The link between COVID-19 and PTSD

PTSD and Pandemics

Post Traumatic Stress Disorder (PTSD) is a common mental health condition which affects around 1 in 20 people in the UK. PTSD develops when symptoms following a psychological trauma disrupt daily functioning and thus can result in a whole host of negative physical and psychological symptoms. This psychological trauma can be defined as a direct threat to one’s life, serious physical injury, violence, and/or witnessing an unexpected death, immediate threat to life, or physical injury to another person – as such, it’s not a surprise that there is expected to be a huge increase in cases of PTSD in the coming months and years.

Studies have shown that after previous epidemics such as Ebola, MERS and SARS, there was a high prevalence of mental health problems such as PTSD among survivors, victim families, medical professionals, and the general public. While most of these mental health problems dissipated after the epidemic, there were a significant proportion of people left with PTSD symptoms.

This article explains a little more about why there are such high PTSD prevalence rates amongst people exposed to the trauma of a pandemic, and what can be done to help.

Why will the Covid-19 pandemic increase rates of PTSD?

Broadly speaking, infectious disease epidemics such as COVID-19 typically result in a particular type of psychological trauma, which can be categorised into 3 groups:

1. Directly experiencing and suffering from the disease and subsequent symptoms; and the potentially traumatic treatment that follows, e.g. respiratory failure, alteration of conscious states, threatening of death, tracheotomy, intubation etc.
2. Witnessing patients who suffer from, struggle against and die of the disease. This includes fellow patients, family members of patients, or the healthcare workers.
3. Experiencing the realistic (or unrealistic fear) of infection.

‘In addition, whilst lockdown measures were necessary to reduce the spread of the virus, for many people they have unintentionally created heavy psychological, emotional and financial problems. For some of our patients, the ‘stay at home’ guidance has created a toxic environment, leading to an increase in domestic abuse.” added, Dr Jonathan Leach, the RCGP Joint Honorary Secretary.

There are a number of groups and communities which are a higher risk of PTSD due to a number of factors:

Frontline Staff

Our NHS workers have received an outpouring of love from all over the UK during the pandemic: the weekly claps, free meals, discounts, and more – but none of these will help the frontline staff deal with the psychological scars they may be left with as a result of their experience with COVID-19. The average prevalence of PTSD among health professionals in previous outbreaks was approximately 21%. Furthermore, 40% of them reported persistently high PTSD symptoms 3 years later. 

DIRECT THREAT: The nation’s healthcare staff face a direct threat to their own lives working with infectious patients, who are often severely ill, and it’s been widely reported that at times, they have had insufficient personal protective equipment (PPE) to guard against the virus. ‘Normally, your own safety is not compromised as a nurse. But that has been a big issue for some – they worry about their own health and that of their families, along with the other concerns.’ said Ellen Waldren, co-founder of Frontline UK.

INCREASED DEATH EXPOSURE: Additionally, the increased amount of deaths that staff have had to deal with is emotionally hard. ‘Nurses in critical care were seeing five or six people dying every shift at points when normally it would be no more than one.’ said Nicki Credland, the Chair of the British Association of Critical Care Nurses. This is further exacerbated by the nurse-to-patient ratios being at almost one to four, rather than the usual one to one.

LACK OF REST: ‘We also know that adequate time and opportunity to mentally process stressful and traumatic experiences after they have happened is important, and adequate sleep is vital for the normal processing of memories. However, we also know that many healthcare professionals’ working patterns, with long shifts and only brief periods for rest significantly compromises this.’ notes the COVID Trauma Response Working Group.

People requiring Critical Care Treatment

COVID-19 creates a uniquely frightening and invasive critical care experience. Treatment in intensive care units, in particular when intubation has taken place, is associated with some of the highest rates of medical PTSD, with 35% of ICU survivors having clinically significant PTSD symptoms 2 years after their ICU care.

With COVID-19 however, not only is the risk of death and potential long-term medical complications high, but the necessary treatment, and in particular, the isolation from loved ones and staff, creates a situation where those people are at high risk of developing PTSD. 

The BBC reported one COVID-19 survivors hospital experience as ‘hell’: “I saw people dying, people with the life being sucked from them. The staff all have masks on and all you saw was eyes – it was so lonely and frightening.”

Acknowledging the impact COVID-19 will have on mental health, NHS psychiatrist Dr Michael Bloomfield, and other mental health experts are calling on the NHS to screen all those who were admitted to hospital when they became seriously ill, to look for symptoms of PTSD.

Friends and Family of those who’ve suffered with COVID-19

Current estimates state that over 41,500 people in the UK have died as a result of COVID-19 – most of these deaths will have been sudden, unexpected, and in many cases, particularly traumatic.

UNEXPECTED DEATHS: Many studies have found that the sudden and unexpected death of a loved one is the most common type of traumatic event reported. While many people won’t go on to experience PTSD, an analysis from the World Health Organisation’s ‘World Mental Health Survey’ found there was a 5.2% risk of people developing PTSD after they found out about the unexpected death of someone they love. Additionally, one of the unique challenges of this pandemic is that people have been self-isolating, or socially distanced from friends and family – meaning the support they might normally receive after such an event isn’t available, leading to feelings of loneliness, isolation and abandonment.

CRITICAL CARE HOSPITAL ADMISSIONS OF LOVED ONES: Due to the nature of COVID-19, many patients in critical care units have been isolated from their friends and family – meaning the feelings of helplessness and hopelessness are increased for their loved ones. A fear their loved one may die, or a video link seeing a sedated or ventilated family member may also cause psychological trauma.

Domestic Abuse increases as a result of Lockdown

The United Nations has described the 20% global increase in domestic abuse as a result of lockdown and ‘stay at home’ guidance as a ‘shadow pandemic’. But with more than 40% of women exposed to domestic violence reported to develop PTSD, this will see a huge increase in the cases ongoing.

‘Two-thirds of women in abusive relationships have suffered more violence from their partners during the pandemic’ and ‘three-quarters of victims also say the lockdown has made it harder for them to escape their abusers’ found a BBC Panorama and Women’s Aid investigation. This resulted in an 80% increase in calls and contacts to the National Domestic Abuse Hotline in June. Additionally, the Men’s Advice Line says it received nearly 8,500 calls over the first three months of the lockdown, significantly higher than during the same period last year.

What is being done about the expected surge in PTSD cases?

A COVID Trauma Response Working Group has been formed to help coordinate trauma-informed responses to the COVID outbreak. They ‘are made of psychological trauma specialists, coordinators of the psychosocial response to trauma and wellbeing leads at NHS Trusts. The working group is being coordinated by staff at University College London and the Traumatic Stress Clinic based at St Pancras Hospital in Camden and Islington NHS Trust.’ They continue to inform a number of initiatives across the UK.

Informing GPs and healthcare workers

This expected ‘huge surge’ in patients with PTSD as a result of COVID-19 has also led to The Royal College of GPs reworking it’s learning materials to create specific resources for family doctors to help their patients come to terms with the pandemic and its aftermath. Hopefully, this will help our nations GPs recognise, refer and treat PTSD better.

COVID-19 Survivors

NHS England have said ‘all Covid survivors who stayed in hospital will have a follow up appointment with either their GP or hospital team where their mental health would be assessed. They were also able to refer themselves for psychological support’ – so we urge anyone affected to attend these appointments where possible.

Frontline Workers

Ellen Waldren and Claire Goodwin-Fee, both psychotherapists, have set up an amazing emotional support service Frontline 19 for working on the frontline of COVID-19 (doctors, nurses, auxiliary staff, paramedics, ambulance drivers, midwives, social workers, care home staff, firefighters and police officers.).

The Department of Health and Social Care in England has said that ‘work is under way to increase support, saying the mental health of staff is a ‘top priority’.

Domestic Abuse Victims

The government announced it would give an additional £2million to domestic abuse helplines. Rishi Sunak also pledged £10million towards approaches like ‘Drive’, a partnership between SafeLives, Social Finance and Respect.

The Domestic Abuse Bill is also making its way through Parliament currently – although many charities argue that the legislation should go further than it does.

It is, however, expected that as children return to school, more cases may be reported with children able to speak to teachers and friends.

PTSD UK response

We’re working hard to ensure that we’re ready for the increase in people needing our resources and support. One of our additional tasks will be ensuring that those who develop PTSD, are aware of the symptoms and what to look out for – so they can then be guided to get the help they need. Early intervention will be key to reducing the number of serious cases of PTSD in the UK. This will require proactive work on our behalf, so we’ll be partnering with other charities, agencies and organisations where possible to ensure we can reach all those high risk communities as we’ve mentioned in this article, and others too.

If you’d like to support the work we do, thank you, you can donate here.

What should I look out for in myself/a loved one?

PTSD can develop after experiencing a trauma, and it’s when the ‘normal’ reactions to trauma (being ‘on edge’, nightmares, concern for safety, intrusive thoughts, avoidance of reminders of the trauma etc) persist for a month or more – resulting in substantial distress and disruption in one’s life. 

Although the majority of people exposed to trauma recover within 30 days and do not develop PTSD, it’s important to continue to ‘check in’ with yourself and friends and family over the coming months.

If you feel you (or your friends of family) may be experiencing symptoms of PTSD, it’s important to arrange an appointment with your GP as soon as possible who will be able to advise on the best course of action for you, including a referral to your local mental health team who can advise on treatment options if necessary. We’ve also got lots of information on our website about how to manage symptoms and therapies and activities that may help in the meantime.

Getting Support

If you or someone you love is affected by PTSD, it is important to know that effective treatments for PTSD exist. Please visit your GP who will be able to talk over your diagnosis and options for you.

There are a variety of other support resources you might find useful too, here are a selection:

Frontline Workers

The Samaritans have launched a new, confidential support line for health and social care workers which you can reach on 0800 069 6222 in England and 08004840555 in Wales.

The NHS also has a list of support options for their staff here.

Those who’ve lost loved ones

The British Psychological Society has produced a booklet to help support those coping with death and grief during the COVID-19 pandemic, you can view this here.

Those who were admitted to critical care

Psychology Tools has created a booklet to help those people (and their friends and family) who have been admitted to critical care and intensive care. You can view this here.

Domestic Abuse Victims

Online webchats and text services are also available.

PLEASE NOTE: Household isolation instructions as a result of coronavirus do not apply if you need to leave your home to escape domestic abuse.

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REFERENCES:

RCGP, The Guardian, GHRp, BBC, University of Michigan, RCNI, The Samaritans, COVID Trauma Response Working Group publications: Coordinating a trauma-informed response to COVID 19 – What, why and how? and Guidance on screening and active monitoring for post-traumatic stress disorder (PTSD) and other mental health consequences in people recovering from severe COVID-19 illness, BPS, Psychology Tools, BBC, Financial Times, Vyas KJ, Delaney EM, Jennifer A, et al. Psychological impact of deploying in support of the U.S. response to Ebola: a systematic review and meta-analysis of past outbreaks. Mil Med. 2016;181(11):1515–31. Mak IWC, Chu CM, Pan PC, Yiu MGC, Chan VL. Long-term psychiatric morbidities among SARS survivors. Gen Hosp Psychiatry. 2009;31(4):318–26. Nyanfor SS, Xiao SY: The Psychological Impact of the Ebola epidemic among Survivors in Liberia: a retrospective cohort study, submitted.,

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Photo by Julie-Ann Gylaitis on Unsplash