Meta-analysis of post-traumatic stress disorder and COVID-19 in patients discharged.

Dear editor,

In this journal, Thor Mertz Schou et al. reported that the severity of Coronavirus disease 2019 (COVID-19) has been highlighted as a risk factor for post-traumatic stress disorder (PTSD); thus, suggesting that we should focus on long-term mental illness in COVID-19 patients after discharge. PTSD is a serious mental health condition that is triggered by a terrifying event.

We found that many published studies investigated the occurrence and risk factors of PTSD among discharged COVID-19 patients. They may experience psychosocial difficulties while interacting with others after discharge although patients recover physically in the hospital. It was showed that PTSD is a common psychological problem in patients after discharge, and they found that age, gender, and smoking history can increase the incidence of PTSD in Tianjin, China.

PubMed, Web of Science, Embase, and Cochrane Library databases were extensively searched for all compliant studies published from January 1, 2020, to February 15, 2022. The following keywords were used for the search strategy: “COVID-19,” “2019-nCoV,” “SARS-CoV-2,” “2019 novel coronavirus,” “coronavirus disease 2019,” “severe acute respiratory syndrome coronavirus 2,”“Post-COVID-19,” “post-traumatic stress disorder”, and “PTSD”. Reference lists of the included studies and relevant reviews were searched for additional studies. The inclusion criteria were as follows: (1) adult patients with COVID-19 confirmed by reverse transcriptase–polymerase chain reaction; (2) peer-reviewed original studies in English; (3) individual study populations with at least 100 cases; and (4) key available data of the included studies, four-table data, or effect [95% confidence interval (CI)] clearly stated. Case reports, repeated articles, review papers, and preprints were excluded. After searching the PubMed and other websites, seven eligible studies involving 1426 patients with COVID-19 were included in our meta-analysis. Seven studies reported PTSD symptoms of COVID-19 patients discharged from the hospital. The general information of included studies is summarized in Table 1 . , 4, 5, 6, 7, 8, 9

Table 1

The basic information of the included literature. Total: number of patient included in the study.

Study	PTSD (n)	Total (n)
Zaoxian Mei 20222	23	144
Katharina Beck 20214	10	115
Yumeng Ju 20215	41	114
R. Mendez 20216	45	179
Liqun Huang 20217	64	574
Tarsitani L 20218	12	115
De Lorenzo R 20209	41	185

The results of seven studies listed in Fig. 1 showed the occurrence of PTSD in 18% of the patients (95% CI, 0.12–0.24; P < 0.01). It indicated that, out of every 100 patients, 18 experienced PTSD due to some reason after discharge. This suggested that these symptoms might indeed be the sequelae after recovery of COVID-19 survivors. The reasons for PTSD and other symptoms may be as follows: Infection with COVID-19 causes great psychological stress in patients. Factors, such as hospitalization, isolation, and restrictions on family member visits, may create a psychological burden on patients and their families. Exposure to war, physical or sexual assault, disasters, and vehicle accidents are the most common causes of PTSD. In addition, experience of an acute or critical illness is also considered a potential risk factor for PTSD. Meanwhile, it was showed PTSD during follow-up was associated with persistent respiratory symptoms, sleep difficulty, and a diagnosis of anxiety. Respiratory manifestations are the main symptoms of COVID-19 patients. The association between PTSD and respiratory symptoms and sleep difficulty was bidirectional. Persistent physical symptoms can lead to mental illness, and conversely, increased mental distress can manifest as physical symptoms. In addition, many patients experience difficulty sleeping, and long-term lack of sleep can also lead to mental and psychological disorders. People with anxiety disorders were 15 times more likely to develop PTSD than people without anxiety disorders. However, further research is needed to confirm the correlation.

Fig 1

Forest plot of PTSD rates of among COVID-19 in patients discharged from hospital. ES: PTSD rates.

The results showed that older age, female gender, current smoking status, and the number of involved pulmonary lobes (≥3) are risk factors for PTSD. A research suggests that obesity predicted the development of PTSD and reasons for this unexpected association should be further investigated, but De Lorenzo R did not observe any impact of body mass index (BMI) or other comorbidities on the development of PTSD. Therefore, the association between obesity and PTSD needs to be investigated further. Lower age, female gender, and positive psychiatric history were significantly associated with the risk of developing PTSD after COVID-19.

At present, our research has certain limitations. Most of the included studies assessed the mental health status of discharged patients through instruments, such as telephone interviews and questionnaires. Neuropsychological evaluation in patients was inconsistent across studies, and the research results were heterogeneous to a certain extent; hence, more research is needed in the future.

In conclusion, our study showed that the occurrence of PTSD was not rare among patients with confirmed COVID-19 infection. This also suggests that we should pay attention to the mental health and social interaction status of patients after discharge, which is very important for disease prognosis and healthy life of patients. PTSD can be treated with medication and psychological intervention. Enhancing emotional support during hospitalization could help prevent PTSD in patients with COVID-19. Therefore, clinicians need to pay more attention to the risk predictors of patients' mental health, and develop corresponding diagnosis and treatment measures in a timely manner during treatment.

Funding

This study was supported by fund (Nos. 20191203B96; 20191203B105; 20191231Y039); Youth Fund of Zhejiang Academy of Medical Sciences (No. 2019Y009); (Nos. 2020362651; 2021KY890; 2022KY970); Clinical Research Fund of Zhejiang Medical Association (No. 2020ZYC-A13); Hangzhou Health and Family Planning Technology Plan Key Projects (No. 2017ZD02). Hangzhou Medical and Health Technology Project (No. 0020290592). Zhejiang Traditional Chinese Medicine Scientific Research Fund Project (No. 2022ZB280).

Data sharing statement

All the data and materials mentioned in the manuscript are available.

Declaration of Competing Interest

The authors declare no competing interests.