PTSD symptoms among health workers and public service providers during the COVID-19 outbreak.

In the frontline of the pandemic stand healthcare workers and public service providers, occupations which have proven to be associated with increased mental health problems during pandemic crises. This cross-sectional, survey-based study collected data from 1773 healthcare workers and public service providers throughout Norway between March 31, 2020 and April 7, 2020, which encompasses a timeframe where all non-pharmacological interventions (NPIs) were held constant. Post-traumatic stress disorder (PTSD), anxiety and depression were assessed by the Norwegian version of the PTSD checklist (PCL-5), General Anxiety Disorder -7, and Patient Health Questionnaire-9 (PHQ-9), respectively. Health anxiety and specific predictors were assessed with specific items. Multiple regression analysis was used for predictor analysis. A total of 28.9% of the sample had clinical or subclinical symptoms of PTSD, and 21.2% and 20.5% were above the established cut-offs for anxiety and depression. Those working directly in contrast to indirectly with COVID-19 patients had significantly higher PTSD symptoms. Worries about job and economy, negative metacognitions, burnout, health anxiety and emotional support were significantly associated with PTSD symptoms, after controlling for demographic variables and psychological symptoms. Health workers and public service providers are experiencing high levels of PTSD symptoms, anxiety and depression during the COVID-19 pandemic. Health workers working directly with COVID-19 patients have significantly higher levels of PTSD symptoms and depression compared to those working indirectly. Appropriate action to monitor and reduce PTSD, anxiety, and depression among these groups of individuals working in the frontline of pandemic with crucial societal roles should be taken immediately.

Introduction

The psychological and social consequences of the COVID-19 pandemic have a pervasive effect on current mental health [1-3]. In the frontline of the pandemic stand healthcare workers and public service providers, occupations which have proven to be associated with increased mental health problems during pandemic crises [4, 5]. In particular, these workers are vulnerable to developing post-traumatic stress disorder (PTSD) symptoms. PTSD is a mental health problem that affects people who are exposed to potentially traumatic episodes. Healthcare workers are exposed to increased danger of contamination, loss of patients, responsibility for difficult decisions on treatment retention, and disruption of normal supportive structures [1, 6].

PTSD symptoms are grouped into 4 clusters: re-experiencing, avoidance, negative cognitions and mood, and arousal, according to the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5). Most studies on PTSD report lifetime prevalence, which gives higher estimates of prevalence compared to point prevalence. In American and Canadian studies, with samples from the general adult population, the lifetime prevalence varies from 6.1% to 9.2% [7-10]. Estimates were, however, lower in a World Health Organization study reporting a lifetime prevalence of PTSD in upper-middle and lower-middle income countries of 2.3% and 2.1% [10].

The estimates of PTSD symptoms among healthcare workers are higher compared to the general population and range from 6–10% in a recent COVID-19 survey conducted in Singapore [11], 18% from nurses working in hospitals in general [12], and 20% from the Severe Acute Respiratory Syndrome (SARS) outbreak [13]. Thus, PTSD symptoms appear to be higher during pandemics compared to periods without extraordinary situations.

As reported in earlier pandemics including SARS and Middle East Respiratory Syndrome (MERS), working directly with infected persons has been associated with high levels of PTSD symptoms [14-16] and worry [17]. Thus, evidence from previous studies indicates that working closer and more intensively with COVID-19 patients is associated with higher mental distress.

What predicts the development of PTSD symptoms is another critical question. Meta-analyses [18, 19] and reviews [20, 21] have found that sociodemographic (i.e., female gender and young age) [18, 19], prior mental disorder such as anxiety and mood disorder [20, 21] and social support are associated with PTSD symptoms [18]. Other important predictors found in previous studies include worry [22, 23], burnout [24], interpersonal problems [25], and positive and negative metacognitive beliefs [26, 27]. Positive metacognitive beliefs exist about the usefulness of worry, rumination, threat monitoring and other coping strategies (i.e., “If I worry I will be prepared”). Negative metacognitive beliefs concern the uncontrollability of thoughts and perceived danger (i.e., “I cannot control my thoughts”). Positive and negative metacognitive beliefs give rise to a specific way of tackling emotional distress characterized by worry and rumination, which prolongs and intensifies distress [28].

Thus, a variety of possible predictors of PTSD symptoms exist, including static (sociodemographic) and state predictors, some of which are central to the treatment of PTSD (interpersonal problems, worry and metacognitions).

Research into the mental health consequences for frontline workers in the current ongoing pandemic is critically needed, especially public service providers, providing the basis for the development of adequate treatment and possible prevention of mental problems during the present as well as future pandemics, as recently reflected by multiple urgent calls in the literature [1–3, 29]. To date, no examination differentiating between individuals working directly with infected patients (health personnel) versus professionals working indirectly with pandemic consequences (politicians, social workers and other health personnel) has been conducted in any pandemic, leaving gaps in the literature concerning how these divergent groups differ in mental health outcomes during pandemics. This gap is crucial to fill, as it refines understanding of how different vulnerable professionals working directly versus indirect with pandemic consequences are impacted psychologically, providing the foundation for forthcoming interventions aimed at reducing these symptoms. As a pandemic involves a widespread burden on different labor forces with divergent impacts on each labor group given the tasks of different occupations, an investigation revealing the psychopathology levels of these understudied work forces will be imperative in order to protect them against detrimental mental health outcomes.

The present study aims to provide an assessment of the mental health burden of healthcare workers and public service providers working directly and indirectly with those infected with the COVID-19 virus. Directly is defined as face-to-face contact with patients that have tested positive for COVID-19. Indirectly is defined as working with other consequences of the COVID-19 pandemic, but not face-to-face with patients that is infected with COVID-19.

The following hypotheses were formulated:

H1: Health employees working directly with COVID-19 victims will have higher symptoms of PTSD, anxiety, depression, and health anxiety, compared to health workers and public service providers working indirectly with the virus.

Exploratory: Examine the differences in levels of PTSD symptoms, anxiety, depression and health anxiety among different subgroups of health workers and public service providers.

H2: Presence of a psychological disorder and more anxiety and depression symptoms will be associated with more PTSD symptoms.

H3: Less emotional support, more burnout, more health anxiety, more worries about job and economy, more interpersonal problems and stronger metacognitions will be associated with more PTSD symptoms controlling for direct vs. indirect exposure to trauma, pre-existing psychiatric diagnosis, anxiety and depression, and demographic variables (age and gender, living with a partner, living with children).

Materials and methods

Study design and recruitment procedure

The study has a cross-sectional survey design. Health personnel and public service providers were systematically targeted through various channels: First, a selection of those qualifying as healthcare workers and public service providers were randomly targeted on Facebook. The Facebook algorithm reaches a random sample of individuals including and above 18 years of age who have reported their labor to fit our target categories, such as nurses, doctors, psychologists, and other individuals working in the health-care system, in addition to those reported to be politicians and social workers. The algorithm is inherently designed to optimize for genuine human activity and uses a variety of methods to remove false and duplicate accounts from the selection algorithm. Upon taking the survey, these participants identify and register themselves through a platform referred to as Services for Sensitive Data (TSD), where their information is safely stored. With the imputed parameters, the algorithm reached a total of 12 113 individuals meeting the aforementioned criteria. Second, hospitals in Norway were reached out to systematically and health personnel were invited to participate. Third, the associations of all major health worker groups were contacted. Moreover, national TV, national, regional and local radio stations, and national, regional and local newspapers were used. Politicians were further systematically contacted, with all political parties sending an e-mail with the survey to their members. Participants were asked to fill out a set of validated questionnaires including demographic variables, psychological symptoms including symptoms of depression, anxiety and PTSD symptoms.

The period of data collection lasted seven days and was undertaken between March 31, 2020 and April 7, 2020, which encompasses a timeframe where all non-pharmacological interventions (NPIs) were held constant during the two weeks prior to data collection, as well as during the data collection week. NPIs are actions that people, and communities can take to help slow the spread pandemics, like the COVID-19. No information was given from the government about possible changes in any epidemic protocols during the data-collection, controlling for expectation effects.

Approval from the Regional Committee for Medical Research Ethics was received prior to commencement of study (reference number: 125510). Participants were allowed to terminate the survey at any time without any consequences. The study was pre-registered at ClinicalTrials.gov after data collection, but before any analysis (Identifier: NCT04374097) and is part of the Norwegian COVID-19, Mental Health and Adherence project. Articles from the same project, but with different topics, concerning the prevalence of anxiety and depression [30], loneliness [31] and parental stress [32] are under consideration for publication.

Participants

Participants eligible for participation were individuals > 18 years of age, who have provided their consent to participate in the survey. The participants were either health personnel or public service providers working directly or indirectly with COVID-19 patients. The following groups of health personnel were assessed: Medical doctors, nurses, clinical psychologist and other health workers (not specified). The following group of public service providers working with consequences of the COVID-19 pandemic were assessed and grouped: social workers, politicians and other professions (not specified).

The target sample size of 1900 participants was determined using a conservative recommendation of a sample size ten times larger than the estimated parameters for multivariate analysis [33].

Outcomes and covariates

The following measure were used in the current study:

PTSD checklist for DSM-5 (PCL-5) were used to measure PTSD symptoms (0–80), which had an α = 0.94 in the current sample [34]. The participants were asked about the most distressing event from the COVID-19 period. The DSM-5 diagnostic guidelines were applied to the PCL-5 to categorize participants as fulfilling the PTSD symptom criteria or not [34].

Participants indicating scores of 2 or above on at least one of five re-experiencing symptoms, one of two avoidance symptoms, two of seven symptoms of negative alterations in cognition and mood and two of six arousal symptoms were classified as fulfilling the PTSD symptom criteria (maximum of 6). Subclinical PTSD was defined as those who had at least 4 criteria fulfilled, with a diagnostic score in at least two symptom clusters of PTSD. This is in accordance with the recommendation in the literature of two to three DSM-5 criteria in symptom clusters fulfilled [35].

General Anxiety Disorder -7 (GAD-7) was used to measure anxiety (0–21) and had a Cronbach α = 0.87 in this sample [36]. Patient Health Questionnaire-9 (PHQ-9) was used to measure depression (0–27), α = 0.86 [37]. For GAD-7 the scores were classified as; normal (0–4), mild (5–7), moderate (8–14) and severe (15–21). For the PHQ-9 scores; normal (0–4), mild (5–9), moderate (10–14) and moderately severe (15–19) and severe (20–27). These cut-offs have been well established in the literature [36-38].

Four items were combined into the subscale positive metacognition, α = 0.62, and four items were combined into the subscale negative metacognition, α = 0.69, from the Cognitive Attentional Syndrome Scale-1 (CAS-1) [39]. Seventeen items from the Inventory of interpersonal problems (IIP) [40] were combined into the scale interpersonal problems, α = 0.81. Four variables that measure health anxiety and fear of death related to COVID-19 represented health anxiety, α = 0.77. Furthermore, two items were combined to represent worries about work and economy, α = 0.72. Three items were combined to measure emotional support, α = 0.79. Burnout was measured through a single item, “I feel burned out”. See S1 File for an overview of all the different items. The demographic data assessed were gender (male, female, transgender), type of occupation (doctors, nurses, clinical psychologists, social workers, politicians and other health workers), age (18–24, 25–44, 45–59, >60), marital status, living with children and education level.

Statistical methods

There were no missing data, because the online survey system included mandatory fields of response. However, in analyses involving gender, transgendered (N = 1) and intersexed individuals (N = 1), there were too few individuals to be included. First, as the variables were highly left skewed, the level of PTSD symptoms, anxiety, depression, and health anxiety between those that worked directly with Covid-19 patients and indirectly was compared using the Mann-Whitney U test. Second, the different groups was compared using the Kruskal-Wallis test. Third, two multiple regression analyses with PTSD symptoms as the dependent variable was performed. The first with anxiety, depression, and pre-existing psychiatric diagnosis as predictors. The second assessed predictors of trauma symptoms such as worry, health anxiety, burnout, emotional support, interpersonal problems and positive and negative metacognitions, after controlling for confounders.

In all regression analyses, multicollinearity and other assumptions were checked; in particular if the multicollinearity assumption was violated (if VIF < 5 and Tolerance < 0.2) [41]. Given the large sample size, a more conservative significance criteria of .01 was pre-defined. Furthermore, part correlation which is the correlation between the outcome and the aspect of the predictor unique from all the other predictors, was reported. Thus, the part correlation makes it possible to investigate the relative strengths of the predictors. The strength of the correlation was evaluated according to the following criteria: small = >0.10, medium = >0.30, large = >0.50 [42].

The current sample was matched with the general population of health personnel to ensure that the sample accurately reflected the characteristics of this group. In this population, 15.5% are men and 84% women, and 41.5% are below 39 years of age [43]. In the current sample 84.7% were women and 15.2% were men. However, the sample was somewhat younger than the population, and consequently a sensitivity analysis was performed where the data were stratified for the right percentages of age. The sensitivity analysis yielded identical results to the main analyses, indicating the robustness of the sampling strategy and the presented findings. All analyses were performed using SPSS statistical software version 26.0 [44].

Results and discussion

Demographic characteristics

In this epidemiological investigation, 1773 participants were included. Of the participants 178 [10.0%] were medical doctors, 770 [43.4%] were nurses, 244 clinical psychologists [13.7%], and 78 other health workers [4.4%]. Public service providers included social workers (158 [8.9%]), politicians (37 [2.1%]) and other professions (308 [17.4%]). Most of the participants were women (1507 [84.7%]), and had as expected higher education from university (1593 [89.8%], were in married or in a civil union (1193 [67.3%]) and had children (908 [51.2%]), as shown in Table 1.

Table 1

Demographics and characteristics of the sample.

Variable	Frequency, n (%)
Gender
Male	269 (15.2)
Female	1502 (84.7)
Intersex/transgender	2 (0.01)
Age
18–24	242 (13.6)
25–44	1054 (59.4)
45–59	377 (21.2)
>60	100 (5.6)
Presence of psychological disorder
No	1547 (87.3)
Yes	226 (12.7)
Higher education
No	180 (10.1)
University	1593 (89.8)
Married /Civil union
Yes	1193 (67.3)
No	580 (32.7)
Children
Yes	908 (51.2)
No	865 (48.7)

Level of PTSD symptoms, anxiety and depression

The levels of PTSD symptoms, anxiety, depression and health anxiety among health personnel and public service providers were high. A total of 28.9% of the sample had clinical or subclinical symptoms of PTSD. Furthermore, 21.2% had moderate to severe symptoms of depression and 20.5% had moderate to severe symptoms of anxiety using established cut-offs, as presented in Table 2.

Table 2

Cut off scores on PTSD symptoms, anxiety and depression.

Scale	Total sample	Working position		Sex
Severity category		Direct	Indirect	Men	Women
PCL-5, Diagnostic criteria PTSD
Non-clinical	1261 (71.1)	189 (63.4)	1072 (72.7)	215 (79.9)	1044 (69.5)
Subclinical	305 (17.2)	67 (22.5)	238 (16.1)	38 (14.1)	267 (17.8)
PTSD	207 (11.7)	42 (14.1)	165 (11.2)	16 (5.9)	191 (12.7)
PHQ-9, depression symptoms
Normal	774 (43.7)	106 (35.6)	668 (45.3)	159 (59.1)	613 (40.8)
Mild	624 (35.2)	114 (38.3)	510 (34.6)	84 (31.2)	540 (36.0)
Moderate	237 (13.4)	46 (15.4)	191 (12.9)	16 (5.9)	221 (14.7)
Moderate severe	96 (5.4)	24 (8.1)	72 (4.9)	5 (1.9)	91 (6.1)
Severe	42 (2.4)	8 (2.7)	34 (2.3)	5 (1.9)	37 (2.5)
GAD-7, anxiety symptoms
Normal	963 (54.3)	152 (51.0)	811 (55.0)	189 (70.3)	773 (51.5)
Mild	446 (25.2)	75 (25.2)	371 (25.2)	49 (18.2)	396 (26.4)
Moderate	286 (16.1)	53 (17.8)	233 (15.8)	22 (8.2)	264 (17.6)
Severe	78 (4.4)	18 (6.0)	60 (4.1)	9 (3.3)	69 (4.6)

Note: PCL-5 used 31> as a cut-off for PTSD. Diagnostic criterion was based on DSM-5. Percentages in parenthesis.

Of those working directly with Covid-19 patients 36.5% had clinical or subclinical symptoms of PTSD in contrast to 27.3% for those working indirectly (see Table 2). A Mann-Whitney U test showed that those working directly in contrast to indirectly with COVID-19 patients had significantly higher PTSD symptoms, U (Ndirect = 298, Nindirect = 1475) = 183267, z = -4.62, p = <0.001, and significantly higher depression scores U (Ndirect = 298, Nindirect = 1475) = 194446, z = -3.15, p = 0.002. However, there were no significant differences between direct vs. indirect on anxiety U (Ndirect = 298, Nindirect = 1475) = 207628, z = -1.51, p = 0.130 and health anxiety, U (Ndirect = 298, Nindirect = 1475) = 212156, z = -0.97, p = 0.345.

Levels of PTSD symptoms among subgroups

Politicians, social workers, and nurses had the highest levels of PTSD symptoms (Table 3). A Kruskal-Wallis H test showed that there was a statistically significant difference in PTSD scores between the different worker groups, χ2 (6) = 130.3, p = <0.001. There were also significant differences between the groups on anxiety χ2 (6) = 54.6, p = <0.001 and depression scores, χ2 (6) = 103.0, p = <0.001, with nurses, social workers and other health workers having the highest levels of symptoms.

Table 3

Scores of post-traumatic symptoms, anxiety, depression and health anxiety in total sample and subgroups.

Sample	PCL-5 Median (IQR)	GAD-7 Median (IQR)	PHQ-9 Median (IQR)	Health anxiety Median (IQR)
Total sample (N = 1773)	8 (2.0–19.0)	4 (2.0–7.0)	5 (3.0–9.0)	1 (0–3.0)
Direct Covid-19 (n = 298)	11 (4.0–26.3)	4 (2.0–7.0)	6 (3.0–10.0)	1 (0.8–3.0)
Indirect Covid-19 (n = 1475)	8 (2.0–18.0)	4 (2.0–7.0)	5 (3.0–9.0)	1 (0–3.0)
Medical doctors (n = 178)	5 (1.0–14.0)	3 (1.0–6.0)	3 (2.0–6.0)	1 (0–2.0)
Nurses (n = 770)	10 (3.0–24.0)	5 (2.0–8.0)	6 (3.0–10.0)	2 (1.0–3.0)
Clinical Psychologists (n = 244)	3 (0–8.0)	3 (1.0–6.0)	4 (2.0–6.0)	1 (0–2.0)
Social workers (n = 158)	11 (4.0–23.0)	5 (2.0–7.0)	6 (4.0–11.0)	2 (1.0–3.0)
Politicians (n = 37)	14 (3.5–24.5)	3 (1.0–7.5)	5 (3.0–8.0)	2 (0–4.5)
Other health workers (n = 78)	9 (4.8–20.3)	5 (2.0–7.0)	6 (3.0–9.0)	2 (1.0–3.0)
Other (n = 308)	8 (2.3–18.8)	4 (2.0–7.0)	5 (3.0–9.0)	1 (0–3.0)

Note: Other included health personnel working in other sectors or public service providers not working as social workers.

Anxiety and depression as a predictor of PTSD symptoms

A pre-existing psychiatric diagnosis (p = 0.002, part correlation = 0.05), higher anxiety (p = <0.001, part correlation = 0.25) and higher depression (p = <0.001, part correlation = 0.23) was, as hypothesized, associated with higher PTSD symptoms (Table 4).

Table 4

Anxiety, depression, and diagnosis as predictor for PTSD symptoms.

	Unstandardized regression coefficient	Standard Error	T-value	p	Part
Predictors of PTSD symptoms (PCL-5), N = 1773, Adjusted R2 = 0.47
Intercept	0.34	0.39	0.86	.392
Diagnosis	2.32	0.76	3.03	.002	0.05
Anxiety	1.19	0.08	14.21	< .001	0.25
Depression	0.96	0.07	13.21	< .001	0.23

Other predictors of PTSD symptoms

Worries about job and economy (p = <0.001, part correlation = 0.07), negative metacognitions (p = <0.001, part correlation = 0.09), burnout (p = 0.001, part correlation = 0.05) and health anxiety (p = <0.001, part correlation = 0.10), and emotional support (p = 0.007, part correlation = -0.04 were significantly associated with PTSD symptoms. After controlling for demographic variables, anxiety and depression, and working directly vs. indirect with Covid-19 patients, interpersonal problems (p = 0.015, part correlation = 0.04), and positive metacognitions (p = 0.011, part correlation = 0.04) were not associated with PTSD symptoms, as reported in Table 5.

Table 5

Risk factors for PTSD symptoms identified by multiple regression analysis.

	Unstandardized regression coefficient	Standard Error	T-value	p	Part
Predictors of PTSD symptoms (PCL-5), N = 1771, Adjusted R2 = 0.53
Intercept	-4.66	1.55	-3.01	< .001
Indirect vs. direct	2.28	0.60	3.79	< .001	0.06
Diagnosis	1.22	0.73	1.67	.095	0.03
Age category	1.73	0.32	5.44	< .001	0.09
Gender	-1.13	0.64	-1.76	.079	-0.03
Relationship	0.30	0.52	0.58	.564	<0.01
Children	-1.18	0.49	-2.37	.018	-0.04
Depression	0.67	0.08	8.23	< .001	0.14
Anxiety	0.76	0.09	8.48	< .001	0.14
Emotional support	-0.33	0.12	-2.71	.007	-0.04
Worry job/eco.	0.76	0.18	4.32	< .001	0.07
Health anxiety	0.69	0.12	5.80	< .001	0.10
Burnout	1.02	0.31	3.27	.002	0.05
Interpersonal prob.	0.08	0.03	2.43	.015	0.04
Metacog. pos	0.008	0.003	2.55	.011	0.04
Metacog. neg	0.020	0.004	5.41	< .001	0.09

Discussion

The current epidemiological investigation, among 1773 health personnel and public service providers, reveals a high point-prevalence of PTSD symptoms (28.9%), anxiety (20.5%) and depression (21.2%). The results demonstrate levels of PTSD that have been reported among health personnel in other surveys, but are considerably higher than a recent COVID-19 study from Singapore [11-15]. However, exact comparisons are made difficult by the fact that some of the other studies have used different measures and not consistently reported sub-clinical symptoms. The current study used PCL-5, which fully aligns to DSM-V criteria. However, in a recent study, PTSD symptoms among health-workers in India and Singapore during the COVID-19 outbreak the prevalence-rate of 9.3% experiencing PTSD-symptoms, were lower than in the current study [45]. There could be several reasons for differences in prevalence-rates between countries and firm conclusions are hampered by the use of different measures to assess PTSD symptoms. It is suggested, however, that that some western countries have higher risk of PTSD because there are high expectations for risk-fee life and high attention to potential harmful mental health effects of serious life events [46].

Health personnel and public service providers working directly with COVID-19 patients reported more severe symptoms of PTSD and depression. The results mirror the findings in similar COVID-19 studies from China [6] and other pandemics [4, 5], where health workers working in the frontline of pandemics reported higher levels of distress. A large proportion of the respondents had subclinical PTSD symptoms, 22.5% of those working directly and 16.1% of those working indirectly. Those having subclinical symptoms are vulnerable to developing clinical PTSD, especially because the work situation will constantly pose challenges and stressful incidents. Hence, working directly or indirectly with COVID-19 patients should be regarded as a risk factor for developing PTSD symptoms, thus underlining the importance of monitoring the subclinical symptoms among individuals working with COVID-19 patients. Moreover, the findings revealed that occupations other than nurses and medical doctors are also highly affected by the pandemic, especially social workers, other health workers and politicians.

Predictors of PTSD are of importance to identify those who may be at risk of developing PTSD. Having a pre-existing psychiatric diagnosis, higher levels of anxiety, and depression symptoms were associated with more PTSD symptoms, which is in accordance with previous findings in the literature [21]. Thus, anxiety and depression symptoms may be a source of vulnerability to developing PTSD symptoms during pandemics. Among state predictors relevant as possible targets for intervention, worries about job and economy were significant, highlighting the importance of these worry themes in association with PTSD symptoms. Worry is a central maintaining factor in psychopathology [28]. Thus, governments may try to take specific actions to reduce worries during pandemics, which may be achieved by providing accurate information about viral transmission chains, and reducing uncertainty about jobs and the economy if possible. A recent study on the COVID-19 pandemic revealed the beneficial impact of sufficient information on depression and anxiety [30]. Health anxiety was also significantly associated with PTSD symptoms, which may indicate the importance of also addressing worry about health.

Burnout was positively associated with PTSD symptoms. Previous findings have revealed that health workers have high levels of stress [47] which may lead to burnout, highlighting the importance of investigating the associations between stress, burnout and PTSD symptoms.

Negative metacognitions, but not positive, predicted PTSD symptoms, which is in accordance with the previous literature [27, 28]. The patients’ negative thoughts about their own thinking, such as “I cannot control my thinking” are an important variable related to PTSD symptoms. Reducing dysfunctional metacognitions and increasing participants’ ability to reduce worry and rumination may therefore be an important asset during pandemics, and negative metacognitions should be further investigated as a possible treatment-target [28].

Interpersonal problems was not significantly associated with PTSD symptoms, however emotional support was, but the part correlations were low, which is not in accordance with the hypothesis as outlined [18, 25]. The numerous significant predictors show that there may be many routes to reducing PTSD symptoms among health workers and public service providers. However, health anxiety, anxiety and depression had clinically relevant effect sizes = >0.1 as measured by part correlation. The other predictors had smaller effect sizes, which may be less relevant in terms of clinical significance.

Protecting government officials and politicians against symptoms of anxiety and depression are imperative, as these disorders are associated with reduced cognitive capacities [48], which may lead to unfavorable consequences in pandemics where the pressure to make decision is already high given the intensity of pandemic incidents. Similarly, doctors and nurses often have to make decisions about life and death, decisions requiring cognitive capacities which may be burdened by symptoms of depression and anxiety. Similarly public service providers are of critical importance during a pandemic, and care must be to ensure that they receive the best treatment possible.

As requested in several papers, some form of psychological first aid could be needed to help healthcare workers [2, 29]. Specific action on negative metacognition, worry, anxiety, and depression may be a pathway forward to reducing PTSD symptoms. However, studies with repeated measurements are needed to assess temporal precedence, which is important for identifying causal relations and inform treatments.

Strengths and limitations

Strengths of this study include that it captured the effects of NPIs momentarily as they happened and were held constant during the measurement period. Given that the NIPs were globally implemented, the results in this study is probably generalizable to other countries. Limitations include that burnout was measured by only one item, making it prone to measurement error. The sample was cross-sectional which precludes conclusions about causality. The group public service providers had lack of diversity consisting of only social workers and politicians reducing the possibility to generalize across this group. The sample was somewhat biased on age. However, the main findings were replicated with a sensitivity analysis of a randomly selected subset of individuals with demographic characteristics accurately matching population parameters, further attesting to the robustness of the presented results.

Conclusions

Health workers and public service providers have markedly high levels of PTSD symptoms, anxiety and depression during the COVID-19 pandemic. Those working directly with COVID-19 patients have significantly higher levels of PTSD symptoms and depression compared to those working indirectly. These increases in symptoms are markedly higher than estimates from pre-pandemic populations, suggesting that this issue may be a major cause for concern. Special care should be taken to assess the level of PTSD symptoms among both health personnel and public service providers in the forthcoming period. Appropriate action to monitor and reduce PTSD, anxiety, and depression among these groups of individuals working in the frontline of pandemic with crucial societal roles should be taken immediately.

Overview of questionnaires and items.

(DOCX)

Click here for additional data file.

24 Jul 2020

PONE-D-20-19419

PTSD-symptoms Among Health Workers and Public Service Providers During the COVID-19 Outbreak

PLOS ONE

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An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

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We look forward to receiving your revised manuscript.

Kind regards,

Kristin Vickers, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

Dear Dr. Johnson,

Thank you for submitting your timely research (“PTSD-symptoms Among Health Workers and Public Service Providers During the COVID-19 Outbreak”) to PLoS ONE. The submission received three thoughtful reviews yielding three different decisions (Accept, Minor Revision and Major Revision). After carefully considering the reviews, and my own thoughts, I am making a decision of Minor Revision. This decision to me reflects the essence of the reviewers' comments. Specifically, all reviewers noted strengths of this work, but varied in the extent to which they had suggestions for revision. The Major Revision decision (Reviewer 3) includes important suggestions, but addressing the feedback of Reviewer 3 will not require extensive re-writing or numerous data analyses. Even the reviewer who offered an Accept decision did pose a suggestion (to make the data more available if possible).

I will not repeat all of the reviewers' comments here, but ask you to attend carefully to each suggestion. In your revision, please explain how the comments were addressed. If you decide not to action a particular comment, please explain why. Two of the three reviewers (Reviewers 2 and 3) both asked about the availability of the data. I understand the grave importance of following the ethics board's rules, but data availability is extremely important. If you would please consider finding a way to enable access to the de-identified data without restriction (after consultation with the ethics board), that would be appreciated. Please note the limitations that Reviewers 1 and 3 each suggested, as well as the additional information that each felt would be important to include. I look forward to receiving your revision. Thank you again for submitting this research to PLos ONE.

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2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

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We will update your Data Availability statement on your behalf to reflect the information you provide.

3. Please upload a copy of the Supporting Information which you refer to in your text on page 8.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors present findings from a large cohort size, reporting the prevalence of PTSD symptoms amongst their cohort. This manuscript may not be novel, but it does add to the body of literature to help understand the psychological impact of covid both in Norway and Globally. The overall methodology and analyses is robust. A few minor amendments is suggested.

1. In discussion, please attempt to compare PTSD symptom prevalence to other countries and discuss accordingly: e.g. Chew NW, Lee GK, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain, behavior, and immunity. 2020 Apr 21.

---Although other papers may use different instruments to measure PTSD and this is an inherent limitation.

--did factors like case volume in the country, healthcare resources strain, mortality rate play a role?

2. one major limitation is that it is a cross-sectional study. we are unsure how much of this is related to covid directly, or may have been pre-existing prior to covid. the authors should include this as a limitation. further longitudinal study in a similar cohort can also be used to assess the long-term PTSD impact once the pandemic blows over.

Reviewer #2: The authors present a timely examination of PTSD, depression, and anxiety in relation to COVID-19 pandemic in a large sample of healthcare providers out of Norway. While this is a large study with self-report data, the timeliness of the topic combined with efficient and well-done study design (in choice of measures, etc.) make this manuscript a useful contribution to the literature as we try to figure out what needs to be done to reduce the mental health impacts of the current pandemic.

Introduction is concise and well written to support the design.

Methods are good and results clearly presented.

Discussion is well reasoned, sticks to the results presented and provides a key contribution to the literature.

Given the journal requirements to provide data or a rationale why data cannot be provided, I believe additional rationale beyond ethics needs to be provided, but that is my only hesitation.

Reviewer #3: Thank you for the opportunity to review this manuscript. The authors conducted a timely examination of self-reported symptoms for front-line workers during the current global pandemic. The novelty of examining public service workers is unique to the study, but not as distinguished in both the methodology nor discussion. Rather, the study methodologies, in particular, the recruitment of target populations was not supported by, or in line with the strong theoretical rationale. Below, I outline some of my thoughts.

Background and introduction:

1. Background is well-written, with strong rationale in conducting this research.

Methods:

1. Some clarifications are needed as there seems to be a disconnect between the background rationale and study methodology. While the examination of healthcare and public service providers are clear from the background and rationale, the exact recruitment and populations reached are not. For example, which groups were considered healthcare professional – those working in ER/COVID units? Nurses in long-term homes? What about other healthcare professionals, and particularly for elective procedures, like mental health professionals, family physician, physiotherapists, pharmacists, etc.

2. Similarly, for public service professionals, what is considered "public service"? What about essential workers such as bus drivers, grocery store clerks, who likely have less protection compared to healthcare professionals, earn a lower wage, and are still required to work during the pandemic? Are they factored into your recruitment strategy?

3. The recruitment strategy is missing some details. For example, what did the Facebook algorithm determine for health personnel and public service providers, and who were the politicians reached?

4. For public service providers, there was only options for social workers and politicians. This is not reflective of the diversity of public service providers nor exhaustive enough to draw conclusions from.

5. Demographic variables did not consider contact and exposure to covid-19, which may be central to this line of research.

6. Please clarify experimental groupings and rationale. Which groups/professions were considered healthcare workers vs. public service workers. These were not mentioned until demographic characteristics in the results section.

7. I was not able to locate the supplementary file for the single item measure of burnout. How was this construct quantified/operationalized? If it’s a single item, please insert item right into text.

Results:

1. Unclear about direct vs indirect work relationships with COVID-19 from both methodology and results. How was this operationalized, was frequency of contact, size of hospital/healthcare institution, presence of outbreaks, and other variables considered?

2. Please fix "other predictors of treatment outcome". This is a cross-sectional inferential analysis, no treatment was offered.

Discussion:

1. Given the focus of the discussion on distinctions between public service vs. healthcare professionals, it is important to clearly operationalize and provide clear details about recruitment strategies and conditions for inclusion/exclusion.

2. With small proportion of public service professionals sampled, and lack of clarify regarding the types and diversity of profession, I caution the authors in drawing such strong conclusions from data collected. Would recommend to highlight as a limitation in data interpretations.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

27 Aug 2020

Response to Reviewers

PONE-D-20-19419

PTSD-symptoms Among Health Workers and Public Service Providers During the COVID-19 Outbreak

We would like to thank the reviewers and editorial team for their comments on the paper, which gave us the opportunity to make improvements in the manuscript. Detailed responses to reviewers’ comments are given for each point separately. Each response is identified by the number of the reviewers and the number of the comment. Our responses are given below the comment.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

The PLOS ONE style requirements have been revisited, and the paper should currently meet these requirements.

2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

As requested by the editor I have been in contact with NSD and REK.

The present dataset includes information about specific behaviors, trait variables, and health outcomes of a large and representative sample of the adults. In accordance with the guidelines of The Centre for Research Data (NSD) and The Regional Committee for Medical and Health Research Ethics (REK), access to the data can only be provided to qualified investigators whose proposed use of the data have been approved by all relevant independent review committees in the conducted countries of the study, including REK and NSD, and whose research plans provide a defensible proposal and methodologically sound design with the aims approved by REK, NSD, the university ethics board, and other necessary organizations that require an application process for providing access to sensitive data containing predictive information on a large and representative sample of the adult population in the sample country.

The main reasons for the constrain on the use of the data is the following. First, free use of the data, even in anonymized form, is not mentioned in the letter of informed consent, which is a prerequisite for the study. Second, the deposit of anonymized data, on an international server is not allowed according the ethical board based on our informed consent. However as specified, the data can be requested from the first author following ethical approval of access to the data from NSD and REK. REK and NSD does not handle request for the use of data on behalf of the author.

We suggest the following data availability statement which is in accordance with other papers from Norway published in PLOS ONE:

Suggestion for Data Availability Statement:

Our ethical approval granted by the Regional Committees for Medical and Health Research Ethics in Norway does not allow us to submit the data to a Public repository. In line with the ethics approval, the data are to be kept at a secure server only accessible by the authors at the University of Oslo. Access to the data can be granted from the first author following ethical approval of suggested project plan for the use of data from NSD and REK. Such requests are to be sent to Associate Professor, Sverre Urnes Johnson, Department of Psychology, University of Oslo, Forskningsveien 3 A, 0373 Oslo, Norway, Email: s.u.johnson@psykologi.uio.no, phone: +47-22845295

3. Please upload a copy of the Supporting Information which you refer to in your text on page

A copy of the supplementary material encompassing all the different items used in the study is now uploaded.

Reviewer #1:

The authors present findings from a large cohort size, reporting the prevalence of PTSD symptoms amongst their cohort. This manuscript may not be novel, but it does add to the body of literature to help understand the psychological impact of covid both in Norway and Globally. The overall methodology and analyses is robust. A few minor amendments is suggested.

1. In discussion, please attempt to compare PTSD symptom prevalence to other countries and discuss accordingly: e.g. Chew NW, Lee GK, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain, behavior, and immunity. 2020 Apr 21.

The paper by Chew et al is included in the revised manuscript.

The results from the current paper is discussed in comparison with other studies, including the study from Chew et al: See page 12: “However in a recent study, PTSD symptoms among health-workers in India and Singapore during the COVID-19 outbreak the prevalence-rate of 9.3% experiencing PTSD-symptoms, were lower than in the current study [43]. There could be several reasons for differences in prevalence-rates between countries and firm conclusions are hampered by the use of different measures to assess PTSD symptoms. It is suggested, however, that that some western countries have higher risk of PTSD because there are high expectations for risk-fee life and high attention to potential harmful mental health effects of serious life events [44]”.

-Although other papers may use different instruments to measure PTSD and this is an inherent limitation.

This is a clear limitation, and is mentioned in the discussion, see page 12.

--did factors like case volume in the country, healthcare resources strain, mortality rate play a role?

Thank you for a good suggestion. Norway did not have extraordinary many deaths related to Covid-19 and normally you would expect that more strain on healthcare resources and higher mortality rate would be associated with higher PTSD-symptoms, but this does not seem to be the case. India have for example higher mortality rate compared to Norway (https://coronavirus.jhu.edu/data/mortality). Thus, the paper by Heir et al about possible higher prevalence of PTSD in the certain western populations is relevant and mentioned in the discussion (page 12).

2. one major limitation is that it is a cross-sectional study. we are unsure how much of this is related to covid directly, or may have been pre-existing prior to covid. the authors should include this as a limitation. further longitudinal study in a similar cohort can also be used to assess the long-term PTSD impact once the pandemic blows over.

We have highlighted that the cross-sectional methodology hinders causal conclusion, see page 15. Further longitudinal studies of the same cohort are planned.

Reviewer #2: The authors present a timely examination of PTSD, depression, and anxiety in relation to COVID-19 pandemic in a large sample of healthcare providers out of Norway. While this is a large study with self-report data, the timeliness of the topic combined with efficient and well-done study design (in choice of measures, etc.) make this manuscript a useful contribution to the literature as we try to figure out what needs to be done to reduce the mental health impacts of the current pandemic.

Introduction is concise and well written to support the design.

Methods are good and results clearly presented.

Discussion is well reasoned, sticks to the results presented and provides a key contribution to the literature.

Thank you for the positive feedback.

Given the journal requirements to provide data or a rationale why data cannot be provided, I believe additional rationale beyond ethics needs to be provided, but that is my only hesitation.

The reason for unavailability of sharing through a deposit of anonymized data is given in the beginning of this document.

Reviewer #3: Thank you for the opportunity to review this manuscript. The authors conducted a timely examination of self-reported symptoms for front-line workers during the current global pandemic. The novelty of examining public service workers is unique to the study, but not as distinguished in both the methodology nor discussion. Rather, the study methodologies, in particular, the recruitment of target populations was not supported by, or in line with the strong theoretical rationale. Below, I outline some of my thoughts.

Background and introduction:

1. Background is well-written, with strong rationale in conducting this research.

Thank you

Methods:

1. Some clarifications are needed as there seems to be a disconnect between the background rationale and study methodology. While the examination of healthcare and public service providers are clear from the background and rationale, the exact recruitment and populations reached are not. For example, which groups were considered healthcare professional – those working in ER/COVID units? Nurses in long-term homes? What about other healthcare professionals, and particularly for elective procedures, like mental health professionals, family physician, physiotherapists, pharmacists, etc.

We have created at new paragraph, where we explain in further details the recruitment procedure. “The participants were either health personnel or public service providers working directly or indirectly with COVID-19 patients. The following groups of health personnel were assessed: Medical doctors, nurses, clinical psychologist and other health workers (not specified). The following group of public service providers working with consequences of the COVID-19 pandemic were assessed and grouped: social workers, politicians and other professions (not specified).”

As specified we did not assess the level of detail as the reviewer suggest, thus a category of “other” exist both for health personnel and public service providers.

2. Similarly, for public service professionals, what is considered "public service"? What about essential workers such as bus drivers, grocery store clerks, who likely have less protection compared to healthcare professionals, earn a lower wage, and are still required to work during the pandemic? Are they factored into your recruitment strategy?

Public service is a broad term, but in the questionnaire the work had to be related to consequences of the pandemic and those answering as public service providers worked indirectly with the consequences. However, the questionnaire was not detailed enough to separate between grocery store clerks, bus drivers etc. We have specified the term public service provider, see page 7: “The following group of public service providers working with consequences of the COVID-19 pandemic were assessed and grouped: social workers, politicians and other professions (not specified)”.

3. The recruitment strategy is missing some details. For example, what did the Facebook algorithm determine for health personnel and public service providers, and who were the politicians reached?

The Facebook algorithm reaches a random sample of individuals including and above 18 years of age who have reported their labor to fit our target categories, such as nurses, doctors, psychologists, and other individuals working in the health-care system, in addition to those reported to be politicians and social workers. The algorithm is inherently designed to optimize for genuine human activity and uses a variety of methods to remove false and duplicate accounts from the selection algorithm. Upon taking the survey, these participants identify and register themselves through a platform referred to as Services for Sensitive Data (TSD), where their information is safely stored. With the imputed parameters, the algorithm reached a total of 12 113 individuals meeting the aforementioned criteria.

4. For public service providers, there was only options for social workers and politicians. This is not reflective of the diversity of public service providers nor exhaustive enough to draw conclusions from.

This is a relevant point, and the lack of diversity of the construct “public service providers” is now mentioned as a limitation at page 15: “The group public service providers had lack of diversity consisting of only social workers and politicians reducing the possibility to generalize across this group.”

5. Demographic variables did not consider contact and exposure to covid-19, which may be central to this line of research.

We did have questions about contact and exposure to Covid-19 and whether the person was in quarantine, but we did not use the variables in this paper, because we think the variables are less central for the questions asked in this study and the variables were used in another publication:

Ebrahimi OV, Hoffart A, Johnson SU. The mental health impact of non-pharmacological interventions aimed at impeding viral transmission during the COVID-19 pandemic in a general adult population and the factors associated with adherence to these mitigation strategies. 2020, May 9. doi: https://doi.org/10.31234/osf.io/kjzsp.

6. Please clarify experimental groupings and rationale. Which groups/professions were considered healthcare workers vs. public service workers. These were not mentioned until demographic characteristics in the results section.

The groups are clarified and mentioned below the heading “participants”, see page 7:

“The participants were either health personnel or public service providers working directly or indirectly with COVID-19 patients. The following groups of health personnel were assessed: Medical doctors, nurses, clinical psychologist and other health workers (not specified). The following group of public service providers working with consequences of the COVID-19 pandemic were assessed and grouped: social workers, politicians and other professions (not specified).”

7. I was not able to locate the supplementary file for the single item measure of burnout. How was this construct quantified/operationalized? If it’s a single item, please insert item right into text.

A supplementary file consisting of all the questionnaires used in the study is uploaded. Furthermore, the single items “I feel burned out” is inserted in the text.

Results:

1. Unclear about direct vs indirect work relationships with COVID-19 from both methodology and results. How was this operationalized, was frequency of contact, size of hospital/healthcare institution, presence of outbreaks, and other variables considered?

As specified on page 5 at the end of the introduction:

Directly is defined as face-to-face contact with patients that have tested positive for COVID-19. Indirectly is defined as working with other consequences of the COVID-19 pandemic, but not face-to-face with patients that is infected with COVID-19.

2. Please fix "other predictors of treatment outcome". This is a cross-sectional inferential analysis, no treatment was offered.

The sentence is changed to “Other predictors of PTSD symptoms”.

Discussion:

1. Given the focus of the discussion on distinctions between public service vs. healthcare professionals, it is important to clearly operationalize and provide clear details about recruitment strategies and conditions for inclusion/exclusion.

We have tried to make the information about the two groups clearer throughout the manuscript.

2. With small proportion of public service professionals sampled, and lack of clarify regarding the types and diversity of profession, I caution the authors in drawing such strong conclusions from data collected. Would recommend to highlight as a limitation in data interpretations.

We have highlighted the heterogeneity of the group “public service providers” as a limitation, see page 15: “The group public service providers had lack of diversity consisting of only social workers and politicians reducing the possibility to generalize across this group.”

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

30 Sep 2020

PONE-D-20-19419R1

PTSD-symptoms Among Health Workers and Public Service Providers During the COVID-19 Outbreak

PLOS ONE

Dear Dr. Johnson,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by November 15, 2020. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Kristin Vickers, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

Dear Dr. Johnson,

Reviewers were very satisfied with your revisions; thank you for your efforts. The reason for the Minor Revision decision is that I need to ask you to clarify the extent to which there is overlap (if any) between this manuscript and the work by Ebrahimi et al. Specifically, in the Response to Reviewers document, the following is noted:

"We did have questions about contact and exposure to Covid-19 and whether the person was in quarantine, but we did not use the variables in this paper, because we think the variables are less central for the questions asked in this study and the variables were used in another publication:

Ebrahimi OV, Hoffart A, Johnson SU. The mental health impact of nonpharmacological interventions aimed at impeding viral transmission during the COVID-9 pandemic in a general adult population and the factors associated with adherence to these mitigation strategies. 2020, May 9. doi: " ext-link-type="uri" xlink:type="simple">https://doi.org/10.31234/osf.io/kjzsp."

PLOS ONE has guidelines when different publications are related. If there is no overlap between this manuscript and the other publication (Ebrahimi et al.), please let me know that. If there is any overlap, please follow the PLOS ONE guidelines at

https://journals.plos.org/plosone/s/submission-guidelines#loc-related-manuscripts

Specifically, upon your submission of your revised manuscript, please indicate whether there are any related manuscripts under consideration or published elsewhere. If related work has been submitted or published elsewhere, please include a copy of it with your revised manuscript and describe its relation to the submitted work. I will also ask that that the authors make it clear in the revised manuscript that results from a related dataset have been published previously or are under consideration for publication, if applicable.

Thank you for submitting your research to PLOS ONE and I look forward to receiving your revision. Please let me know if you have any questions.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have responded appropriately to the comments. I have no further comments, and I feel the manuscript is now suitable for publication.

Reviewer #2: All reviewer comments have been adequately addressed. The bypass was not working for me to bypass entering all fields.

Reviewer #3: The authors have addressed my feedback. This will make a timely contribution to our understanding of the literature surrounding global COVID19 responses.

**********

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Reviewer #1: No

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Reviewer #3: No

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5 Oct 2020

Revision letter 5.10.2020

PONE-D-20-19419

PTSD-symptoms Among Health Workers and Public Service Providers During the COVID-19 Outbreak

We would like to thank the reviewers and editorial team for their comments on related manuscripts. Detailed responses to editor comments (E) are given for each point separately, behind the letter A (authors).

E1: PLOS ONE has guidelines when different publications are related. If there is no overlap between this manuscript and the other publication (Ebrahimi et al.), please let me know that. If there is any overlap, please follow the PLOS ONE guidelines at

https://journals.plos.org/plosone/s/submission-guidelines#loc-related-manuscripts

A: It is unclear for the authors how PLOS ONE defines “overlap”, but for the sake of transparency we have given a statement about any potential overlap.

E2: Specifically, upon your submission of your revised manuscript, please indicate whether there are any related manuscripts under consideration or published elsewhere. If related work has been submitted or published elsewhere, please include a copy of it with your revised manuscript and describe its relation to the submitted work.

A2: We have included a copy of three separate papers from the same dataset which have been submitted for publication. We don`t think that there are any substantial overlap since the first, Ebrahimi et al, targets the general population for anxiety and depression, Hoffart et al., targets loneliness in the general population and Johnson et al., targets parental stress in the general population. However, the data from the same data-collection.

E3: I will also ask that that the authors make it clear in the revised manuscript that results from a related dataset have been published previously or are under consideration for publication, if applicable.

A3: In the revised manuscript the following information is added: “Articles from the same project, but with different topics, concerning the prevalence of anxiety and depression [30], loneliness [31]and parental stress [32] are under consideration for publication.”

Submitted filename: Response to Reviewers 5.10.2020.docx

Click here for additional data file.

8 Oct 2020

PTSD-symptoms Among Health Workers and Public Service Providers During the COVID-19 Outbreak

PONE-D-20-19419R2

Dear Dr. Johnson,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Kristin Vickers, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you to the authors for fully explaining the nature of the different papers coming from this project. I also appreciate that the authors re-did analyses. This is timely and important research.

14 Oct 2020

PONE-D-20-19419R2

PTSD symptoms among health workers and publicservice providers during the COVID-19 outbreak

Dear Dr. Johnson:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Kristin Vickers

Academic Editor

PLOS ONE