Understanding the mental health impacts of COVID-19 through a trauma lens.

This special issue of the European Journal of Psychotraumatology (EJPT) presents the first studies published by EJPT on COVID-19. We present 26 qualitative and quantitative studies assessing the prevalence of trauma-related symptoms and psychopathology within specific vulnerable populations such as health-care workers, students, children, and managers, or more broadly at a country level with a diverse set of outcomes including post-traumatic stress, moral injury, grief and post-traumatic growth. Intervention studies focus on whether telehealth delivery of mental health therapy in the pandemic environment was useful and effective. It is clear that the pandemic has brought with it a rise in trauma exposure and consequently impacted on trauma-related mental health. While for many individuals, COVID-19-related events met criteria for a DSM-5 Criterion A event, challenges remain in disentangling trauma exposure from stress, anxiety, and other phenomena. It is important to determine the contexts in which a trauma lens makes a useful contribution to understanding the mental health impacts of COVID-19 and the ways in which this may facilitate recovery. The papers included in this Special Issue provide an important and much-needed evidence-based foundation for developing trauma-informed understanding and responses to the pandemic.

Introduction

When the first-reported cases of a mysterious illness were coming out of China, no-one could have predicted what this meant for the trauma field. As it became evident that we were dealing with a global pandemic, there was a rush to conduct mental health research. Systematic reviews of previous epidemics such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) prepared us for what to expect (Serrano-Ripoll et al., 2020) while early reviews of COVID-19 specific data told us that posttraumatic stress symptoms were high in various populations (Luo, Chua, Xiong, Ho, & Ho, 2020; Vindegaard & Benros, 2020). However, in the early days of COVID-19, it was important for the trauma field to establish whether a trauma lens was useful to explain some of the mental health findings, to better understand risk and resilience in the COVID-19 context, and potentially to help inform which interventions might be useful. In some situations, there was a direct case for applying a trauma lens because certain events met DSM-5 Criterion A (American Psychiatric Association, 2013). These included surviving the COVID-19 illness or sudden death of loved ones. However, in much of the early research, the assumption that COVID-19 equated to trauma was not clearly established.

Once COVID-19 was recognized as a global pandemic, it became clear that COVID-19 was both a national and global disaster, and this recognition meant the trauma field was well-placed to contribute to the research and practice narrative. A quick search of Pub-Med shows that in the past two years there have been many thousands of publications taking a post-traumatic stress lens to the COVID-19 pandemic. As such, it is a good time to reflect on how a trauma lens advances our understanding of the sequelae of this pandemic.

In July 2020, the European Society for Traumatic Stress Studies (ESTSS) published a position paper on trauma-informed responses to address the mental health consequences of COVID-19. (Javakhishvili et al., 2020) A Special Issue of EJPT was announced as a way to promote dissemination of knowledge and experience on a large scale.

In this issue

This EJPT COVID-19 Special Issue is a collection of research conducted over the first 18 months of the pandemic, and tracks the development of research as it happened in real time. This research is summarized in Table 1. Initially, we started publishing commentary (n = 3) and literature reviews (n = 1). This was followed by cross-sectional research (n = 16), research protocols (n = 1), and eventually longitudinal (n = 2) and intervention research (n = 3). Publications within this special issue have been grouped into two themes. The first theme covers prevalence of trauma-related symptoms and psychopathology within specific vulnerable populations such as health care workers, students, children, managers, or more broadly at a country level. This research utilizes different methodologies including both qualitative and quantitative techniques and covers a diverse set of outcomes including post-traumatic stress, moral injury, grief and post-traumatic growth. The second theme is related to interventions. These studies focus on whether the pivot to telehealth when delivering mental health therapy in the pandemic environment was useful and effective.

Table 1.

A brief description of the COVID-19 studies in this special edition of the European Journal of Psychotraumatology

Commentary
Graf-Vlachy, L., Sun, S., Zhang, S. (in press) Predictors of managers’ mental health during the COVID-19 pandemic.	This letter to the editor found that Managers’ ‘illegitimate tasks’ caused by COVID-19 was associated with anxiety, distress and depression. Graf-Vlachy et al., 2020
Gersons, B. P., Smid, G. E., Smit, A. S., Kazlauskas, E., & McFarlane, A. (2020). Can a ‘second disaster’ during and after the COVID-19 pandemic be mitigated?	This commentary presents lessons from past disasters suggesting that communities and their leaders, as well as mental healthcare providers, need to pay attention to fear regarding the ongoing threat, as well as sadness and grief, and to provide hope to mitigate social disruption. (Gersons, Smid, Smit, Kazlauskas, & McFarlane, 2020)
Denckla, C. A., Gelaye, B., Orlinsky, L., & Koenen, K. C. (2020). REACH for mental health in the COVID19 pandemic: an urgent call for public health action.	This comment piece proposes a mental health equivalent to the World Health Organization’s ‘Do the Five’ concept, and describe the ‘REACH for Mental Health’ public health measure launched at the Harvard T.H. Chan School of Public Health.(Denckla, Gelaye, Orlinsky, & Koenen, 2020)
Literature Review
Allan, S., Bealey, r., Birch, J., Cushing, T., Parke, S., Sergi, G., Bloomfield, M., & Meiser-Stedman, R. (2020) The prevalence of common and stress-related mental health disorders in healthcare workers based in pandemic-affected hospitals: a rapid systematic review and meta-analysis, European Journal of Psychotraumatology, 11:1.	This systematic review examined the impact on Health Care Workers working in hospital where pandemic affected patients are treated. Most of the studies related to SARS and found that posttraumatic stress and general psychological distress were elevated, and this is maintained over time. (Allan et al., 2020)
Cross-sectional Studies
Chen, C., Tang., S. (in press) Profiles of grief, post-traumatic stress, and post-traumatic growth among people bereaved due to COVID-19.	This study investigated the mental health of people bereaved due to COVID-19. Using latent profile analysis the authors found four classes with the majority of participants falling in a moderate or high symptom class. Those who lost someone younger, lost a partner or shared a close relationship with the deceased were most vulnerable to high symptoms. (Chen & Tang, Chen and Tang, 2021)
Pat-Horenczyk, R., Bergman, Y., M, Schiff., et. al., (in press). COVID-19 related difficulties and perceived coping among university and college students: The moderating role of media-related exposure and stress.	This study found a positive associations between COVID-19-related difficulties, media exposure, media-related stress, and decreased level of perceived coping with the pandemic. (Pat-Horenczyk et al., 2021)
Vasileva, M., Alisic, E., De Young, A. (in press) COVID-19 Unmasked: Preschool children’s negative thoughts and worries during the COVID-19 pandemic in Australia.	This qualitative study found that caregivers indicated that preschool children had difficulties understanding causality and overestimated the risk of COVID-19 infection. Caregivers observed their children’s preoccupation with COVID-19 and worries in conversations, play and drawings as well as in behavioural changes – increased arousal, cautiousness, avoidance and attachment-seeking behaviour.(Vasileva, Alisic, & De Young, 2021)
McGlinchey, E., Hitch, C., Butter, S., McCaughey, L., Berry, E., Armour, A. (in press). Understanding the lived experiences of Healthcare Professionals during the COVID-19 Pandemic: An Interpretative phenomenological analysis.	This qualitative study found three themes. Theme one centred on specific challenges of HCPs working during the pandemic, such as redeployment, and isolation from loved ones. Theme two focused on mental health symptoms including experienced feelings of fear, sadness and hypervigilance, all also demonstrated a marked resilience. Finally, many healthcare professionals felt undervalued and misunderstood. (McGlinchey et al., 2021)
Sun, R., Qi, J., Huang, J., Zhou, X. (in press). Network analysis of PTSD in college students across different areas after the COVID-19 epidemic.	This network analysis found that although there were some similarities, in general, different PTSD symptom networks existed depending on the intensity of COVID-19 exposure. (Sun, Qi, Huang, & Zhou, 2021)
Maftei, A., Holman, A. (in press). The prevalence of exposure to potentially morally injurious events among physicians during the COVID-19 pandemic.	This study found half of participants reported exposure to potentially morally injurious events although this was not associated with type of medical unit physicians worked in (COVID-19 or non-COVID-19), nor their specialization and medical experience.(Maftei & Holman, 2021)
Greene, T., Harju-Seppanen, J., Adeniji, M., Steel, C., Grey, N., Brewin, C., Bloomfield, M., Billings, J. (in press) Predictors and rates of PTSD, depression and anxiety in UK frontline health and social care workers during COVID-19.	This study found high rates of clinically significant mental disorder in frontline health and social care workers. Participants who were concerned about infecting others, who could not talk with their managers if there were not coping, who reported feeling stigmatized and who had not had reliable access to personal protective equipment (PPE) were more likely to meet criteria for a clinically significant mental disorder. (Greene et al., 2021)
Ikizer, G., Nuray Karanci, A., Gul, E., Dilekler, I. (in press) Posttraumatic stress, growth, and depreciation during the COVID-19 pandemic: Evidence from Turkey.	This study found that financial loss during the pandemic, more frequent social media use to follow COVID-related news and posts, and longer time spent at home during the pandemic were associated with higher levels of posttraumatic stress. (Ikizer, Karanci, Gul, & Dilekler, 2021)
Ju, Y., Liu, J., Ng, R., Liu, B., Wang, M., Chen, w., Huang, M., Yang, A., Shu, K., Zhou, Y., Zhang, L., Liao, M., Liu, J., Zhang, y. (in press). Prevalence and predictors of PTSD in patients with cured COVID-19 one month post-discharge.	This study found that PTSD was commonly seen in patients with COVID-19 one month post-discharge (36%). Female patients, patients with lower educational levels, patients with higher anxiety levels and lower perceptions of emotional support during hospitalization might be more likely to develop PTSD in the near future. (Ju et al., 2021)
Olff, M., Primasari, I., Qing, Y., Coimbra, B. M., Hovnanyan, A., Grace, E., … & Consortium, T. G. C. (2021). Mental health responses to COVID-19 around the world.	This study found that events related to COVID-19 were associated with more mental health symptoms compared to other stressful events, especially symptoms of PTSD, anxiety, depression, insomnia, and dissociation. Lack of social support, psychiatric history, childhood trauma, additional stressful events in the past month, and low resilience predicted more mental health problems for COVID-19 and other stressful events. Higher COVID-19 country impact was associated with increased mental health impact of both COVID-19 and other stressful events. Analysis of differences across geographic regions revealed that in Latin America more mental health symptoms were reported for COVID-19 related events versus other stressful events, while the opposite pattern was seen in North America. (Olff et al., 2021)
Celik, D., Alpay, E.H., Celebi, B., Turkali, A. Intolerance of uncertainty, rumination, post-traumatic stress symptoms and aggression during COVID-19: A serial mediation model (in press).	This study found an association between intolerance of uncertainty and aggressive behaviours. Moreover, the result of serial mediation analysis showed that intolerance of uncertainty, predict aggressive behaviours via rumination and PTSS. Besides, socioeconomic stressors are significantly associated with the level of PTSS and aggression while health stressors are not significantly association with the level of PTSS and aggression. (Celik, Alpay, Celebi, & Turkali, Celik, et al., 2012)
Liu, C., Huang, N., Ahmed, F., Shahid, M., Wang, X., Guo, J. The Reverse Buffering Effects of Social Support on the Relationships between Stresses and Mental Health: A survey of Chinese adults during the COVID-19 lockdown (in press).	The study revealed that stresses from lockdown policy presented stronger associations with mental health symptoms for depressive symptoms and posttraumatic stress symptoms than stresses from pandemic fear. Moreover, greater social support enhanced the positive associations between stresses and mental health symptoms. (Liu et al., Liu, et al., 2021)
Bountress, K.E., Cusack, SE, Conley, AH, Aggen, SH, Vassileva, J., Dick, DM, Amstadter, AB & The Spit for Science Working Group (2021) Unpacking the impact of the COVID-19 pandemic: identifying structural domains.	This study examined the structure of pandemic related stressor domains in a student cohort. Following estimation of a single-factor model, a correlated five factors model, as well as two second-order factor structures, the five correlated factors (exposure, worry, housing/food instability, social media, substance use) model was found to represent the data most appropriately, while producing an interpretable solution. (Bountress et al., 2021)
Rossi, R., Socci, V., Talevi, D., Niolu, C., Pacitti, F., Di Marco, A., … & Olff, M. (2021). Trauma-spectrum symptoms among the Italian general population in the time of the COVID-19 outbreak. European Journal of Psychotraumatology, 12(1), 1855888.	This study found that a wide range of trauma-spectrum symptoms were reported by a large Italian sample during the COVID-19 pandemic. The GPS symptoms clustered best in three factors: Negative Affect symptoms, Core PTSS, and Dissociative symptoms. In particular, high rates of core PTSS and negative affect symptoms were associated with the COVID-19 pandemic in Italy and should be routinely assessed in clinical practice. (Rossi et al., 2021)
Schmidt, S. J., Barblan, L. P., Lory, I., & Landolt, M. A. (2021). Age-related effects of the COVID-19 pandemic on mental health of children and adolescents.	Between 2.2% and 9.9% reported emotional and behavioural problems above the clinical cut-off and between 15.3% and 43.0% reported an increase in these problems during the pandemic. Preschoolers (1–6 years) had the largest increase in oppositional-defiant behaviours, adolescents reported the largest increase in emotional problems. Adolescents experienced a significantly larger decrease in emotional and behavioural problems than both preschoolers and school-children. (Schmidt, Barblan, Lory, & Landolt, 2021)
Chao, M., Chen, X., Liu, T., Yang, H., & Hall, B. J. (2020). Psychological distress and state boredom during the COVID-19 outbreak in China: the role of meaning in life and media use.	This study indicated that the effect of state boredom on anxiety and stress, but not depression, were mediated by media use and that sense of meaning in life modified this association. Meaning in life served as a risk factor, rather than a protective factor for the negative psychological outcomes when people experienced boredom. The association between boredom and media use was significant for high but not low meaning in life individuals. (Chao, Chen, Liu, Yang, & Hall, 2020)
Longitudinal Studies
BinDhim, N. F., Althumiri, N. A., Basyouni, M. H., Alageel, A. A., Alghnam, S., Al-Qunaibet, A. M., … & Ad-Dab’bagh, Y. (2021). Saudi Arabia Mental Health Surveillance System (MHSS): Mental health trends amid COVID-19 and comparison with pre-COVID-19 trends.	This study used cross-sectional surveys conducted over different points in time (each individual only participated once). The risk of MDD on PHQ-2 increased by 71.2%, from 12.5% in 2018 to 21.4% in 2020. During COVID, the weighted national prevalence of people at risk of MDD was 14.9%. The weighted national prevalence of people at risk of GAD was 11.4%. (BinDhim et al., 2021)
Valiente, C., Vázquez, C., Contreras, A., Peinado, V., & Trucharte, A. (2021). A symptom-based definition of resilience in times of pandemics: Patterns of psychological responses over time and their predictors.	Analyses of the levels of disturbance associated with the symptoms provided support to that four-fold distinction of patterns of responses. Furthermore, resilience responses were the most common psychological response to the pandemic. The main variables increasing the probability of resilience to COVID-19 were being male, older, having no history of mental health difficulties, higher levels of psychological well-being and high identification with all humanity. Also, having low scores in several variables (i.e. anxiety and economic threat due to COVID-19, substance use during the confinement, intolerance to uncertainty, death anxiety, loneliness, and suspiciousness) was a significant predictor of a resilient response to COVID-19.(Valiente, Vázquez, Contreras, Peinado, & Trucharte, 2021)
Intervention Studies
ter Heide, J., de la Rie, S., de Haan, A., Boeschoten, M., Nijdam, M., Smid, G., Wind, T., Mooren, T. (in press) Wellbeing and clinical videoconferencing satisfaction among patients in psychotrauma treatment during the coronavirus pandemic: Cross-sectional study.	This study found that COVID-19 was associated with increased mental health symptoms in participants already seeking mental health care. Videoconferencing was found to be acceptable was of receiving therapy, although face-to-face treatment remained the preference for specific target groups with limited access to VCT (such as refugees) and patients with high levels of general psychopathology. (ter Heide et al., 2021)
Bongaerts, H., Voorendonk, E. M., van Minnen, A., & de Jongh, A. (2021). Safety and effectiveness of intensive treatment for complex PTSD delivered via home-based telehealth.	Pilot study of six patients. Suggests that intensive, trauma-focused treatment of severe or Complex PTSD delivered via home-based telehealth is feasible, safe and effective, and can be a viable alternative to face-to-face delivered intensive trauma-focused treatment. (Bongaerts et al., 2021)
Wild, J., Warnock-Parkes, E., Murray, H., Kerr, A., Thew, G., Grey, N., … & Ehlers, A. (2020). Treating posttraumatic stress disorder remotely with cognitive therapy for PTSD.	This study describes ways to adapt CT-PTSD treatment to be delivered remotely so that patients presenting with PTSD during the COVID-19 pandemic can benefit from this evidence-based treatment. (Wild et al., 2020)
Research protocol
De Young, A., Vasileva, M., Boruszak-Kiziukiewicz, J., Demipence Seçinti, D., Christie, H., Egberts, M., Anastassiou-Hadjicharalambousi, X., Marsac, M., Ruiz, G. COVID-19 Unmasked Global Collaboration Protocol: Longitudinal cohort study examining mental health of young children and caregivers during the pandemic.	The collaborating researchers aim to (1) describe and compare the COVID-19 related experiences within and across countries; (2) examine mental health outcomes for young children (1 to 5 years) and caregivers over a 12-month period during the COVID-19 pandemic; (3) explore the trajectories/time course of psychological outcomes of the children and parents over this period and (4) identify the risk and protective factors for different mental health trajectories. Data will be combined from all participating countries into one large open access cross-cultural dataset to facilitate further international collaborations and joint publications. Currently, partnerships have been formed with 9 countries (Australia, Cyprus, Greece, the Netherlands, Poland, Spain, Turkey, the UK, and the USA). (De Young, et al., 2021)

It is important when reading this literature to recognize that rates of trauma exposure and PTSD reported in any given paper are highly dependent on where the research was conducted and what was happening in that country at that time. In many ways, prevalence research represents a snapshot in time. As such, it is important that manuscripts include this contextual information, especially as the pandemic has been enduring over time, and many countries have experienced two, three or four waves of the virus. Prevalence rates of COVID-related mental symptoms or disorders in a specific country or in a specific population may differ over time as the virus infection rates fluctuate. Furthermore, prevalence rates will be impacted by the design of the study with the majority of studies relying on the internet as a way of recruiting participants. (e.g., Graf-Vlachy, Sun, & Zhang, 2020) While web-based surveys represent a pragmatic and useful way to collect data during a pandemic, they also have their limitations in generalizability.

The COVID-19 pandemic saw a sudden shift to telehealth for trauma-related mental health in countries where this was possible. A number of studies in this Special Issue investigated whether this was effective and satisfactory for patients (Bongaerts, Voorendonk, van Minnen, & de Jongh, 2021; ter Heide et al., 2021; Wild et al., 2020). This research is important because many clinics may be interested in maintaining a large focus on telehealth once the pandemic is brought under control. Generally, this research found that patients who received telehealth were just as satisfied with their treatment as those who received their treatment face-to-face, although sub-populations such as those with higher symptoms preferred face-to-face.

Moving forwards

The papers included in this Special Issue provide an important and much-needed evidence-based foundation for developing trauma-informed understanding and responses to the pandemic. Yet, many unanswered questions about trauma during COVID-19 still remain. It is clear that the pandemic has brought with it a rise in trauma exposure and consequently impacted on trauma-related mental health. Yet, for many individuals, while COVID-19 has undoubtable been stressful and challenging, for many people, their experience may not meet DSM-5 Criterion A (American Psychiatric Association, 2013) definition for a traumatic event, which has implications for the diagnosis of various disorders including post-traumatic stress disorder and acute stress disorder (Norrholm et al., 2021). One of the main challenges therefore is disentangling trauma from stress, anxiety, and other phenomena, and determining the contexts in which a trauma lens is (or is not) helpful. Importantly, research should examine the impact on COVID-19 on trauma-exposed communities (such as natural disaster survivors or survivors of childhood trauma) to see how COVID-19 and its consequences have impacted on recovery trajectories or pre-existing symptoms.

A second challenge is to understand how to translate these findings that may be specific to time and place, thereby increasing our general understanding of risk and resilience in the face of global crises. One of the solutions is to come together to pool data in order to conduct comparative research and identify universal risk factors. Optimally, however, this collaborative research will not be conducted after disaster strikes. Rather, we should focus on disaster preparedness, and develop international research networks and infrastructure to launch new multi-country studies as and when required. We already have the foundations of this with the European Society of Traumatic Stress Studies (ESTSS) and the International Society of Traumatic Stress Studies (ISTSS), professional societies, and with the Global Collaboration on Traumatic Stress where researchers from around the world work together on global topics like COVID-19 (https://www.global-psychotrauma.net/covid-19-projects).

A third challenge is to understand the long-term impacts of the pandemic on mental health. Most of the research published so far has been based on cross-sectional research, and this Special Issue is reflective of that trend. Yet while some pandemic-related effects are immediate and direct and can be captured by cross-sectional studies, it is crucial to understand the factors that contribute to distress, resilience and recovery over time. Furthermore, it is likely that central risk factors for mental health problems, such as financial deprivation, bereavement, and chronic physical health problems, will increase vulnerability to mental disorders for many years to come, and we must gather prospective longitudinal data that can help us understand how best to predict, mitigate and prevent these anticipated negative outcomes. In particular, we need to consider the countries and communities that were badly affected by COVID-19 illness, and those that were already vulnerable with low levels of resources even before the pandemic broke out.

COVID-19 highlighted the urgency of secondary prevention of mental disorders following traumatic exposure, and tertiary prevention of comorbidity and other complex presentations. However, while COVID-19 has been an extreme and unprecedented crisis, it is not the only global crisis that we currently face. Given the threat of global crises such as pandemics, terrorism, and climate change, which raise the risk of trauma exposure, we must come together to research and learn from COVID-19 to better identify high-risk individuals, deliver timely support and interventions when they are needed, and understand factors that may boost resilience (Bonanno, 2021; Denckla et al., 2020). With this in mind, the current EJPT Special Issue represents the first phase of this mission. A second EJPT Special Issue of COVID-19 related studies will also be published.