality of life [3,4].

Limitations
There are few limitations to this study. First, the COVID-19 survivors were selected from only Zagazig University hospitals. Despite being the largest general hospitals, which were serving the populations in Sharkia Province, but the present findings would not be readily generalized to all COVID-19 survivors of Egypt. Future studies need to include subjects from various governorates so that they will be more representative of the Egyptian population. Second, the main outcome in this study, PTSS, was measured by a self-rating scale with the liability of response bias. Third, it was a crosssectional study, so interpretation for causality cannot be established. Nonetheless, this study would be one of the earliest studies to reveal the post-remission psychiatric outcomes of COVID-19 survivors in Egypt.

Funding
This research did not receive financial support from any funding agencies.

Availability of data and materials
The datasets utilized in this study are available from the corresponding author upon reasonable request.

Declarations
Ethics approval and consent to participate The Institutional Research Review Board (IRB) of Zagazig college of Medicine and Zagazig Hospitals Administration had approved this study (no. 6304-2-9-2020). All procedures were conducted following the ethical guidelines outlined in the Declaration of Helsinki and its amendments. After explaining the