key: cord- - f r nv authors: lang, ariel j.; casmar, pollyanna; hurst, samantha; harrison, timothy; golshan, shahrokh; good, raquel; essex, michael; negi, lobsang title: compassion meditation for veterans with posttraumatic stress disorder (ptsd): a nonrandomized study date: - - journal: mindfulness (n y) doi: . /s - - -z sha: doc_id: cord_uid: f r nv compassion meditation (cm) is a contemplative practice that is intended to cultivate the ability to extend and sustain compassion toward self and others. although research documents the benefits of cm in healthy populations, its use in the context of psychopathology is largely unexamined. the purpose of this study was to refine and initially evaluate a cm protocol, cognitively based compassion training (cbct®), for use with veterans with ptsd. to this end, our research team developed and refined a manualized protocol, cbct-vet, over sets of groups involving veterans. this protocol was delivered in – sessions, each lasting – min and led by a cbct®-trained clinical psychologist. quantitative and qualitative data were used to identify areas to be improved and to assess change that occurred during the treatment period. based on pooled data from this series of groups, cm appears to be acceptable to veterans with ptsd. group participation was associated with reduced symptoms of ptsd (partial eta squared = . ) and depression (partial eta squared = . ), but causality should not be inferred given the nonrandomized design. no change was observed in additional outcomes, including positive emotion and social connectedness. the results of this open trial support additional exploration of cm as part of the recovery process for veterans with ptsd. although empirically supported treatments are available for posttraumatic stress disorder (ptsd), most military personnel and veterans choose not to engage in these treatments or have residual symptoms after treatment completion (steenkamp et al. ) . a growing literature suggests that meditation may be useful in recovery from ptsd (see lang et al. for a review). data from clinical and non-clinical samples suggest that compassion meditation (cm) has a positive impact on positive emotion and social functioning, which are areas of difficulty for many individuals with ptsd. nonetheless, cm has yet to be evaluated for treatment of ptsd. cognitively based compassion training (cbct®) is a cm training program. it consists of a sequence of contemplative practices that are believed to cultivate the ability to extend and sustain compassion toward self and others (negi ) . cbct® combines present-moment practices (i.e., focused attention and open monitoring) with analytical contemplative methods, which encourage cognitive reappraisal and alteration of usual mental patterns to expand compassion. cm and similar approaches (e.g., loving kindness meditation [lkm] ) lead to increases in positive emotion in both clinical and nonclinical samples (for a recent meta-analysis see zeng et al. ) . the first published clinical application showed that lkm increased positive emotion and decreased negative emotion among individuals with negative symptoms of schizophrenia (n = ; johnson et al. ) . more recently, an open trial with veterans with ptsd (n = ) found that lkm was associated with decreased symptoms of ptsd and depression (kearney et al. ) , increased unactivated positive emotions, and decreased both activated and unactivated negative emotions (kearney et al. ). finally, evidence from functional mri shows activation in areas typically associated with positive affect (left medial prefrontal cortex and anterior cingulate gyrus) in an expert meditator engaged in cm (engstrom and soderfeldt ) . compassion-based meditative practices have also been suggested to alter social functioning in nonclinical samples. brief lkm practice was associated with a greater sense of social connectedness and positivity toward others based on explicit and implicit reactions in a laboratory setting (hutcherson et al. ). cm has also been linked to increased empathic accuracy and activation of associated brain circuitry (mascaro et al. ) , as well as increased altruistic behavior (galante et al. ; weng et al. ) and activation of brain regions associated with social cognition and emotion regulation, suggesting greater capacity to understanding the suffering of others (weng et al. ) . it is unknown, however, what effect cm may have on social connectedness in the context of psychopathology. both positive emotion and social functioning are potentially important targets in recovery from ptsd. ptsd is a maladaptive response to exposure to a traumatic event, characterized by unwanted re-experiencing of the event, avoidance, negative cognitive appraisals, and hyperarousal (american psychiatric association ). in addition to strong negative affect, ptsd is characterized by deficits in positive affect (litz and gray ) and avoidance of positive affective stimuli (clausen et al. ) . the importance of cultivating positive emotion is suggested by fredrickson's ( ) broaden and build theory, which posits that positive emotions enhance the ability to think flexibly and thereby build psychological resources that enable successful coping. in this way, positive emotions are believed to counteract the deleterious effects of negative emotions (fredrickson ) . high positive emotionality and intentionally inducing positive emotion have been associated with resilience, i.e., the ability to recover from negative experiences and to change based on situational demands (tugade and fredrickson ) and the ability to cope with highly stressful events (fredrickson et al. ) . thus, positive emotion induced by cm may independently reduce dysphoria, which appears to be the best predictor of problems in psychosocial functioning among those with ptsd (pietrzak et al. ). in addition, positive emotion has been shown to reduce fear-based reactivity (fredrickson et al. ) so may ameliorate ptsd-related anxious responding and hyperarousal. finally, positive emotions cultivated in cm may enhance one's ability to take another's perspective and foster closeness, thus providing social reinforcement and support. sharing of positive events, rather than providing support during negative events, is predictive of relationship health (gable et al. ) . problems with social functioning also are common among those with ptsd. individuals with ptsd have diminished ability to empathically connect with others (nietlisbach et al. ) and demonstrate poorer marital and family functioning and more impairment in interpersonal relationships and social activities (schnurr et al. ). social impairment is a predictor of chronicity of the disorder (marshall et al. ) , has been linked to increased risk of suicide for ptsd patients (panagioti et al. ) , and predicts return for additional care after initial treatment (fontana and rosenheck ) . social support, on the other hand, has been shown to buffer against development of ptsd and to predict improvement (e.g., ozer et al. ) . a greater sense of social connection is associated with better psychological and social functioning (hagerty et al. ) , including reduced anxiety and greater selfesteem (lee and robbins ) , and may have a protective effect against stress, depression, and ptsd (see, for example, cacioppo et al. ; cacioppo and patrick ) . thus, a greater sense of connection to and caring for others as encouraged by this practice may also translate into symptom reduction. for example, higher levels of altruism have been associated with lower levels of symptomatology in veterans with ptsd (kishon- barash et al. ) . the goal of the study presented herein was to adapt and collect preliminary data on the clinical impact of a modified version of cbct® for veterans with ptsd. an iterative refinement process using quantitative and qualitative feedback was used to refine the original cbct® protocol to reflect military/veteran culture and to enhance digestibility of the material and relevance to ptsd. pooled data from this set of groups are presented as an initial index of the feasibility and potential clinical utility of the intervention. participants participants (n = ) were veterans with ptsd who were able to consent and willing to participate. co-occurring disorders such as depression, anxiety, or treated substance abuse or dependence problems were permitted provided that ptsd was the primary presenting complaint as determined by clinical interview. exclusion was on the basis of the following: ( ) high risk for suicide or homicide that required urgent or emergent evaluation or treatment within the three months prior to study entry, ( ) untreated substance abuse or dependence problems, ( ) serious axis i mental disorders, such as psychotic disorders or bipolar type i, or serious dissociative symptoms ( ) cognitive impairment that would interfere with treatment, ( ) current circumstances that involve recurrent traumatization (e.g., currently engaged in a violent relationship), and ( ) concurrent enrollment in any other treatment specifically targeting ptsd symptoms or social functioning (e.g., couples therapy). participants were allowed to continue current pharmacological treatment provided that no additional treatment response was expected and no changes were anticipated during the study period. the enrolled sample included veterans, of whom went on to begin the intervention (refer to fig. for detailed study flow). the enrolled group was mostly male (n = , %) with an average age of . years (sd = . ). the group was also predominantly caucasian (n = , %), with ( %) individuals identifying with more than one race, native american/alaskan native, african-american and native hawaiian/pacific islander; twelve ( %) individuals identified as hispanic. on average, the group reported . years (sd = . ) of education, and eleven ( %) were currently employed. twelve ( %) veterans were married or had a permanent partner. the average number of lifetime traumatic events endorsed was . (sd = . , range - ); the most commonly endorsed events were transportation accidents (n = ), combat (n = ), and physical assault (n = ). the majority (n = , %) had served in the recent conflicts in iraq and afghanistan, but several major deployments since vietnam were represented. twenty-one ( %) individuals reported some type of combat injury, and most (n = , %) were receiving compensation from the va. this study was approved by the institutional review board of the va san diego heathcare system. potential participants were referred to the study by mental health providers or expressed interest directly in response to advertisement. interested individuals came to the clinic to complete informed consent, hipaa authorization, and the initial evaluation for eligibility. consenting, eligible individuals went on to complete the assessment battery. beginning with the first group meeting, weekly measures of ptsd, depression and alcohol use were gathered. the assessment battery was repeated at post-intervention. credibility was measured after the first session and satisfaction after the last session. finally, weekly diaries were used to quantify meditation practice. participants completed - classes, each lasting - min (refer to table for the final schedule). all groups, which ranged in size from to at the start, were led by a licensed clinical psychologist (pc), who completed the cbct® teacher certification program, which includes a week-long retreat/workshop, a supervised practicum experience, and a post-practicum weekend workshop. as part of the practicum, audiotapes of sessions were reviewed by experts in cbct® (th, ln), and weekly supervision was provided to assure adherence to the intervention. intervention cbct® was designed to engender well-being through a set of meditative practices that aim to increase compassion, i.e., the sense of caring for the well-being of others and wanting them to be free from their difficulties and distress. developed at emory university in by professor negi, cbct® is based on techniques from the indo-tibetan buddhist tradition. as a secularized protocol, however, cbct® is independent from and supportive of any faith or belief system. the course is typically taught in weekly meetings supplemented by daily guided meditation recordings. group meetings for this study were structured approximately as follows: welcome agenda setting ( min), homework review ( min), participants' summary of past week's material ( min), didactics ( min), mindfulness exercise incorporating new concepts ( min), meditation incorporating new concepts ( min), homework assignment, and question/answer session ( min). participants were provided with a written manual to facilitate their understanding of the material. homework involved daily meditation practice, which gradually increased from min per day at the beginning to min per day at the end. cbct® includes tools with the explicit aim of expanding compassion to be more inclusive, broadening the sense of in-group, and dampening out-group bias. broadly speaking, the structured sequence of exercises begins with stabilizing attention and developing presentmoment awareness then provides analytical practices to increase well-being and unbiased compassion toward self and others. participants begin by recalling a time or place in which they were safe and taken care of by another to prime a sense of safety and security to sustain this positive affect and increase the awareness of the value of compassion in their own lives. next, participants take part in an attention-training practicefollowing the sensations of the breath as they unfold-to promote attentional stability and mental clarity; a key objective of this is to learn to notice and release (bcatch and release^) distractions as they arise. this increased mental stability then supports present-moment awareness, sometimes called open monitoring. here, the attentional focus shifts to how mental experiences unfold from moment to moment, as the practitioners attempt to neither push away such experiences nor become overly involved in them. this practice improves calmness of mind and provides insight into habitual mental patterns. the stability and insights from these exercises then support the analytical reflections that follow. the next topic is to examine the nature of distress and dissatisfaction in one's life and cultivate more realistic and constructive attitudes in the face of difficult circumstances. with an emphasis on approaching one's situation with increased self-kindness, the practitioner strengthens the determination to replace unhelpful perspectives and attitudes with more constructive ones, thus increasing a sense of self-efficacy and promoting a realistically based optimism. with a greater caring for self and the insight that constructive attitudes and perspectives are essential to enhancing wellbeing, cbct® then focuses on attitudes and perspectives that are directed toward other people. humans are fundamentally social creatures; relating constructively and positively with others is central to anyone's well-being. thus, the participant goes on to examine how all people, despite many differences, share a fundamental desire for being well, flourishing and avoiding distress and dissatisfaction. this practice leads to a greater capacity to see others as like oneself at a basic level, setting the stage for greater empathic response and more inclusive compassion. next, participants spend time reflecting on how their own well-being is dependent on the efforts of others, thus cultivating an appreciation for the received kindness of others, intended or unintended. these teachings are meant to generate authentic gratitude, moderate unrealistic attitudes of independence and isolation, and generate a deepening affection, even for those outside one's social group. the practice concludes with a focus on the arising and sustaining of compassion toward others. here, the participant embraces others as deserving of understanding and care because everyone-including loved ones, but also strangers and even difficult people-has inherent value and the equal right to pursue freedom from suffering. by focusing on the difficulties and distress experienced by so many, a deeper empathic response is evoked, and when supported by the inner strength introduction of positive cognitive reflection into stabilized meditation. superheroes are used as an example of accepting flaws. expecting perfection or self-blaming is a barrier to self-awareness and compassion. introduction to the idea that that all beings want to avoid suffering and find satisfaction in life. clarity in understanding that it is behavior and not humanity that can be inappropriate assists participants in building a more open acceptance of others. session : appreciation and gratitude ordinary objects, talents and skills are shown to have been obtained through the contributions of both known and unknown others. this creates an awareness of interdependence and builds appreciation and gratitude for the human family. in the context of interdependence (i.e., others who do not necessarily like them or even know them are continually helping them to live their everyday life), it becomes easier to see that all people have bad habits. understanding that change is difficult for all people and that we are not completely aware of the underlying issues others have helps participants to wish to relieve suffering for others. session : putting it all together ( ) review and relapse prevention. helps participants to understand the links between the sessions and allows participants to create meditation cards to keep to support coping when they might not have access to guided meditations. personalized meanings of the sessions are shared among members. session : putting it all together ( ) coping cards for applying meditation in everyday actions are created in class. homework exercise reviewed to provide a springboard for brainstorming and understanding. lessons on how to avoid compassion fatigue and continue to build positive emotions are taught. developed earlier in the practice, this empathy is transformed to become an engaged and motivated sense of caring for others and lead to more spontaneous and consistent prosocial thoughts and behaviors. protocol refinement the cbct® program was manualized before the initial group based on clinical experience with veterans with ptsd (ajl, pc, me) in collaboration with cbct developers (ln, th) to create the veteran version, cbct-vet. initial modification was aimed at increasing military/veteran relevance and facilitating use by individuals with psychopathology. the guided meditations encourage emotional experiences and thus could be difficult for individuals with ptsd to tolerate. the therapist spent time in session talking about this possibility and how to handle it and made herself available between sessions as needed. veterans were provided with strategies for managing flashbacks or strong emotions that are consistent with the practice, e.g., taking a deep breath and reseating oneself, then returning attention to the breath. similarly, difficulty focusing could be handled by placing hands on one's belly (to get a physical reminder of breathing) and breathing until the experience passed. in addition, we assumed little to no exposure to meditation to make the program accessible to any veteran with interest, so we developed additional materials to facilitate understanding of meditation. education in the science of compassion, including brief videos to illustrate difficult concepts, supplemented straightforward didactic materials that were provided in the participants' manuals. in addition, we believed that it was important that veterans apply meditation practices to ptsd-relevant experiences, so homework was designed to encourage and help trouble-shoot that process. the language from the original cbct® guided meditations was retained to the extent possible to maintain consistency of the intervention, although adaptations to reflect an th grade reading level and veteran-relevant terminology were important to foster accessibility of the material. in addition, group discussion was used to enhance understanding and application of the material. finally, we were concerned that the group nature of the intervention, which is the standard for instruction in meditation, could create a barrier to individuals who typically prefer one-on-one therapy. on one hand, compassion is often enhanced by exposure to experiences of others shared in the class and veterans can help each other through the struggles and joys of learning meditation. on the other hand, individuals who have experienced trauma are frequently uncomfortable with discussing symptoms or traumatic experiences in a group setting. to manage this concern, potential participants were helped to understand that the focus of the class was learning meditation rather than discussing traumatic events. it is our aspiration, however, that the skills developed in the group will facilitate one's ability to discuss and cope with distressing experiences, such as during trauma-focused psychotherapy. to the extent that traumatic events were brought up by group members, the group leader gently redirected the discussion from trauma specifics to expressing the ways in which they were cognitively or emotionally impacted while meditating. participants were encouraged to remain after class to discuss specific concerns that might not be central to the group's current work, and referrals to additional services were provided as needed. the treatment development team (al, pc, me, th, ln) made subsequent refinements to the manual after the completion of each group based on therapist input, qualitative interviews, and quantitative data. the changes, which were evaluated based on subsequent participant feedback, were as follows. the groups were reduced from to min to reflect participant comments about the group seeming too long. veterans requested more time for group discussion and cohesion-building, so classes were reviewed to balance presenting material and exercises with group process. meditation exercises also were reconfigured to involve paired work or group interaction to foster a feeling of group cohesion while maintaining the integrity of the intervention's goals. to address perceived deficits in conceptual understanding of the intervention that we identified in the qualitative interviews, veterans were asked to bteach^previously presented concepts to other group members with others being encouraged to chime in if there were other items that might facilitate learning. the class was extended from sessions to to make up for the change in session length and to allow time for discussion and review/ skill consolidation. one concern that may be unique to this population was that tinnitus was experienced as louder when there were silences in the recorded guided meditations. these participants were reminded that this experience was common for them throughout their lives, that this was their bnew silence,^and that if distracted by the ringing, they could bring their attention back to the breath. finally, some veterans had difficulty accessing the guided meditations because of unfamiliarity with technology. to manage this, study staff took a more active role in providing support. table presents the final intervention outline. demographic information was collected via self-report, and the montreal cognitive assessment (moca; nasreddine et al. ) was used to screen for cognitive impairment. a score lower than the age/education-adjusted cutoff for psychiatric populations (gierus et al. ) triggered additional neuropsychological evaluation and clinician clearance to participate. the mini international neuropsychiatric interview (mini . ; sheehan et al. ) was used to establish psychiatric diagnoses, including primary diagnosis, and to screen for suicide/homicide risk. the dissociative experiences scale (des; bernstein and putnam ) was used to identify problematic dissociative symptoms, and the life events checklist (weathers et al. a ) was used to inventory lifetime trauma exposure. finally, each participant was queried about use of mental health services. issues of clinical concern were further evaluated by clinician review of the electronic medical record. the feasibility of the approach was evaluated based on participant attrition, time spent in practice, credibility as measured by a -item measure adapted from (borkovec and nau ) , satisfaction as measured by the client satisfaction questionnaire (csq- ; attkisson and greenfield ) , and qualitative interview. qualitative interviews were conducted by an experienced qualitative interviewer (sh) with the aim of learning about the understandability, applicability, and efficacy of cm for this group. interviews were conducted by phone within weeks of the conclusion of the last session attended to give participants an opportunity to reflect on their experience and learning. each interview lasted approximately min. the interviews were recorded and notes were taken by the interviewer to capture participant responses. the semistructured interview guide posed nine reflective questions that focused around the (a) experience of practicing cm, (b) potential changes noted from skills they had learned at each intervention session, and (c) personal changes that participants perceived in managing both pleasant and unpleasant situations in their life because of their cm training. clinical outcomes were measured on a weekly basis using the dsm- version of the ptsd checklist (pcl- ; weathers et al. b) , the patient health questionnaire depression items (phq- ; kroenke et al. ) , and the consumption items from the alcohol use disorders identification test (audit-c; bush et al. ) . weekly measures were also used by therapists to monitor participant safety, as is typical practice in ptsd treatment. emotional experience was assessed weekly using the modified differential emotions scale (mdes; fredrickson et al. ) , which consists of daily ratings of the strongest experience of specific emotions in the preceding h. the mdes is scored to quantify positive and negative emotions separately. in addition to the weekly measures, the -item social connectedness scale-revised (scs-r; lee et al. ) and the short form of the self compassion scale (scs-sf; raes et al. ) , which is comprised of six two-item subscales: self-kindness, common humanity, mindfulness, self-judgment, isolation, and overidentification, were administered before and after treatment. the sample description and analysis of clinical change is based on data that were pooled across the four groups of six to eight participants. although there are differences in terms of content and therapy time within the groups, we believe that the aggregated data are informative in terms of our goals of evaluating the feasibility and clinical impact of cbct-vet as the fundamental intervention (cbct®) remained the same. a flowchart was generated to capture the flow of subjects throughout the study (refer to fig. ) . descriptive statistics were used to characterize the participants before treatment. the collection of qualitative data was useful to explore details about participant perceptions of the intervention. specifically, the qualitative data provided a contextual understanding of differences in participants' reactions and how that influenced their adaptability to the dynamics of the intervention, as well as ways in which they negotiated the practice of cm for stressful life situations. descriptive statistics were used to characterize the sample. mixed effects models were applied to measures that were captured weekly, and repeated measures analysis of variance (anova) was used for pre-post change. effect sizes (partial eta squared) were calculated based on the first and last completion of each clinical measure. at the first intervention session attended, participants had a mean pcl- score of . (sd = . ; n = because one participant elected not to complete this measure) and a mean phq- score of . (sd = . ). all had a ptsd diagnosis with the exception of one individual; this person had a primary complaint of subsyndromal ptsd (pcl- = ) with clinically meaningful distress and impairment, so an exception to eligibility criteria was made. the rates of co-occurring diagnoses were as follows: major depressive disorder (n = , %), panic disorder (n = , %), social phobia (n = , %), and obsessive compulsive disorder (n = , %). before treatment, eight people screened positive for potentially problematic drinking behavior based on the audit-c. seven participants had completed one or more empirically supported psychotherapy for ptsd in the past, and veterans were taking one or more psychotropic medication. figure presents attrition throughout the study. eighty-eight percent of those who were assessed for eligibility enrolled in the study; this high rate likely reflects the use of clinician referral and relatively broad eligibility requirements. a significant number ( / ) withdrew before beginning treatment. those who completed six or more sessions (n = , % of those who began treatment) were exposed to the essentials of the intervention, and those who completed four to five sessions (n = ; %) were presented with some concepts but not the full intervention. those who completed - sessions (n = ; %) did not receive a meaningful introduction to the practice and, although they were asked to provide data at the end of their involvement, none of them did so. completers did not differ from drop-outs on any clinical or mechanistic measures (all p > . ). participants generally cited logistical reasons for not completing the group (i.e., surgery, moving, untenable commute, family emergency), although two stated that the group did not meet their expectations. credibility questions were rated on an -point scale, with higher numbers indicating greater credibility. average ratings were as follows: . (sd = . ) for how logical the intervention seems for ptsd, . (sd = . ) for confidence that the intervention will help with functioning, . (sd = . ) for confidence that the approach will help with ptsd, and . (sd = . ) for confidence in referring a friend to the program. the range of scores for those who completed - sessions was . - . whereas the range for those who completed or more sessions was . - . . the average csq- score was . (sd = . , range - , instrument range - ). the average number of minutes participants reported practicing each week (and percent of attendees turning in homework records) were as follows: min ( %) during week (target min), min ( %) during week (target min sessions - ), min ( %) during week , min ( %) during week , min ( %) during week (target min sessions - ), min ( %) during week , min ( %) during week , min during week ( / participants reporting), and min during week ( / participants reporting). based on the qualitative interviews, participants felt that min was too long for the sessions; once group length was reduced to min, participants no longer suggested shortening groups. sessions were reconfigured to allow for additional discussion time because several participants were dissatisfied with the way that time was divided among presentation of new material, discussion, and practiced meditation. many mentioned that it was at least - weeks before people felt comfortable in the group, and they worried that because of the time needed to adjust, they had lost time in adequately learning the initial materials, which were built upon in subsequent later sessions. on the other hand, some felt that it was challenging to give everyone a chance to talk during informal discussions, particularly after the group became comfortable. finally, most participants stated that different learning levels in the class might have been better supported by providing more practice time with new material during the sessions to make some of the homework easier to absorb. this was addressed by having participants summarize past sessions and by using the final two sessions to consolidate learning. figure depicts the change over time in ptsd and depression. the effect sizes, calculated based on change from the first to last session attended, were partial eta squared of . for ptsd and. for depression. these would typically be interpreted as large effect sizes (cohen ) . the change in ptsd symptoms (pcl- total score), f( , . ) = . , p < . , and depression (phq- total score), f( , . ) = . , p = . , reached statistical significance, but audit-c did not, f( , . ) = . , ns. no change was observed in positive emotion (mdes positive), f( , . ) = . , ns, or negative emotion (mdes negative), f( , . ) = . , ns, a presented in fig. . data from the scs-r and scs-sf, which are similarly unchanged, are presented in table . several participants described an increased sense of peace and resilience during the qualitative interviews: for example: bi react a little different to certain things…i'm a lot calmer and i try to think about it first. i try to think about how i'm feeling and why.b my tendency before is that i'd get worked up too easily and act out in anger instead of rationally.b the meditation training had a very high calming ef-fect…i used the breathing to keep me from getting agitated or if i was feeling anxious or stressed in class. lso consistent with the intention of the intervention, participants expressed differences in the way that they think about others and themselves. exemplars of this are as follows: bi feel a little bit more compassion for other people's feelings and mine also. i try not to be so judgmental and give them the benefit of the doubt.b i was the kind of person that i wouldn't look or smile at people but now i try to be more tolerant and be friendlier. i'm trying to open up a little more to people i don't know.b we learned in class that everyone is just trying to be happy and that really clicked for me.Ô thers, however, suggested to us that the group began changes that were not complete. for instance: bi spent a lot of time with unpleasant thoughts. i am able to bcatch and release^a little easier and filter through what i want to be thinking. i still feel i have a long ways to go but i think i can do it.b i'd like to say that i appreciate people more but i don't.b i'm not letting go of things and giving people the benefit of the doubt. i haven't improved in those things but at least i'm aware of it.b i don't think i communicate with people any different yet, but i am learning to refocus in my environment to not react.m this project adapted a standard cm program to meet the needs of veterans with ptsd. the resulting manualized protocol, cbct-vet, appears to have potential in supporting recovery among veterans with ptsd. the now ten-session protocol was implemented in a series of four groups within a general va mental health clinic, involving participants who are generally representative of those who seek care at the facility. this open trial suggests that compassion meditation may help alleviate symptoms of ptsd and depression, although causality cannot be concluded based on this study design and the mechanism by which change occurs is unclear. the intervention was received well by participants based on ratings of credibility and satisfaction as well as qualitative interviews. the program was feasible to implement, although % completion is on the low end of what is typically observed in veterans with ptsd (e.g., polusny et al. ( ) , who had % completion of mindfulness-based stress reduction in their recent randomized trial). our conjecture that cm increases positive emotion, which was based largely on data from non-clinical samples, was not consistent with what we observed in our sessions and are not depicted because the very small sample size in those sessions (n = ) creates a misleading visual weekly emotion measure. qualitative data, however, suggest that participants experienced a greater sense of calm because of the intervention. thus, it is possible that the set of positive emotions measured by the mdes (i.e., joy, gratitude, contentment, interest, hope, pride, amusement, inspiration, awe, love) were relatively less impacted than a sense of peace and calm. in the future, considering emotional arousal and valence dimensionally, as suggested by in the circumplex model of emotions (russell ) , may be helpful in better understanding the emotional impact of cm. kearney et al. ( ) , for example, found some differences in terms of activated and unactivated emotions using the circumplex measure of emotion in their open trial of lkm for ptsd. it is also possible that change in positive emotion did not occur within the timeframe measured within this study but may become evident with continued practice. longerterm follow-up may be important in terms of understanding the nature of emotional change associated with compassion meditation practice. similarly, our measures of social connectedness and self-compassion were apparently unchanged by group participation. although the power is lower for these tests than for measures collected weekly, mean values, fig. change in positive and negative emotions over the period of the group. note: mdes: modified differential emotions scale. sessions and are not depicted because the very small sample size in those sessions (n = ) creates a misleading visual which changed very little, do not suggest that we simply lacked power to detect change. our qualitative data suggest that participants were beginning to change in terms of the way that they think about themselves and others but that such changes would take time. further, social connectedness reflects one's social network; once attitudes about others change, it likely takes time additional time to change one's relationships. it is possible that different measures (e.g., of empathy or social bias) may better reflect this early change than did the measures we used. another possibility would be to offer continuing practice to allow changes to consolidate, which was a request of several of the participants who completed the entire program. the question remains as to what led to the large effect size decreases in ptsd and depression that we observed over the course of the groups. it is always possible that non-specific factors, such as group cohesion (ellis et al. ) or hope (gilman et al. ), led to improvements. although the data should be interpreted with caution due to the small sample size, it appears that much of the change occurred in the first weeks when meditation was being taught but the contemplative work about compassion had yet to be presented. this raises the possibility that the general meditation skills, such as mindfulness, could be leading to the observed improvement. this would be consistent with work by owens et al. ( ) , who linked improvements in acting with awareness to decreased ptsd symptoms. we did not observe a change in the abbreviated mindfulness measure that was used in this project, however, so more thorough assessment may be useful in the future. finally, qualitative data suggest that the group may have improved emotion regulation, as people described being less likely to be triggered and more able to let things go. this possibility, too, is worth investigating as we try to understand the psychological mechanisms at work. in summary, this trial provides strong proof of concept evidence for the use of cm to support recovery among veterans with ptsd. a diverse sample of veterans enrolled in the program and provided productive feedback about the groups. we found large effect size changes in symptomatology, but a randomized trial is needed before drawing conclusions. the nonrandomized design of this study leaves open the possibility that observed changes are due to other factors, such as the passage of time, social support or nonspecific aspects of the intervention. the small sample size and self-selection into the trial are also significant limitations. the observed symptom change is based on self-report measures; in future studies these should be complemented by clinician administered tools, as is the gold standard in ptsd trials. weekly symptom assessment is standard for ptsd treatment; nonetheless, the frequency of use of these tools may influence participant responding. future studies should include alternative measures before and after treatment. finally, the treatment manual was modified over the course of this study, so the results reflect application of the general approach by our therapist rather than application of a manualized approach; this issue should be addressed in future studies. author contributions ajl: designed and executed the study, assisted with the treatment development, and wrote the paper. pc: conducted meditation groups and assisted with treatment development. sh: collected and analyzed qualitative data and assisted with treatment development. th: assessed fidelity to cbct and assisted with treatment development. sg: analyzed quantitative data and contributed to the writing of the paper. rg: acted as the research assistant and assisted with treatment development. me: assisted with treatment development. ln: developed cbct and assisted with treatment development. funding this study was funded by national institute for complementary and integrative health r at - a (pi, lang). ethical approval irb approval for this study was provided by the irb of the va san diego healthcare system. all procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional review board and with the helsinki declaration and its later amendments or comparable ethical standards. informed consent informed consent was obtained from all individual participants included in the study. 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the life events checklist for dsm- (lec- ) the ptsd checklist for dsm- (pcl- ) compassion training alters altruism and neural responses to suffering the effect of loving-kindness meditation on positive emotions: a metaanalytic review key: cord- -u qmvz c authors: livingston, nicholas a.; berke, danielle; scholl, james; ruben, mollie; shipherd, jillian c. title: addressing diversity in ptsd treatment: clinical considerations and guidance for the treatment of ptsd in lgbtq populations date: - - journal: curr treat options psychiatry doi: . /s - - - sha: doc_id: cord_uid: u qmvz c purpose of review: trauma exposure is widespread but is especially common among lesbian, gay, bisexual, transgender, and queer (lgbtq) individuals. lgbtq individuals also experience higher rates of discrimination, victimization, and minority stress which can complicate posttraumatic stress disorder (ptsd) treatment but also represent independent intervention targets. in this review, we highlight existing evidence-based practices, current limitations, and provide recommendations for care in the absence of established guidelines for treatment ptsd among lgbtq patients. recent findings: trauma-focused therapies (e.g., cpt, pe) and medications (e.g., ssris, snris) have shown benefit for people with ptsd. however, evaluations of these interventions have failed to examine the role of lgbtq identities in recovery from trauma, and existing ptsd treatments do not account for ongoing threat to safety or the pervasive minority stress experienced by lgbtq patients. in addition, many lgbtq patients report negative experiences with healthcare, necessitating increased education and cultural awareness on the part of clinicians to provide patient-centered care and, potentially, corrective mental health treatment experiences. summary: providers should routinely assess trauma exposure, ptsd, and minority stress among lgbtq patients. we provide assessment and screening recommendations, outline current evidence-based treatments, and suggest strategies for integrating existing treatments to treat ptsd among lgbtq patients. estimates suggest that - % of the general population will experience a criterion a traumatic event at some point in their lives [ ] , which is defined as "exposure to actual or threatened death, serious injury or sexual violence" [ [ ] ; p. ]. fortunately, most people who experience trauma do not develop posttraumatic stress disorder (ptsd), with the prevalence rate of ptsd in the general population between . and . % [ , ] . while no demographic group is immune to risk of trauma exposure, the nature, frequency, and severity of trauma exposure vary widely across groups. epidemiological data suggests that individuals who identify as lesbian, gay, bisexual, transgender, or queer (lgbtq) experience trauma, including violence and victimization, at higher rates than the general population [ ] [ ] [ ] [ ] . consequently, the estimated prevalence of ptsd tends to be higher among lgbtq individuals, with rates ranging from . to . % among lgb and . to % among transgender and gender diverse (tgd) individuals [ ] [ ] [ ] [ ] [ ] [ ] [ ] . thus, when treating lgbtq patients, screening for trauma exposure and ptsd symptoms is essential (see table ). any effective assessment and/or intervention begin with high-quality patient-provider communication, which is the cornerstone of patient-centered care. with patient-centered care, the focus is on the specific needs and intentions of the patient and encouraging the exploration and expression of these goals during the visit while attending to patient concerns, feelings, and emotions [ ] . for patients who identify as lgbtq, this work can begin even before the patient and provider have met, through content and location of advertisements for services, waiting room signs inclusive of members of the lgbtq community, and through use of inclusive paperwork (e.g., asking about preferred name, sexual orientation, and gender identity with all patients). practical advice about how to approach creation of a welcoming environment is widely available [ , ••] . beyond this, it is incumbent on providers to practice with the fundamental background knowledge and cultural insight to enable effective patient-provider communication. however, few professionals have training in the unique needs of lgbtq patients [ ] , which is essential for asking informed questions, establishing collaborative treatment plans, and engaging in the shared decision-making that makes patientcentered care possible [ ] . in this review, we share some recommendations for working with lgbtq patients, with considerable focus on understanding the unique experiential and cultural factors, as well as disparities, relevant to the care and recovery of lgbtq patients. we also highlight several evidence-based interventions for ptsd, discuss current limitations, and suggest assessment (tables and ) and intervention adaptations for providers to consider as they work with traumaexposed lgbtq patients. the intersection of minority stress and ptsd in addition to higher rates of trauma exposure and ptsd, lgbtq individuals may experience added stress as a function of the social attitudes, stigma, and prevailing policies that include lack of protections against discrimination at work, housing, and in public spaces [ ] . these stressors can include systemic and institutional oppression, discrimination, and microaggression experiences that serve as persistent reminders of lgbtq individuals' minority status [ , ] . these external and felt social stressors, or "distal stressors," can condition lgbtq individuals to anticipate rejection from others, experience shame, and to conceal their minority identity to prevent emotional pain, physical harm, or further trauma(s) [ , ] . these learned adaptations, in turn, are associated with higher rates of mental and physical health complications generally [ ] and can give rise to symptoms similar to each of the four main ptsd symptom clusters: intrusions, avoidance, negative alterations in cognition and mood, and hyperarousal. that is, intrusions share overlap with the occurrence of intrusive thoughts and rumination observed among lgbtq individuals who experience minority stress [ ] , and avoidance is consistent with their elevated rates of identity concealment and social withdrawal [ ] . disruptions in cognition and mood overlap with symptoms of depression, anxiety [ ] , and negative thoughts of self and others observed as well [ •] . hyperarousal, and hypervigilance in particular, has been observed following and in anticipation of discrimination [ ] . thus, the context of pervasive anti-lgbtq sentiment can exacerbate and/or complicate recovery from trauma and can even mimic ptsd symptoms in the absence of a criterion a event. a diagnosis of ptsd requires exposure to one or more criterion a trauma, as well as endorsement of ( ) persistent intrusive re-experiencing of the event ( or more symptoms), ( ) avoidance of stimuli associated with the event ( or more), ( ) negative alterations in their cognitions and mood ( or more), and ( ) increased arousal or reactivity ( or more; [ ] ). to be clear, we are not suggesting that minority stress leads to ptsd in the absence of criterion a trauma. however, clinicians should note that many lgbtq individuals report exposure to criterion a trauma and that minority stress can also lead to related symptom sequela. currently, these associations are poorly understood and warrant further research and clinical attention to better understand and more effectively intervene to address the intersecting consequences of traumatic stress and minority stress. in the meantime, as clinicians approach ptsd treatment among lgbtq individuals, we believe it is essential to understand the psycho-social history within their respective social, environmental, political contexts. understanding the personal history of lgbtq patients in context-often mired in stigma and discrimination-can aid in accurate case conceptualization, intervention planning, and treatment. as with any patient, a comprehensive, patient-centered, and culturally informed conceptualization will guide ptsd treatment planning among lgbtq patients. it is salient to gather information not only about patients' previous experiences and associated symptoms, but about the potential functions of lgbtq individuals' cognitive, affective, physiological, and behavioral responses to past trauma and minority stress experiences. in a recent study of trauma-exposed lgbtq veterans, researchers conducted semi-structured interviews and found that experiences shared by these individuals fell into four unique yet overlapping categories. experience categories derived from these interviews included ( ) "criterion a trauma," ( ) "discrimination," ( ) "microaggressions," and ( ) "minority stress" [ ••] . importantly, while each participant had experienced criterion a trauma, several described non-criterion a events as "traumatic" (e.g., the "trauma of the closet"). qualitative analyses also revealed significant overlap across these categories, such as criterion a trauma perpetrated on the basis of one's lgbtq identity, which also fell under "discrimination," as well as adaptations to high impact yet noncriterion a experiences worthy of clinical attention including paranoia, hypervigilance, drug use, sexual risk taking, and heightened anxiety and depression. these lgbtq veterans' reports suggest that non-diagnostic characteristics (i.e., socio-cultural reactions to lgbtq identity and expression, individual adaptions to hostile, invalidating, and/or traumatic reactions to lgbtq identity and expression, the functions of these adaptations in the context of anti-lgbtq environments) are important to assess. these reactions to environmental stressors can influence diagnostic symptom presentations and also reactions to acceptable and efficacious ptsd treatment for lgbtq individuals [ ] . we therefore recommend approaching treatment in a manner that takes into account and respects lgbtq individuals' previous experiences, as well as past and present context. as such, the context of care delivery deserves some thought, with providers offering an environment that clearly signals support for the lgbtq community. by directly confronting expectations of discrimination and addressing how minority stress and discrimination have impacted the patient's life, it becomes easier to determine the degree to which adaptations observed in treatment represent intervention targets and which are adaptive strategies to cope with minority stress. among trauma-exposed lgbtq patients, quality patient-centered communication may be particularly crucial for optimal ptsd treatment outcomes [ ] given that lgbtq individuals are more likely than the general population to experience discrimination both in daily life and while seeking mental and physical healthcare [ ] . lgbtq individuals may experience a reasonable distrust of the mental health profession due not only to personal experiences of discrimination in the context of help-seeking, but also due to the profession's longstanding history of labeling diversity in sexual orientation and gender identity as mental health disorders. this cultural and historical context is a critical barrier to lgbtq individuals accessing mental health services and disclosing their sexual orientation and gender identity to providers. as such, effective treatment of trauma-exposed lgbtq patients must acknowledge and counter these oppressive contexts [ , ] . the creation of strong patient-provider relationships through patient-centered care practices is a first essential step towards this goal. indeed, evidence suggests that high-quality clinician communication might buffer against disclosure apprehension in the context of previous discrimination in health care settings [ ] . moreover, clinicians who are not familiar with trauma-focused or minority stress-focused treatment can still work to empower patients to be active in managing their mental and physical health [ ] . for example, clinicians working with trauma-exposed lgbtq patients might expand their traditional conceptualization of their role within a particular specialty or subfield to function as advocates for their patients, facilitating referrals, collaborating and consulting with interdisciplinary treatment teams, and acting within one's scope of competence to support patients' treatment adherence. this work requires open dialogue about patients' lgbtq identity and identity-related concerns. as such, clinicians are encouraged to ask patients about their sexual orientation, gender identity, and related concerns as part of the intake process, and on an ongoing basis throughout care [ ] . if done effectively, such practices can impact patients' self-efficacy and autonomy, which can lead to improved emotional well-being, more effective coping, and improved functioning [ , ] . at the very least, patient-centered care that is affirming of lgbtq identities can provide positive and potentially corrective treatment experience, which itself may encourage treatment adherence and promote recovery. a thoughtful approach to assessment and careful and accurate case conceptualization can aid in the provision of evidence-based care in the absence of established ptsd treatment guidelines for lgbtq individuals. for lgbtq patients, this includes assessment of the complex and often overlapping experiences of past trauma(s), using established clinician-administered tools, such as the clinician-administered ptsd scale for dsm- [ ] , or self-report measures like the ptsd symptom checklist- [ ] (see table for suggestions). in addition, assessment of non-criterion a yet highly impactful experiences such as previous and ongoing discrimination, microaggressions, and minority stressors is essential to accurate case conceptualization and effective ptsd treatment. in addition, these non-criterion a stressors may themselves be targets of intervention, such as when patients are seeking additional coping skills. to aid in this endeavor, we provide recommendations for specific screening and assessment tools to facilitate treatment planning in tables and . cognitive behavioral "trauma-focused" therapies, such as prolonged exposure therapy (pe [ ] ) and cognitive processing therapy (cpt [ ••] ), have solid empirical support for use in the general population. these treatments are effective in addressing the psychological and physiological effects of trauma and represent front-line interventions in the treatment of ptsd according to american psychological association (apa) clinical practice guidelines [ ••] and the national center for ptsd [ ] . from a medication perspective, selective serotonin reuptake inhibitors (ssris) and serotonin-norepinephrine reuptake inhibitors (snris) have demonstrated some benefit in treating ptsd, though only sertraline (e.g., zoloft) and paroxetine (e.g., paxil) are fda approved for the treatment of ptsd [ ] . unfortunately, little is known regarding the efficacy of either trauma-focused therapies or medication treatments in the context of concomitant stressors impacting lgbtq individuals' mental health [ ••] . to date, no empirical study has directly tested whether the efficacy of first-line ptsd treatments is moderated by sexual and/or gender minority identity, as no randomized controlled trials of ptsd treatment report the sexual or gender minority status of their sample, nor stratify results by sexual or gender minority status [ ••, ••] . moreover, it is unknown if exposure to anti-lgbtq criterion a traumatic events, and/or comorbid experiences of minority stress impact treatment efficacy. these methodological practices limit the ability to draw empirically grounded conclusions about whether lgbtq individuals experience comparable benefit to their non-lgbtq counterparts from front-line ptsd treatment. in the absence of empirical guidance or established clinical guidelines, we provide preliminary treatment recommendations based on anecdotal evidence with the goal of promoting a broader discourse about the mechanisms, techniques, and assumptions that underlie, and can best advance, the treatment of ptsd among lgbtq patients. the primary focus of this discussion is on talk therapies rather than on medications, as the former has stronger empirical support currently. the latter also offers interpersonal context in which the nuanced issues raised here can be systematically and therapeutically addressed. however, the importance of understanding the interplay between traumatic events, discrimination, minority stress, and microaggressions is essential for all treating providers, including those offering medication only. to begin the review of current best-practice interventions for ptsd, it is important to note that gold-standard ptsd treatments, such as pe and cpt, were not developed for non-criterion a trauma, and that debate continues regarding the appropriateness or sufficiency of these treatments in addressing the range of clinically significant experiences faced by many lgbtq individuals (e.g., discrimination [ ••] ). specifically, pe and cpt were each derived from theoretical frameworks that assume that the lasting harms of trauma exposure are attributable to fear-based life-threat experiences and their impact on subsequent socio-cognitive and or emotional processing [ ] . however, there is growing consensus that clinical distress among trauma-exposed lgbtq individuals may stem from more than life-threat experiences. the pervasive invalidation of a patient's identity in our culture and in our health care systems, such as the pathologizing lgbtq identities, can erode well-being due to the disruption of allostasis and ongoing allostatic load on the individual's system [ ] . for example, as previously mentioned, lgbtq individuals may also experience criterion a events that are directly related to sexual or gender minority identity (e.g., hate crimes). these experiences may threaten identity and integrity resulting in grief and shame responses that may be considerably more complex and toxic than a purely fear-based response to a non-identity linked life-threat trauma (e.g., tornado). for instance, fredriksen-goldsen and colleagues found that identity processes impacted by experiences of victimization, such as identity appraisal and identity management, moderated the relationship between marginalization and health outcomes in a sample of older lgbtq adults [ ] . thus, the experience of trauma related to lgbtq identity may uniquely impact how lgbtq individuals manage identity disclosure and concealment, which in turn may shape access to social resources, mental health outcomes, and health promoting behaviors relevant to ptsd onset and course [ ] . unfortunately, trauma-focused therapies for ptsd, which focus predominantly on de-conditioning overgeneralized fear responses to environmental stimuli and remediation of cognitive distortions stemming from past trauma(s), were not developed to target such identity-related adaptations to trauma exposure. moreover, existing theories do not account for contexts in which chronic victimization experiences, elusive safety, or daily identity-based threats may influence or account for coping strategies (e.g., adaptive vigilance), negative appraisals, and emotions implicated in ptsd etiology [ , ] ). counter to the typical approach of identifying overgeneralized beliefs, distorted thoughts, and exaggerated physiological responses to target in therapy, for many traumaexposed lgbtq individuals, these adaptations may not be exaggerated nor distorted and may serve important ongoing safety functions, such as avoiding realistic threat of future lgbtq-based discrimination. it might be easy for a provider to mischaracterize such an accurate appraisal of realistic environmental threats as "hypervigilance" and overlook the fact legitimate threat persists and precaution may be necessary for their patient [ ••, ] . consequently, we would argue that to be clinically valid, any theory that operationalizes change agents in the treatment of ptsd among lgbtq individuals must account for how the intervention targets these disparate phenomenologies. in addition, and in the absence of existing recommendations for organizing trauma-focused therapy for lgbtq individuals, we recommend careful assessment and delivery of care in a manner that is affirming of patients' lgbtq identity and that leverages an individualized case conceptualization to address co-occurring trauma, minority stress, and related ptsd sequela. for example, the application of emotion processing theory [ , ] , the theoretical basis of pe, can be extended to reduce both fear and shame associated with anti-lgbtq criterion a trauma. specifically, pe can be used to counteract avoidance by activating and exploring the context of memory networks linked to shame, fear, and associated cognitions (e.g., "i was assaulted for being gay. therefore, i will be judged and rejected if i am honest and open about who i am"). exposure-based procedures can be used to reduce problematic emotions and beliefs that maintain avoidance and limit access to social support by providing access to events that prompt these problematic emotions while simultaneously blocking ineffective emotion-expression and action (e.g., hiding, concealment of gay identity). to facilitate new learning and effectively reduce distress, it is essential that exposures occur in contexts in which the feared or avoided outcome is unlikely to occur. the therapeutic relationship is an opportunity to offer a context where that new learning can occur in relative safety, if handled appropriately by the provider. given a broader social context in which negative interactions are pervasive for lgbtq individuals, clinicians must be creative and flexible about structuring exposure opportunities that promote competence and mastery outside of therapy as well. these exposures can be a part of formal pe therapy or an adjunct to medication treatments when indicated. to this end, clinicians are encouraged to develop a familiarity with lgbtq resources, community organizations, and/or support groups in their local area. the use of imaginal-exposure in addition to in vivo exposure procedures may also be helpful and provide patients an opportunity to develop skills for tolerating difficult emotions and coping with feared outcomes in a safe and affirming environment. similarly, tactical modifications may be applied to the use of socratic questioning in cpt to address appraisals about threats to safety, esteem, and social acceptance among lgbtq individuals exposed to ongoing discrimination, microaggressions, and other minority stressors. a case description of application of cpt following an anti-gay physical assault demonstrates the use of cpt to address ptsd symptoms in addition to internalized homophobia [ ] . cpt entails alleviating problematic trauma-linked emotions by modifying the distorted cognitions, or stuck points that manufacture or exacerbate difficult emotions. in cases in which patient's evaluations of risk are indeed distorted, cognitive restructuring may be highly effective in alleviating suffering. however, in many cases, distressing appraisals of ongoing threats to safety, acceptance, and identity may well be reasonable and appropriate. in these cases, a shift from challenging patient's accurate appraisals of risk toward supporting the patient to identify a more affirming context is warranted. in addition, bolstering the patient's perceived ability to cope with and recover from the effects of social rejection or invalidation may be effective. in some cases, teaching or enhancing coping skills may be a direct focus of treatment. recent efforts to develop and evaluate treatments tailored to the concerns of lgbtq patients have produced encouraging results. effective skills to empower effective men (esteem) is a transdiagnostic treatment developed to target minority stress and associated negative health consequences. esteem is a session treatment that enhances emotion regulation skills, reduces avoidance patterns, and improves motivation and self-efficacy for behavior change. in the initial waitlist-controlled pilot trial of esteem treatment among gay and bisexual men, results demonstrated improved depression, alcohol use, and sexual risk-taking outcomes for those undergoing the treatment [ ] . although this was a small-scale pilot study, esteem is currently being investigated in a large multi-site trial (clinicaltrials.gov identifier: nct ) that can potentially lead to further evidence of effectiveness and/or insight for future intervention development. examination of the modular content of the esteem treatment provides insight into ways it might be adapted for use among trauma-exposed lgbtq individuals. the essential components of the esteem intervention include ( ) normalizing the negative impacts of minority stress; ( ) promoting emotional awareness and self-regulation; ( ) empowerment and assertive communication skill development; ( ) cognitive restructuring around minority stress; ( ) identification and validation of individuals' strengths; ( ) building healthy social supports; ( ) supporting adaptive and rewarding sexual expression; and ( ) decreasing avoidance of emotions, situations, or people (e.g., identity concealment, social isolation [ ] ). the emotion avoidance module of the esteem intervention specifically targets emotion avoidance behavior leading to unhealthy behaviors such as social isolation and substance use. other modules with direct relevance to recovery from trauma and ptsd include those examining the impacts and developing skills to manage minority stress, empowermentbased assertiveness training and social support seeking, cognitive restructuring of maladaptive thinking patterns, and "relapse prevention" to help sustain therapeutic gains. in addition to the esteem protocol, parsons and colleagues recently reported pilot outcomes of their intervention [ •] , adapted from the unified protocol for transdiagnostic treatment of emotional disorders [ ] and focused on promoting emotion regulation. results provided preliminary support for the efficacy of an emotion-focused intervention to reduce anxiety and depression among gay and bisexual men [ •] . as the field stands, most attempts to develop targeted interventions for this population have focused on gay and bisexual men, and specifically on sexual risk-taking and related symptoms of anxiety, depression, and substance use which are associated with hiv transmission. for example, a trial of men who have sex with men (msm) with risky sexual behaviors and childhood sexual abuse histories were offered cognitive-behavioral therapy for trauma and self-care (cbt-tsc). the cbt-tsc treatment included a modified version of cpt treatment coupled with sexual risk reduction education and were compared to those receiving only hiv risk reduction and testing. both ptsd symptoms and hiv risk-taking reduced over the course of cbt-tsc treatment relative to those in the control condition, with gains maintained through -month follow-up [ • ]. however, it should be noted that the primary outcome of the cbt-tsc was risky sexual behavior and a ptsd diagnosis was not an inclusion criterion. the development of esteem and cbt-tsc and their promising outcome data provide encouraging directions for further treatment development, as well as implications for integration of its modular content with existing evidence-based ptsd treatments. that is, front-line evidencebased ptsd treatments, like pe and cpt, focus on cognitive restructuring, habituation to overgeneralized fear responses to trauma cues, and helping individuals reducing ineffective avoidance behaviors impacting recovery and quality of life. acknowledging the important differences between intervention like esteem or cbt-tsc and evidence-based ptsd treatments, we also see areas of important overlap and more importantly, opportunity for integration. in the absence of evidence-based ptsd treatments that are inclusive of minority stressors, and lgbtqbased or minority stress-oriented treatments that extend to criterion a trauma and ptsd sequela, informal integration of these interventions might help bridge the gap while researcher work to develop and evaluate novel intervention strategies. in the future, we hope these innovations will also be inclusive of lesbian and bisexual women as well as transgender individuals. given the pervasive nature of stress, stigma, and discrimination against lgbtq people, and the concomitant high rates of trauma exposure, it is critical for health care providers to ensure cultural awareness, sensitivity, and responsiveness to the experiences and healthcare 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designed to help gay and bisexual men manage emotions and reduce sexual risk and related risk-taking behaviors unified protocol for transdiagnostic treatment of emotional disorders: therapist guide publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -bo ui zh authors: shervington, denese o.; richardson, lisa title: mental health framework: coronavirus pandemic in post-katrina new orleans date: - - journal: j inj violence res doi: . /jivr.vo i . sha: doc_id: cord_uid: bo ui zh the united nations office of disaster risk reduction defines disaster risk as the “likelihood of loss of life, injury or destruction and damage from a disaster in a given period, and a product of the complex interactions that generate conditions of exposure, vulnerability and hazard”. racial and ethnic minorities in the united states have been shown to have increased vulnerability and risk to disasters due to links between racism, vulnerability, and economic power, based on disadvantage related to different disaster stages: ) reduced perception of personal disaster risk; ) lack of preparedness; ) reduced access and response to warning systems; ) increased physical impacts due to substandard housing; ) likelihood of poorer psychological outcomes; ) cultural insensitivity on the part of emergency workers; ) marginalization, lower socio-economic status, and less familiarity with support resources leading to protracted recovery; and ) diminished standard of living, job loss, and exacerbated poverty during reconstruction and community rebuilding. moreover, given that psychiatric morbidity is predictable in populations exposed to disasters, mental health and psychosocial support programs should increasingly become a standard part of a humanitarian response. in the crisis and immediate recovery phase of disasters, the focus should be on making survivors feel safe and giving them assistance in decreasing their anxiety by addressing their basic needs and welfare. so, it is critical that governmental institutions, business, and non-profit organizations proactively find mechanisms to work collaboratively and share resources. special attention and extra resources must be directed towards vulnerable and marginalized populations. in this editorial we share lessons learned from experiencing disproportionate impact of health crisis and advocate for the notion that recovery efforts must address trauma at individual, interpersonal and community levels, and be based in a healing justice framework. new orleans' annual mardi gras celebration culminated in the last two weeks of february , with over . million visitors in the city. the first case of covid- was reported on march , and the first death was reported on march . on friday, march , after at least people died due to covidrelated illnesses, the mayor issued a stay-at-home order asking residents to avoid large crowds and to go outside only for essential services. according to the louisiana department of health office of public health, as of march , cases had been reported in louisiana, with deaths. eighteen hundred and thirty-four cases were reported in orleans parish, of which people have died. the city of new orleans has become one of the national epicenters of the covid- pandemic. an article appearing on march in the atlantic entitled, "watch new orleans: with the country's attention turned north, the coronavirus pandemic is exploding in louisiana," journalist van newkirk paints an alarming picture of the public health crisis. approximately % of the u.s. population lives in louisiana, but the state reports % of all covid- deaths, % of all hospitalizations, and % of all positive tests nationwide. the louisiana department of health and hospitals statistics indicate that orleans and jefferson parishes have the highest coronavirus death rates in the country. in orleans parish, there are . covid- deaths for every , residents, and . for jefferson parish. by comparison, both parishes have significantly higher death rates than king county, in seattle, which reports . deaths for every , residents and new york city that reports . deaths for every , residents. the united nations office of disaster risk reduction defines disaster risk as the "likelihood of loss of life, injury or destruction and damage from a disaster in a given period, and a product of the complex interactions that generate conditions of exposure, vulnerability and hazard". racial and ethnic minorities in the united states have been shown to have increased vulnerability and risk to disasters due to links between racism, vulnerability, and economic power, based on disadvantage in each of the eight disaster stages: ) reduced perception of personal disaster risk; ) lack of preparedness; ) reduced access and response to warning systems; ) increased physical impacts due to substandard housing; ) likelihood of poorer psychological outcomes; ) cultural insensitivity on the part of emergency workers; ) marginalization, lower socio-economic status, and less familiarity with support resources leading to protracted recovery; and ) diminished standard of living, job loss, and exacerbated poverty during reconstruction and community rebuilding. the new orleans data center has highlighted that the disparate severity of covid- in orleans parish can be attributed to a long history of racial inequities and socioeconomic disadvantages. the report went on to highlight various inequities, inequalities, and disparities, due largely to race and socio-economic status: ) compared to other hotspots, new orleans has higher poverty rates and lower average incomes; ) nearly in new orleans households do not have access to a vehicle, making drive-up testing close to impossible; ) twenty two percent of new orleanians have no access to internet, including smart phones; ) new orleans adults suffer from high blood pressure, diabetes, chronic kidney disease, and other preexisting conditions at rates higher than in seattle, new rochelle, or new york city. the impact of covid- is further amplified by the well-documented legacy of institutional racism and stark economic and health inequities, including limited access to quality healthcare. the high prevalence of the pre-existing conditions that put people at risk for serious complications from the coronavirus reflect the outcomes associated with negative social determinants of health. disasters reflect an encounter between a hazardous force (in this case the coronavirus) and a human population in harm's way which, within the ecological context, can create demands that exceed the coping capacity of the affected community. a disaster's forces of harm (loss and change) are a complex interplay of the interrelationship and interdependence of social and ecological factors-the individual/family context, the community context, and the societal/structural context. new orleans, nearly years ago, experienced a major disaster. on august , , hurricane katrina struck america's gulf coast. katrina was the deadliest hurricane in seven decades to hit the united states, bringing severe winds and record rainfall into new orleans for a -hour period. two days of intense storm surge damaged the city's pumping system, rendering it incapable of draining the rising water as major floodwalls failed along multiple city wa-terways. as a result, % of the city flooded, and homes, communities, and the urban infrastructure were destroyed. for weeks, the city was submerged in floodwaters as high as five meters, which resulted in extensive structural damage. service delivery was brought to a standstill, and emergency and rescue efforts were severely hampered. more than , people were evacuated, and a minimum of people died from storm-related causes. , in , the national weather service estimated that there was at least $ billion dollars in property damage from hurricane katrina, making it the costliest natural disaster in u.s. history at that time. a survey conducted two months post-katrina by the centers for disease control and prevention and the louisiana office of mental health found that % of those sampled were suffering from ptsd. a longitudinal survey of adult gulf coast residents (n= ) who were directly affected by hurricane katrina found the prevalence of ptsd six months post-katrina was twice as high as the prevalence estimates for the population in the years prior to the hurricane. in this study, poor, racial and ethnic minorities and those with fewer years of formal education more commonly reported stressful experiences postevacuation. notably, ptsd symptomatology was most common among those who lived in new orleans- . % of these respondents reported nightmares, . % reported being jumpier or startled more easily, and . % reported being more irritable or angry than usual. the follow-up survey conducted a year later found that anxiety or mood disorders persisted and increased slightly from . % to . %, and the prevalence of ptsd had almost doubled among those residents who remained displaced. similarly, suicidality was significantly higher with regard to suicidal ideation and suicide plans. a longitudinal study of low-income african american mothers pre-and post-katrina found that even though symptoms of post-traumatic stress disorder (ptsd) declined over time after the hurricane, they remained high- % of the sample showed scores suggesting continued symptoms of ptsd - months after the hurricane. the study also found that there was in increase in psychological distress from % pre-katrina to % - months after the hurricane. home damage was an important predictor of chronic symptoms of ptsd. these data differ from the typical post-disaster circumstances where mental disorders significantly decrease with time and up to % typically resolve within a year. for example, the dou-bling of ptsd levels noted two months after the september attacks returned to baseline - months later. these data illustrate the more severe adverse psychological effects of hurricane katrina compared to other disasters and emphasize the disproportionate mental health impacts of disasters on socio-economically disadvantaged racial and ethnic minority groups. a survey conducted by the institute of women and ethnic studies (iwes) in with adult african american katrina evacuees who had returned to new orleans within two years of the hurricane revealed that % reported irritability and depression, % reported appetite changes, % reported sleep disturbances, and % reported difficulty concentrating. regarding symptoms of ptsd, % reported flashbacks, % reported avoidance of stimuli, and % reported startling more easily. since , iwes has assessed youth for symptoms of ptsd and depression based on criteria from the american psychiatric association's diagnostic and statistical manual fifth edition and screened youth for exposure to violence and worries about their basic needs. close to years post-katrina, psychosocial screenings show an extremely high prevalence of traumatic stress and mental health disorder symptoms among youth aged - in new orleans. of the youth surveyed thus far, % endorse symptoms of depression; % endorse symptoms of lifetime ptsd with % endorsing symptoms of current ptsd; % report exposure to domestic violence; % report having lost a family member or someone close to murder; and % worry about not being loved. of note, the national prevalence rate for adolescent ptsd is % while the rate for depression is %. unlike disasters that are land-based, visually apparent, and time-bound-hurricanes, fires, earthquakes, tornadoes, flooding, and wind/sand storms-this disaster is silent, unseen, and highly unpredictable, and at this point there is no way of determining when the pandemic will end. this uncertainty and unpredictability about the spread of covid- and its impact has created significant emotional distress. a recent poll by the american psychiatric association conducted march - , found that a significant number of americans ( %) are anxious about the possibility of family and loved ones contracting covid- . the survey also found that % of americans report that the coronavirus is having a serious impact on their mental health, with % reporting that the virus is having a significant impact on their day-to-day lives. over % are worried about running out of food, medicine and/or supplies, and % worry that the virus will have a significant impact on their finances. it should be anticipated that mental health needs in new orleans during and after the coronavirus crisis will be significant and may be greater than in other us cities, given higher baseline (katrina-related) levels of trauma-based conditions. additionally, as has occurred globally, it is expected that frontline healthcare providers, at greatest risk for contagion from the virus, will be at great risk of developing unfavorable mental health outcomes. those who experience catastrophic events show a wide range of reactions: some suffer only worries and bad memories that fade with emotional support and the passage of time; others are more deeply affected and experience long-term problems-ptsd, depression, generalized anxiety disorders, and substance use disorders are the most common post trauma psychiatric sequelae. a systematic review of posttraumatic stress disorders following disasters in the past three decades concluded that the burden of ptsd among people exposed to disasters is substantial and is correlated with factors such as sociodemographic and background factors, event exposure, social support, and personality traits. in a february blog, the american psychiatric association committee on psychiatric dimensions noted that adverse psychological and behavioral responses to infectious disease outbreaks are common and include insomnia, reduced feelings of safety, scapegoating, increased use of alcohol and tobacco, somatic symptoms (physical symptoms) such as lack of energy and general aches and pains), and increased use of medical resources. given that psychiatric morbidity is predictable in populations exposed to disasters, mental health and psychosocial support programs should increasingly become a standard part of a humanitarian response. a global panel of experts on disaster and mass violence identified five key intervention principles that should be used to guide and inform intervention and prevention efforts at the early to midterm stages of the event. these principles are: ) promote a sense of safety; ) promote calm; ) promote a sense of self-and collective efficacy; ) promote connectedness; and ) promote hope. these principles were empirically found to restore social and behavioral functioning after disasters. in the crisis and immediate recovery phase of disdisasters, the focus should be on making survivors feel safe and giving them assistance in decreasing their anxiety by addressing their basic needs and welfare. in the lessons learned after the fireworks disaster in enschede, netherlands, soon after a disaster, survivors must be helped to regain their autonomy, reserving clinical psychiatric help for those exhibiting dissociative symptoms or those with prolonged mental health symptoms that showed no improvement after two months. similarly, the world health organization's guidance (june ) regarding mental health in emergencies advises.  strengthen community self-help and social support  offer psychological first aid-first-line emotional and practical support  assure basic mental health care for priority conditions (e.g. depression, psychotic disorders, epilepsy, substance use disorder, etc.) is provided at every health-care facility by trained and supervised general health staff)  provide psychological interventions offered by specialists, trained in trauma-focused approaches, for people impaired by prolonged distress  protect and promote the rights of people with severe mental health conditions and psychosocial disabilities  create links and referral mechanisms between mental health specialists, general health-care providers, community-based support, and other services (e.g. schools, social services, and emergency relief services such as those providing food, water, and housing/shelter) the national child traumatic stress network and the national center recommend psychological first aid (pfa) for ptsd when providing early assistance within days or weeks following an event. pfa is an evidence-informed modular approach to help children, adolescents, adults, and families in the immediate aftermath of disaster and terrorism. pfa is designed to reduce the initial distress caused by traumatic events and to foster short-and long-term adaptive functioning and coping. the core objectives are listed in table . in response to the current viral pandemic, the following strategic activities are being recommended based on local adaption to the aforementioned global and national frameworks, as well as lessons learned from hurricane katrina: to respond to contacts initiated by survivors or to initiate contacts in a non-intrusive, compassionate, and helpful manner. to enhance immediate and ongoing safety and provide physical and emotional comfort. to calm and orient emotionally overwhelmed or disoriented survivors. to identify immediate needs and concerns, gather additional information, and tailor psychological first aid interventions. to offer practical help to survivors in addressing immediate needs and concerns. to offer practical help to survivors in addressing immediate needs and concerns. to provide information about stress reactions and coping to reduce distress and promote adaptive functioning . linkage with collaborative services to link survivors with available services needed at the time or in the future. . support organizations/institutions addressing basic needs (food, housing, finances) and access to healthcare . promote physical safety in the population at large a. provide education regarding coronavirus transmission and steps to prevent transmission and dispel myths b. provide education regarding when to seek testing and/or hospital services . promote psychological safety through virtual/digital and social media; traditional media-print, radio, tv, and billboards: a. provide normalizing psycho-education regarding fear, anxiety, and mood disturbances (normal response to the threat of harm from virus) b. create virtual connection and community to enhance individual and collective efficacy, interpersonal learning, and hopefulness/optimism c. teach calming and coping mechanisms for the general population and targeted populations (medical providers, teachers, new parents, cbos) i. deep breathing ii. mindfulness meditation iii. overall wellness and self-care affirmations . assure access to tele-health resources and medication for residents with existing or newly acquired serious mental health disorders . conduct a rapid assessment of community knowledge, attitudes, beliefs, and actions regarding coronavirus. . prepare mental health systems (public and private) to provide culturally-proficient trauma-based services for children, adolescents, and adults . conduct research to assess level of traumabased disorders . conduct trainings at multiple levels in educational system to assist schools in being able to realize, recognize, and respond to increased levels of trauma conditions in students -i.e. assist schools in adopting trauma-informed and restorative practices . increase access to mental health servicescommunity and school-based with hurricane katrina, widespread assessment of disaster response and recovery efforts emphasized the lack of effective leadership within the federal emergency management agency which, under the authorization of the u.s. department of homeland security, coordinates communications across federal agencies in response to disasters. the inadequate rescue and failed governmental response to the disaster was decried by human rights experts as "shocking, a gross violation of human rights". a select bipartisan committee of the u.s. house of representatives investigating the hurricane cited failures at all levels of government. the report, "a failure of initiative," noted that medical care and evacuations suffered from a lack of advance preparations, inadequate communications, and inadequate coordination, and that the failure of complete evacuations led to preventable deaths, great suffering, and further delays in relief. the impact that the virus will have on the city will inevitably conjure memories of katrina for many new orleanians. covid- will affect every aspect of life. its predicted force is akin to a tsunami: a devastating eruption generating a series of progressive waves that sweep across the land in ever-widening circles. so as to never repeat the failures of hurricane katrina, it is critical that governmental institutions, business, and non-profit organizations proactively find mechanisms to work collaboratively and share resources. special attention and extra resources must be directed towards vulnerable and marginalized populations. for example, children that were born into and lived through the aftermath of katrina continue to show emotional distress nearly years after the disaster. the trauma caused by this public health crisis will be carried and embodied for the longest time by the youth that are living through it. meaningful action must be taken immediately to mitigate the possible devastating impact of this virus on the youth of new orleans. experts are calling for wide-ranging federal action including direct payments to families during this crisis, a national moratorium on rent and eviction, additional support for the homeless, and emergency resources for children in foster care. vann newkirk's march , article in the atlantic, "the kids aren't all right", focuses on the trauma and long-term economic impact that the crisis will have on children. newkirk interviewed bruce lesley, the president of first focus on children, who is advocating for an expansion of the supplemental nutrition assis-tance program (snap), and alice fothergill, who coauthored "children of katrina" with lori peek. fothergill spent seven years studying the effects of katrina on young people and found that existing social disadvantages, in this case poverty and race, fueled an uneven recovery among kids based on their socio-economic circumstances. she noted, "disasters last a really long time in the lives of children. people are talking about vulnerability, but they are not talking about children at all." as dr. shervington has advised on billboards throughout the city of new orleans in the years post-katrina as youth violence began to spike, 'untreated trauma is the underbelly of violence'. the covid- pandemic now grips new orleans in another disaster. we have learned that response and recovery efforts must address trauma at individual, interpersonal and community levels, and be based in a healing justice framework, as outlined in iwes' publication, healing is the revolution. united nations international strategy for disaster reduction race, ethnicity and disasters in the united states: a review of the literature monitoring the covid- pandemic in new orleans and louisiana textbook of disaster psychiatry hurricane katrina: facts, damage and aftermath control cfd, prevention. surveillance for illness and injury after hurricane katrina--three counties overview of baseline survey results: hurricane katrina community advisory group five years later: recovery from post traumatic stress and psychological distress among low-income mothers affected by hurricane katrina post-traumatic stress disorder following disasters: a systematic review mental health in new york city after the september terrorist attacks: results from two population surveys no one is coming to save us: coping with the stressful aftermath of katrina american psychiatric association. diagnostic and statistical manual of mental disorders prevalence, persistence, and sociodemographic correlates of dsm-iv disorders in the national comorbidity survey replication adolescent supplement. arch gen psychiatry factors associated with mental health outcomes among health care workers exposed to coronavirus disease the epidemiology of post-traumatic stress disorder after disasters committee on psychiatric dimensions of disasters. psychiatry.org/news-room/apa-blogs/apa-blog , accessed evidence-based mental health and psychosocial support in humanitarian settings: gaps and opportunities. evi-dencebased mental health five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. psychiatry mental health services required after disasters: leaning from the lasting effects of disasters mental health center in post-disaster recovery: ten-year retrospective of mediant's work in enschede, netherlands national child traumatic stress network and national center for ptsd poverty expert finds new orleans 'shocking select bipartisan committee to investigate the preparation for and response to hurricane katrina. a failure of initiative the kids aren't all right healing is the revolution. institute of women and ethnic studies competing interests: none declared. ethical approval: not required. key: cord- -bz ui a authors: hans-peter, kapfhammer title: posttraumatic stress disorder in survivors of acute respiratory distress syndrome (ards) and septic shock date: - - journal: psychosom konsiliarpsychiatr doi: . /s - - -x sha: doc_id: cord_uid: bz ui a acute lung injury (ali) and acute respiratory distress syndrome (ards) define medical conditions of acute respiratory insufficiency deriving from direct and indirect damage of the alveolar parenchyma and often associated with multiorgan dysfunction (mods). as a rule, intensive care is based on mechanical ventilation often requiring high doses of sedatives and narcotics. despite major progress in intensive care medicine the rate of mortality is still very high. whereas in the past the level of medical progress has been rated based on the mortality rate alone, the many negative somatic and psychological sequelae in long-term-survivors of ards are only now being appreciated. from a perspective of c/l psychiatry persisting cognitive dysfunctions, anxiety and mood disorders, posttraumatic stress disorders (ptsd) in their negative impact on health-related quality of life are intensively investigated. in the etiopathogenesis of ptsd associated with ali/ards, many influences have to be discussed, e.g., increases in co( ) triggering panic affects, a mismatch of norepinephric overstimulation and cortisol insufficiency, negative effects of high doses of benzodiazepines resulting in oversedation, prolonged phases of weaning and more frequent states of delirium. consolidation and retrieval of traumatic memories of the icu stay are influenced by complex factors. from a clinical point of view prophylactic stress doses of hydrocortisone may reduce the major risk of ptsd associated with ali / ards. abstract acute lung injury (ali) and acute respiratory distress syndrome (ards) define medical conditions of acute respiratory insufficiency deriving from direct and indirect damage of the alveolar parenchyma and often associated with multiorgan dysfunction (mods). as a rule, intensive care is based on mechanical ventilation often requiring high doses of sedatives and narcotics. despite major progress in intensive care medicine the rate of mortality is still very high. whereas in the past the level of medical progress has been rated based on the mortality rate alone, the many negative somatic and psychological sequelae in long-term-survivors of ards are only now being appreciated. from a perspective of c/l psychiatry persisting cognitive dysfunctions, anxiety and mood disorders, posttraumatic stress disorders (ptsd) in their negative impact on health- in the etiopathogenesis of ptsd associated with ali/ ards, many influences have to be discussed, e.g., increases in co triggering panic affects, a mismatch of norepinephric overstimulation and cortisol insufficiency, negative effects of high doses of benzodiazepines resulting in oversedation, prolonged phases of weaning and more frequent states of delirium. consolidation and retrieval of traumatic memories of the icu stay are influenced by complex factors. from a clinical point of view prophylactic stress doses of hydrocortisone may reduce the major risk of ptsd associated with ali / ards. [ ] . in den letzen bis jahren gab es geradezu einen explosionsartigen wissenszuwachs zur pathophysiologie und differenzialtherapie von mods bis hin zur aufdeckung molekularer mechanismen. neben untersuchungen zu akuten krankheitsstadien von ali und ards zeichnen sich die mittel-und langfristigen probleme eines Überlebens aber ebenfalls immer deutlicher ab. auf einer somatischen ebene sind vor allem ein reduziertes körpergewicht, eine eingeschränkte körperliche belastungsfähigkeit, persistierende schmerzsyndrome, neuropathien, heterotrophe ossifikationen, kosmetisch störende narben von tracheostomien, fixierte deformationen an fingern und schulter hervorzuheben [ ] . hiermit assoziierte bedeutsame einbußen in der gesundheitsbezogenen lebensqualität sind im langzeitverlauf zu beachten [ ] . in einer konsiliarpsychiatrischen perspektive sind die vielfältigen psychopathologischen komplikationen, die eine schwerwiegende somatische erkrankung wie ards oder septischer schock sowie deren intensivmedizinische therapiemodalitäten während des aufenthalts auf einer intensivstation begleiten können, seit langem bekannt [ ] . die langfristigen psychosozialen und psychologischen probleme als konsequenzen aus dieser erkrankung und dem notwendigen intensivmedizinischen behandlungskontext werden in studien erst in den letzten jahren zunehmend stärker beachtet. diskutiert wird vor allem eine erhöhte psychiatrische komorbidität hinsichtlich neurokognitiver dysfunktionen, angst-und stimmungsstörungen und speziell posttraumatischer belastungsstörungen. negative interferenzen sowohl mit der gesundheitsbezogenen lebensqualität als auch mit der somatischen morbidität werden erkennbar. einflussfaktoren auf diese komplexen somatopsychischen und psychosomatischen zusammenhänge zeichnen sich erst allmählich ab. dies gilt auch für die erprobung therapeutischer und präventiver interventionsstrategien. Überlebende einer akuten respiratorischen insuffizienz im rahmen eines ali oder ards weisen ein signifikant erhöhtes risiko für anhaltende neurokognitive dysfunktionen im langzeitverlauf auf. hierauf machte bereits eine frühere neuropsychologische studie aufmerksam [ ] . mittlerweile existieren mehrere untersuchungen von unterschiedlichen arbeitsgruppen zu diesem thema. sie bestätigen, dass eine subgruppe von früheren ards-patienten in der tat persistierende kognitive leistungseinbußen zeigt [ ] . die prävalenzzahlen schwanken zwischen einem drittel und ca. drei viertel der Überlebenden eines ards. zahlreiche methodologische probleme erschweren aber die interpretation dieser stark divergierenden häufigkeitsangaben. nicht selten ist die unterscheidung von daten zur prävalenz und zur inzidenz unmöglich, da in den studien nur ausnahmsweise informationen zur prämorbiden kognitiven performanz enthalten sind. dies ist von bedeutung, da in einigen bedingungskonstellationen wie z. b. einer vorbestehenden alkoholabhängigkeit nicht nur ein erhöhtes risiko zu einem ards selbst besteht, sondern auch eigenständig kognitive dysfunktionen assoziiert sein können. ebenso bleibt unklar, ob eher spezifische kognitive leistungsdomänen wie aufmerksamkeit, merkfähigkeit oder exekutivfunktionen oder überwiegend das globale kognitive leistungsvermögen diffus durch den somatischen krankheitsprozess und/oder interferierende therapiemaßnahmen negativ beeinflusst werden. auch wenn zahlreiche variable wie hypoxie, delir, glukosedysregulation, metabolische entgleisung, inflammation, medikamenteneffekte von sedativa und narkotika mögliche und auch wahrscheinliche mechanismen einer vermittlung dieser kognitiven beeinträchtigungen andeuten, ist eine differenzielle ätiopathogenetische bewertung noch nicht möglich. der sich in einigen studien andeutende spezielle zusammenhang von deliranten zuständen während der intensivmedizinischen behandlung und kognitiven defiziten in der langzeitperspektive stellt sich wiederum in anderen untersuchungen nicht so klar dar [ ] . von großer klinischer relevanz allerdings erscheint, dass diese dauerhaften neurokognitiven defizite mit signifikanten einschränkungen der gesundheitsbezogenen lebensqualität, der beruflichen rehabilitation sowie mit beachtlichen ökonomischen kosten einhergehen [ , , ] . nach intensivmedizinischen behandlungen wegen eines ards liegt die inzidenz einer neu auftretenden major depression bei ca. % [ ] , nach sars (severe acute respiratory syndrome im kontext einer infektion mit dem sars-coronavirus) in einem ähnlich hohen umfang [ , ] . die rate an angststörungen, vor allem an panikstörungen ist ebenfalls deutlich erhöht und bewegt sich zwischen bis % [ , ] . in einer konsiliarpsychiatrischen perspektive überwiegen angststörungen eher schon während der unmittelbaren intensivmedizinischen behandlung, während depressive störungen sich erst allmählich gegen ende des aufenthalts auf intensivstation und in der weiteren folge darstellen. nicht selten kann bei letzteren auch bereits prämorbid eine depressive vulnerabilität nachgewiesen werden [ ] . in einer allgemeinen ätiopathogenetischen betrachtung darf nicht allein auf die bedingungen von ali/ ards und intensivmedizinische interventionen fokussiert werden, sondern ist eine multifaktorielle betrachtungsweise zu fordern. somatische folgezustände nach überlebtem ali/ards bedeuten für viele patienten erhebliche funktionsbehinderungen (s. oben). sie können pessimismus, resignation und demoralisierung fördern. sowohl angst als auch depression bewirken im verlauf sehr häufig eine subjektive befundverschlimmerung, ohne dass hiermit auch objektivierbare verschlechterungen der lungenfunktionsparameter einhergehen müssen. sie führen zu einer erhöhten inanspruchnahme von medizinischen einrichtungen und zu einer unnötig intensivierten medikamentösen therapie. die gesundheitsbezogene lebensqualität ist oft gerade infolge persistierender angst und depressivität dramatisch reduziert [ ] . im kontext einer betrachtung von affektiven und vor allem von angst-und panikstörungen nach ali und ards ist in den letzten jahren eine klinische und wissenschaftliche diskussion auch um ein erhöhtes risiko einer posttraumatischen belastungsstörung als möglicher langzeitfolge entstanden. in einer ersten retrospektiven untersuchung wiesen schelling et al. [ ] bei insgesamt patienten ( patienten nach ards und nach septischem schock) ca. jahre nach der erkrankung auf eine prävalenz von ca. % an schweren posttraumatischen stresssyndromen hin. prävalenz und schweregrad der in einem selbstfragebogen (ptss- ) erfassten posttraumatischen stresssymptome korrelierten in dieser studie nicht mit dem schweregrad von ards/septischem schock oder dem ausmaß der assoziierten organdysfunktionen sondern mit der von den patienten nach intensivbehandlung jeweils erinnerten anzahl traumatischer erlebnisse (definiert als angst / panikreaktionen, atemnot, schmerz und alpträume / halluzinationen). patienten mit multiplen (> ) traumatischen erfahrungen während der intensivmedizinischen behandlung zeigten eine signifikant schlechtere gesundheitsbezogene lebensqualität, wobei insbesondere die psychosoziale, weniger die körperliche funktionsfähigkeit der patienten eingeschränkt war. kapfhammer et al. [ ] bestätigten an derselben patientenpopulation in einer nachfolgenden konsiliarpsychiatrischen studie, die sich methodisch auf ein standardisiertes klinisches interview mittels scid sowie auf verschiedene psychometrische tests stützte, im wesentlichen diese zusammenhänge. zum zeitpunkt der entlassung von der intensivstation hatten , % dieser patienten das vollbild einer ptsd, , % wiesen eine sub-ptsd auf. zum follow-up termin acht jahre später zeigte sich bei noch , % das vollbild eines ptsd und bei , % ein sub-ptsd. kein patient ohne posttraumatische symptome bei der entlassung hatte eine ptsd mit verzögerter manifestation entwickelt. bei patienten mit ptsd-vollbild zum zeitpunkt der entlassung persistierte diese störung über die gesamte follow-up zeit und schwächte sich im günstigeren fall in richtung eines sub-ptsd ab. in der psychometrischen testung erzielten die patienten mit dem vollbild einer ptsd durchwegs ungünstigere resultate. die deutlichsten einbussen zeigten sich in der gesundheitsbezogenen lebensqualität (sf- ), der situationsangst (stai-x ) sowie der somatisierung (soms). das ausmaß an koexistenter depressivität (madrs) erschien in dieser gruppe vergleichsweise nur moderat auffällig. kognitive dysfunktionen (skt) waren zwar in einer subgruppe nachweisbar, diskriminierten aber nicht hinsichtlich des ptsd-status. als risikofaktoren für die entwicklung eines ptsd konnten nicht die schwere der somatischen erkrankung (apa-che ii score, lung injury score), aber die anzahl der tage der intensivmedizinischen therapie sowie multiple subjektive traumatische erinnerungen (> alpträume, angst/panik, respiratorischer distress, erstickungsgefühle oder unzureichend behandelte schmerzen) auf intensivstation identifiziert werden. mittlerweile existiert eine reihe weiterer studien aus unterschiedlichen arbeitsgruppen, deren ergebnisse in mehreren systematischen reviews detailliert dargestellt sind [ , , ] . in einer zusammenfassenden beurteilung scheint wenig zweifel daran zu bestehen, dass persistierende symptome eines ptsd mögliche langzeitfolgen nach ali/ards sein können und hiermit erhebliche einschränkungen in der gesundheitsbezogenen lebens-qualität einhergehen. ebenso klar muss aber festgehalten werden, dass große unterschiede in den designs der einzelnen studien, ihr überwiegend retrospektiver charakter, meist nur sehr kleine sample-größen, heterogene messzeitpunkte im hinblick auf den zeitabstand zur intensivmedizinischen behandlung, ein erheblicher verlust von patienten in der perspektive des follow up und damit fragliche generalisierbarkeit der gefundenen ergebnisse hinsichtlich der definierten ausgangsstichprobe, eine häufig unzureichende psychiatrische diagnostik, eine nichtbeachtung von zwischenzeitlichen einflussfaktoren eine realistische einschätzung des ausmaßes eines ptsd nach ali/ ards etwa im vergleich nach exposition gegenüber anderen traumatischen ereignissen noch nicht erlauben. diese zurückhaltung ist auch im hinblick auf diskutierte risikovariablen wie länge des aufenthalts auf intensivstation und krankenhaus, beatmungsdauer, sedierungsgrad, weibliches geschlecht, lebensalter, prämorbide psychopathologie, anzahl traumatischer erinnerungen, verfügbare psychosoziale unterstützung angezeigt [ , ] . Über neurobiologische mechanismen der traumatisierung und der entwicklung eines ptsd jenseits der oft beeindruckenden subjektiven berichte von patienten, an welche traumatische erfahrungen sie sich während einer intensivmedizinischen behandlung erinnern und sowohl in intrusiven tagesbildern als auch in wiederkehrenden alpträumen oft über viele jahre wiedererleben, kann vorläufig nur in ersten ansätzen diskutiert werden. einige aspekte sollen aufgenommen werden. nach der prominenten hypothese von klein [ ] ist das auftreten von panik pathophysiologisch auf einen falschen erstickungsalarm zu beziehen. panikattacken resultieren demnach aus einer abnorm sensitiven reagibilität des medullären chemorezeptorensystems, dem entscheidenden atmungskontrollsystem im hirnstamm auf ein ansteigendes arterielles carbondioxid (co health-related quality of life stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomized, double-blind, single center study indications and 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distress syndrome the effect of stress doses of hydrocortisone during septic shock on post-traumatic stress disorder and health-related quality of in life in survivors (eds) handbook of liaison psychiatry epidemiology and treatment of psychiatric conditions that develop after critical illness epidemiology of depression and antidepressant therapy after acute respiratory failure medical post-traumatic stress disorder. catching up with the cutting edge in stress research post-icu consequences of patient wakefulness and sedative exposure during mechanical ventilation stress doses of hydrocortisone reduce chronic stress symptoms and improve healthrelated quality of life in high-risk patients after cardiac surgery: a randomized study posttraumatic stress, anxiety, and depression in survivors of severe acute respiratory syndrome (sars) post-traumatic stress disorder key: cord- - m psxri authors: park, hye yoon; park, wan beom; lee, so hee; kim, jeong lan; lee, jung jae; lee, haewoo; shin, hyoung-shik title: posttraumatic stress disorder and depression of survivors months after the outbreak of middle east respiratory syndrome in south korea date: - - journal: bmc public health doi: . /s - - - sha: doc_id: cord_uid: m psxri background: the outbreak of middle east respiratory syndrome (mers) in the republic of korea is a recent and representative occurrence of nationwide outbreaks of emerging infectious diseases (eids). in addition to physical symptoms, posttraumatic stress disorder (ptsd) and depression are common following outbreaks of eid. methods: the present study investigated the long-term mental health outcomes and related risk factors in survivors of mers. a prospective nationwide cohort study was conducted months after the mers outbreak at multi-centers throughout korea. ptsd and depression as the main mental health outcomes were assessed with the impact of event scale-revised korean version (ies-r-k) and the patient health questionnaire- (phq- ) respectively. results: . % of survivors reported ptsd (ies-r-k ≥ ) and . % reported depression (phq- ≥ ) at months post-mers. a multivariate analysis revealed that anxiety (adjusted odds ratio [aor], . ; %ci, . – . ; p = . ), and a greater recognition of stigma (aor, . , %ci, . – . ; p = . ) during the mers-affected period were independent predictors of ptsd at months after the mers outbreak. having a family member who died from mers predicted the development of depression (aor, . , %ci, . – . ; p = . ). conclusion: this finding implies that psychosocial factors, particularly during the outbreak phase, influenced the mental health of patients over a long-term period. mental health support among the infected subjects and efforts to reduce stigma may improve recovery from psychological distress in an eid outbreak. the outbreak of the middle east respiratory syndrome coronavirus (mers-cov) in the republic of korea had an enormous impact on medical, psychological, and social issues nationwide [ ] . the outbreak lasted from may to dec. and resulted in infected patients within the initial months, , officially isolated individuals, and an overall mortality of patients in a total of million population [ ] . acute infectious outbreaks of emerging infectious diseases (eids) are known to influence the physical as well as the mental health of affected patients, as observed during similar events such as the severe acute respiratory syndrome (sars) outbreak [ ] , which was associated with such issues during the acute phase [ ] and the long-term follow-up phase [ , ] . % of survivors expressed anxiety or depressive symptoms at -month post-sars in hong kong where citizens were infected, and its fatality was . % [ ] . in ninety survivors' cohort study for months in hong kong, post-sars cumulative incidence of psychiatric disorders was . %. the most common diagnoses were ptsd ( . %) and depression ( . %) [ ] . few studies have investigated the psychological impact of the korean mers-cov outbreak, but a survey conducted during this period found that % of the general public reported worrying about being infected by mers-cov and that % of this population experienced psychological distress [ ] . another study reported that . % of isolated individuals exhibited anxiety symptoms and that . % of this group reported feelings of anger during the isolation period [ ] . in contrast, anxiety was present in . % of mers patients [ ] , which was more prevalent than the rate of anxiety in isolated people without the mers-cov infection. compared to patients with other diseases, those with eids may experience greater suffering in terms of the physical and psychiatric symptoms of the infectious illness itself [ ] ; extreme fear and anxiety due to their unfamiliarity with the disease, which may be lifethreatening [ ] ; abrupt isolation from family and society during the illness [ ] ; stigma due to the infectious disease [ ] ; the unexpected death of a family member; and/or social impairments [ ] . given that some factors, such as grief or stigma, may be persistent following the mers illness, the suffering of afflicted individuals may negatively influence recovery in their daily lives during the acute outbreak period as well as the post-mers period. studies of sars survivors in hong kong and china reported persistent psychological burdens, including post-traumatic stress disorder (ptsd), in over % of the survivors after years [ ] . however, no studies have investigated the mental health status of mers survivors. thus, the present study explored mental health issues and related factors in mers survivors months after the outbreak to determine the long-term psychological outcomes of this population. the present study was part of a prospective nationwide cohort study of mers survivors conducted at multicenters in the republic of korea. for purposes of this study, a mers survivor was defined as a patient who was diagnosed with the mers-cov infection and then completely recovered, as confirmed by the korean government during the outbreak. of mers survivors who were eligible, consented to participate in the study initially when they were contacted by phone and mail at months post-mers (fig. ). of these participants, survivors completed the -month assessment that consisted of medical tests between june and august . among them, participants provided consent to participate in the psychological assessments in five tertiary hospitals: national medical center, seoul national university hospital, chungnam national university hospital, seoul medical center, and dankook university hospital. all subjects were older than years of age at enrollment, voluntarily participated in the study, and answered the questionnaires independently. written informed consent was obtained from all subjects, and the study was approved by the institutional review board of each study hospital. all subjects responded to self-report questionnaires assessing sociodemographic characteristics, previous history of medical illness or psychiatric visit, illness experiences during the mers-cov infection period, and psychological features. questions about mers-related illness experiences solicited information regarding status during infection, duration of hospitalization, presence of pneumonia, whether a ventilator or extracorporeal membrane oxygenation was applied, and whether a family member died from mers. to determine psychological outcomes, ptsd was assessed with the impact of event scale-revised korean version (ies-r-k) [ , ] , and depression was evaluated with the patient health questionnaire- (phq- ) [ , ] . the ies-r-k is a -item scale that assesses symptoms of intrusion, avoidance and numbing, and hyperarousal related to a particular life-threatening event (i.e., mers-cov infection in the present study). each item is rated on a scale ranging from to , and a total score ≥ is considered to be clinically significant [ ] . the phq- is a nine-item scale that assesses depression based on the symptoms of major depressive disorder included in the diagnostic and statistical manual of mental disorders-fourth edition (dsm-iv) [ ] . significant depression is considered to be present when the total score is > [ ] . current suicidality was assessed with the suicidality module of the mini-international neuropsychiatric interview (k-mini) [ , ] , which is composed of six weighted items rated as 'yes' or 'no': wish for death (weight of ), wish for self-harm (weight of ), suicidal thoughts (weight of ), suicide plan (weight of ), suicide attempt in the past month (weight of ), and lifetime suicide attempt (weight of ). the suicidality score is the sum of the weighted score of the six items, and a total score ≥ is considered to be above moderate degree of risk. anxiety was assessed with the generalized anxiety disorder- (gad- ) scale, which consists of seven items rated using a four-point likert scoring system [ ] . a total score ≥ is considered to be significant. the phq- and the gad- were administered additionally at two points, before and during infection with mers-cov, based on participant recall. insomnia was evaluated with the korean version of the insomnia severity index (isi-k) [ ] , a five-item measure relying on a five-point scale that assesses current sleep problems and interference with daily functioning; clinical insomnia was considered to be present if the total score was ≥ . mers stigma was assessed with an adjusted version of the -item berger human immunodeficiency virus (hiv) stigma scale [ ] and the -item short version of the hiv stigma scale [ ] . this questionnaire contains eight items rated on a four-point likert-type scale that ranges from "strongly disagree" to "strongly agree" and assesses the four domains of stigma: personalized stigma, disclosure concerns, negative selfimage, and concerns with public attitudes; the cronbach's α in the present study was . . the present study also included the brief cope, which is a -item questionnaire that uses a four-point likert scale to measure three distinctive coping strategies: emotionfocused, problem-focused, and dysfunctional [ ] . the social support systems of participants were assessed with the medical outcome study social support survey (mos-sss) [ ] , which includes items that are scored on a scale from to and assesses emotional/information support, tangible support, positive social interactions, and affectionate support. to examine the impact of social support on mental health in a regression analysis, poor social support was defined as a mos-sss score lower than that of the th percentile for all participants. the sociodemographic characteristics, mers-related clinical characteristics, and mental health status of the participants are presented as both numerical values and percentages. the present study placed a particular focus on ptsd and depression, which were the two most prevalent problems months post-mers in the descriptive analysis. accordingly, the subjects were divided into two groups based on the presence of significant ptsd or depression. independent t-tests were conducted to compare the mental health status between the two groups (p < . , adjusted for multiple comparisons), a stepwise regression analysis was performed to identify independent risk factors for ptsd and depression at months after the mers outbreak, and a univariate analysis was used to identify potential mediating factors associated with ptsd/depression (p < . ). subsequently, a backward multivariate logistic regression analysis was performed using variables identified as significant in the univariate analysis (p < . ). although depression during mers and current mers stigma were significant in the univariate analysis, these variables were not entered into the multivariate regression analysis due to multicollinearity with anxiety during mers (r = . , p < . ) and mers stigma during mers (r = . , p < . ), respectively. all data were analyzed with spss for windows version . (ibm corp.; armonk, ny, usa) except for the multivariate logistic regression analysis, which was performed with stata version . (stata; college station, tx, usa). the demographic characteristics of the subjects are presented in table . although more male (n = , . %) than female subjects were included in the study, the age distribution was relatively even (mean age: . years, standard deviation [sd]: . ). of the subjects, . % had a history of a visit to a psychiatric clinic prior to the mers outbreak. the distribution of respondents at the point of mers-cov infection was as follows: patients, . %; healthcare providers, . %; caregivers, . %; and those visiting the patients in hospitals, . % ( table ). the median length of hospitalization was overall, % of the subjects had at least one symptom of ptsd, depression, suicidality, or insomnia that was significantly above the clinical threshold. the mean total score on the ies-r was . (sd = . ), and . % of the subjects had significant ptsd ( table ). the mean score on the phq- was . (sd = . ) before infection with mers-cov, . (sd = . ) during the infection, and . (sd = . ) at months after the initial infection. moreover, % of the subjects had depression at months post-mers. most subjects had a minimum risk of suicidality, but . % showed at least a moderate degree of suicidal risk. of the survivors, % reported significant insomnia at months after the mers outbreak. during mers and months post-mers, all domains of ptsd, anxiety, and depression were more severe, and the quality of life was worse in survivors with current ptsd or depression compared to those without ptsd or depression (p < . ) (table s ). however, anxiety and depression prior to mers did not significantly differ in either comparison. survivors with ptsd reported higher scores for negative coping strategies compared to those without ptsd (p = . ). univariate and multivariate logistic regression analyses were performed to identify risk factors associated with ptsd or depression at months post-mers. the univariate analysis revealed that several factors were significantly associated with ptsd, including previous psychiatry history, having a family member who died from mers, depression and anxiety during the mersaffected period, greater perceived stigma currently and during the illness, and negative coping strategies (table s ) . depression was associated with gender, previous psychiatry history, anxiety before mers, having a family member who died from mers, and depression, anxiety, and greater stigma during the affected phase. neither the severity of mers nor complications, such as the development of pneumonia, use of a ventilator, or extracorporeal membrane oxygenation was associated with ptsd or depression. likewise, not having a spouse, living with a child, and poor social support were not associated with these outcomes. the multivariate logistic regression analysis revealed that previous psychiatric history (adjusted odds ratio [aor]: . , % confidence interval [ci]: . - . ; p = . ), anxiety (aor: . , % ci: . - . ; p = . ), and greater recognition of stigma (aor: . , % ci: . - . ; p = . ) during the mersaffected period were independent predictors of ptsd at months after mers (table ) . additionally, previous psychiatric history (aor: . , % ci: . - . ; p = . ) and having a family member who died from mers (aor: . , % ci: . - . ; p = . ) predicted the development of depression at this timepoint. the mers outbreak in is a noteworthy example of a national disaster that impacted most korean people. its early and rapid dissemination via hospitals concentrated in metropolitan areas [ ] , high fatality rate of nearly % [ ] , and unfamiliarity as a novel infectious disease [ ] may have led to high levels of anxiety and fear about being infected among the public and about death among affected people [ ] . the present findings confirmed high prevalence of mental health problems in survivors at the recovery phase after the outbreak. the prevalence of ptsd in survivors at months post-mers in the present study was comparable to the rate of . % observed in a study of sars survivors at months post-discharge from a hospital in singapore [ ] and higher or comparable to the rates of ptsd in patients with hiv ( - %), adult survivors of a human-made disaster ( - %) [ ] , and survivors of a stay in an intensive care unit ( - %) [ , ] . this indicates that an eid is not only a serious medical illness but also a psychologically traumatic experience for patients that can result in long-term psychological burdens. additionally, the result suggests that mental health adjusting for gender, presence of previous visit to psychiatric clinic, presence of a family member who died from mers, anxiety prior to mers (gad> = ), anxiety during mers (gad> = ), mers stigma during mers problems caused by an eid outbreak can continue for a long period. for example, another study showed that . % of sars survivors in hong kong still showed active psychiatric illnesses at years post-sars infection [ ] . furthermore, a second study demonstrated that % of chinese sars survivors still experienced ptsd at years post-sars [ ] . assuming that the experiences of the patients in the mers outbreak are similar in terms of eids, the mental health problems of the mers survivors in the present study may persist for longer than months. therefore, a study on mental health outcomes after months post-mers will be required. of the premorbid characteristics of the subjects, only a history of a visit to a psychiatric clinic was independently related to ptsd and depression at months post-mers, whereas demographic factors, such as gender, age, and level of education were not. on the other hand, high anxiety levels, perceived stigma about mers, and having a family member who died from mers predicted the development of ptsd or depression. these findings indicate that the psychological outcomes associated with an eid are mainly affected by factors during the outbreak period. furthermore, the presence of a physical illness prior to the mers-cov infection and the severity of mers were not associated with ptsd or depression. thus, psychosocial factors, rather than medical factors, may play an important role during mers-cov infection in terms of mental health status. these findings differ from those of a study investigating sars survivors at months post-infection, which found that the risk factors of ptsd included being female, the pre-sars presence of chronic medical illness, and the presence of complications caused by sars treatment [ ] . it is possible that the relatively small sample size of the present study was insufficient to statistically identify the influences of demographic characteristics and medical severity on adverse psychological outcomes. however, psychological burdens, such as widespread and extreme fear or feelings of isolation caused by mers [ ] , may have outweighed the possible contributions of these other factors. a previous report showing that only a history of mental disease and financial burden are related to anxiety in mers patients [ ] supports this assumption. the present findings suggest a need for appropriate psychosocial support during infectious outbreaks to reduce psychological distress in patients [ ] . therefore, healthcare professionals who treat these patients should be aware of the risk of developing adverse psychological outcomes during the acute stage of the illness as well as during the follow-up period. in particular, patients with a prior psychiatric history, high levels of psychological distress during the illness, or a negative perception about mers should be given more attention. interestingly, on our univariate analysis, we can assume that negative coping strategy such as denial, substance use, and selfblame may affect the development of ptsd. this relationship between negative coping style and ptsd is consistent with the previous findings in natural disaster and infectious disease [ , ] . it suggests that providing what is a useful coping strategy should be included in psychosocial support for survivors from eid. similarly, the governmental strategy for the management of eids should include psychosocial support based on group characteristics, risk factors, and severity of distress. the white paper, 'mers ,' issued by the korean government proposed that the national policy for eids should include content for "improving ethical problems and strengthening psychological support in eid control." [ ] the present findings suggest several considerations in this regard. in general, during the early outbreak phase, it is important that effective risk communication is incorporated into the overall strategy to reduce fear among the general public and quarantined people [ ] ; when developing such a strategy for this phase, it is also important to consider the ethical issues related to patients and quarantined people to minimize stigma [ ] . more specifically, due to the high prevalence of mental health problems, routine care for eid patients should include effective psychological support that reflects individual risk factors and the current level of distress. in fact, the central and local korean governments provided psychological support for quarantined people, patients, and families who had a member die from mers using designated public mental health care centers and telephone counseling during the outbreak [ ] . the core value associated with this program was adequate public accessibility; indeed, rather than rely on the passive provision of information, the program was implemented in a proactive manner [ ] . in addition, we should pay attention to stigma as a risk factor amenable to change rather than other psychosocial variables for ptsd in the study. in eid outbreak, the perspective is easily made that an infected patient is regarded as a dangerous vector or perpetrator to spread virus who should be isolated from the society [ ] . it can be maintained even after the outbreak [ ] . the stigma may produce discrimination and exclusion from a community regardless of medical indications. it would significantly threaten a patient's mental health and social relationship. consequently, their life could be influenced in a variety of domains such as residence, occupation and the use of healthcare for a long time [ ] . this study showed that reducing stigma can be an effective strategy to ameliorate psychological consequence after an eid. media and government should respect a patient or quarantined people as a citizen who are suffering and be sensitive to words or actions that might stigmatize a specific person or group. a community and healthcare service need to provide active support for an isolated patient to relieve their burden from the stigma [ ] . the present study has several limitations that should be noted. because this study assessed only % of the overall mers survivors, the results may not reflect the status of all survivors. however, the distributions of the demographic data on age, gender, and area of residence in the present study were similar to those in the official reports for all mers patients [ ] . second, psychological distress and stigma during the pre-mers period and during the mers-cov infection were evaluated based on participant recall and may not accurately represent the actual status of the subjects. additionally, the relatively small sample size may have limited the ability to identify risk factors due to low statistical power. however, given that . % of patients reported anxiety using the same scale in a previous study conducted during the isolation period [ ] , it can be assumed that the subjects in the present study were not likely to overestimate their symptoms during recall. finally, we assessed only with self-questionnaire that could be considered less accurate than the ratings of a clinician. our study showed that nearly half the assessed mers survivors experienced significant mental health problems, including ptsd and depression, at months post-mers. mers-specific psychosocial distress may influence long-term psychological sequelae. thus, efforts to control eids should include all levels of government and involve the implementation of effective strategies to reduce fear and stigma among the public; they should also enable the provision of adequate psychological support and hospital care for infected people. supplementary information accompanies this paper at https://doi.org/ . /s - 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amoy gardens stress and health: major findings and policy implications publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations we would like to acknowledge all the participants and researchers in the cohort study for mers survivors.authors' contributions shl and hss coordinated the overall study. hyp, shl, jlk, jjl, hl, and hss were involved in the concept and the design of the study. hyp and shl undertook the statistical analysis and drafted the manuscript. hyp, wbp, shl, jlk, jjl, hl, and hss contributed to the acquisition and the interpretation of the data, revised the manuscript and approved the article of its final version. the study was supported by a grant of the korea health technology r&d project through the korea health industry development institute (khidi), funded by the ministry of health and welfare, republic of korea (hi c ) and a grant from the korean mental health technology r&d project, ministry of health & welfare, republic of korea (hl c ). the funding bodies were not involved in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. the data obtained from the current study are not publicly available due to the sensitive nature of the study. not applicable. the authors declare that they have no competing interests. key: cord- - dr xupy authors: liang, leilei; gao, tingting; ren, hui; cao, ruilin; qin, zeying; hu, yueyang; li, chuanen; mei, songli title: post-traumatic stress disorder and psychological distress in chinese youths following the covid- emergency date: - - journal: j health psychol doi: . / sha: doc_id: cord_uid: dr xupy this study aims to explore the relationship between psychological distress and post-traumatic stress disorder among chinese participants as the result of covid- outbreak. this study was conducted within month after covid- appeared in china, it included participants age from to . the results indicated that . % of all participants with the symptoms of post-traumatic stress disorder and the effects of psychological distress on post-traumatic stress disorder was mediated by negative coping style. gender moderated the direct effect between psychological distress and post-traumatic stress disorder, which is a significant discovery for relevant departments to take further measures. at the end of , a series of cases of an unfamiliar type of pneumonia has been reported in wuhan city, hubei province, china. it has been confirmed that this pneumonia is caused by a new type of coronavirus, which world health organization has officially named it novel coronavirus disease (du et al., ) . on january , the world health organization announced a public health emergency of international concern (pheic) (who, ) . this public health emergency not only damages people's physical health, but also have a significant impact on their mental health (huang et al., ; wang et al., c) . psychological distress as a broader manifestation of mental health-related problems, which is characterized by symptoms of depression anxiety, stressrelated concerns and it is known to continue to show severity (drapeau et al., ) . in previous studies, psychological distress mainly included related psychological problems such as depression, anxiety, and stress (higuchi et al., ; o'brien et al., ) . in a survey with regard to the mental health of general population weeks after the covid- outbreak in china, which the result showed about one-third of participants reported moderate to severe level of anxiety (wang et al., a) , and nearly . % of the youth had a tendency to have psychological problems . simultaneously, medical staff also showed signs of irritability, unwillingness to rest, and difficulties in emotion management and existential stress zaka et al., ) . in addition, the impact of infectious diseases and microbial threats on mental health has become an important public health issue (holloway et al ; norwood et al., ) . however, most of previous studies focused on the impacts of public health emergencies such as infectious diseases on the medical staffs who are diagnosed with post-traumatic stress disorder (ptsd) (brooks et al., ; kang et al., ) , and less on the impacts of ptsd diagnoses among younger people with lower adaptive capacities and less mature cognitive abilities which make them vulnerable against psychological distresses (cénat and derivois, ) . thus, about within month after covid- occurred in china, we conducted this cross-sectional study to assess the mental state of young people who are diagnosed with ptsd due to this outbreak. pstd is a psychological disorder which can occur after people went through a traumatic experience such as earthquakes, hurricanes and sars (ding and xia, ; gonzalez et al., ; mak et al., ) . its basic feature is the characteristic symptoms result from the exposure to a traumatic experience, or a personal tragic life event, or witness events involving death, injury or threat to the physical integrity of others (lin et al., ) . and people with ptsd also will be forced to relive the negative effect caused by traumatic event that gives them the disorder, which can cause dramatic changes in their cognition and mood, make them avoid trauma-related stimuli at all cost, these symptoms has an important impact on daily life and work of people (farooqui et al., ; sekiguchi et al., ) . with the extremely high infection concerns, enough evidences has demonstrated covid- was considered as a life-threatening public health emergency and a disease serious enough to cause ptsd. according to the cognitive model of ptsd, the negative emotions experienced by traumatized patients (such as fear, sadness, and anger) can cause them to adopt negative assessment as a way to deal with traumatic events, which may lead to ptsd. furthermore, previous studies have shown that participants with higher level of psychological distress, such as anxiety, depression, and fear, are more likely to develop ptsd symptoms (wang et al., b; xi et al., ) . this may be because people fear injury and death, especially under unexpected and unprepared situations, which can create panic, fear, and tension (xu et al., ) . since the events are unexpected, people will feel confused about their current situation, and they will be uncertain about their future (yates and stone, ) . furthermore, this uncertainty may cause psychological distress in people, which would result in huge psychological stress aggravating ptsd symptoms. therefore, psychological distress is a predictor of ptsd. however, the mediating and moderating mechanisms underlying psychological distress and ptsd need further investigation. studies have shown that in the absence of other adaptive coping strategies, youths may use material coping as a negative coping style (ncs) to cope with psychological distress (acierno et al., ; pollice et al., ; vlahov et al., ) . in addition, numerous empirical studies also proved that adolescents who use ncs after experienced traumatic events such as earthquakes and hurricanes have a negative impact on their ptsd symptoms (carr et al., ; pina et al., ; ) , which may be a way to alleviate the symptoms of ptsd in youths with psychological distress. it was mainly reflected in the use of methods including denial, blaming, social withdrawal, and disengagement aim to avoid the problematic situations during and after emergencies (zheng et al., ) . thus, this study proposed the hypothesis that ncs would mediate the association between psychological distress and ptsd. in addition, gender is an important biological determinant of vulnerability to psychosocial stress (wang et al., ) . there was no consistent conclusion regarding the relationship between gender and psychological distress and ptsd. research indicates that compare to males, females show more ptsd symptoms (kun et al., ; qi et al., ) . when an emergency occurs, women may be more vulnerable than men, less likely to use effective coping strategies, and tend to interpret ptsd negatively (tolin and foa, ) . on the other hand, women are instinctively more sensitive to loss and stress, and therefore may develop negative emotions and ptsd symptoms (dell'osso et al., ) . however, some studies have found that men have more ptsd diagnoses than women (du et al., ; liang et al., ) , this may be because the men take more responsibility in taking care of the family (guo et al., ) , therefore show more symptoms of ptsd. these different results inspired us to further explore the relationship between gender, psychological distress and ptsd. thus, this study proposes the hypothesis that the gender would moderate the direct association between the psychological distress and ptsd ( figure ). a cross-sectional study was designed in the first month since covid- outbreak hits china. the study took a snowball sampling approach to collect questionnaires remotely, targeting people age from to . the questionnaires will be sent to participants through a wellknown smartphone social network application called wechat. participants can share their questionnaires with their friends, who can then share with their friends, as a way to expand the sample size. finally, approximately questionnaires were collected from participants. after deleting the duplicate ids and random questionnaires, this study collected a total of valid questionnaires, the valid response rate was . %. before collecting the data, the participant was given an informed consent, and researchers received a verbal consent from the participant in return. the ptsd checklist-civilian version. the diagnosis of ptsd was done by using the ptsd checklist-civilian version (pcl-c) (weathers et al., ) , which was designed to assess participants' responses to traumatic experiences encountered in daily lives. the severity of ptsd symptoms was measured using a fivepoint likert scale. the total score range from to , with higher score indicates more serious symptomatological ptsd and participants with a cut-off score of or higher were diagnosed with ptsd symptoms (grubaugh et al., ) . this scale was widely used to evaluate symptomatic ptsd of chinese adolescents, with high reliability and validity (yang et al., ). an early study using this threshold reported cronbach's alpha of the whole scale was . (zhou et al., ) . in this study, the cronbach's alpha of pcl-c was . . the general health questionnaire scale. the psychological distress was measured using the general health questionnaire (ghq- ) (goldberg et al., ) , which contains items assessing participant's mental health. it uses a four-point likert scale, which higher score indicates higher degree of disturbance in the mind. the questionnaire has been proven with great reliability and validity, and it is commonly used by different chinese research (fares et al., ) . previous research has shown that the ghq- coefficients ranged from . to . (arnberg et al., ; yusoff et al., ) . in the present study, the cronbach's alpha of ghq- was . . simplified copying style questionnaire. the simplified coping style questionnaire (scsq) (xie, ) was a -item self-report scale, including two sub-scales: positive coping ( items) and negative coping (eight items). each item options ranged from (never) to (very frequently), and the scores on corresponding sub-scale indicates the level of coping strategy everyone possesses, this study selects the subscale of negative coping style in this questionnaire. previous study has showed that the cronbach's alpha of negative coping was . (lin et al., ) . in the present study, the cronbach's alpha of negative coping was . . in this study, we conducted a descriptive analysis to describe the basic sociodemographic characteristics of participants, and a correlation analysis to verify the relationship between variables. we also used multiple linear regression analysis via spss . (ibm corp) and a process macro to tests the mediating effect of ncs and the moderating effect of gender between psychological distress and ptsd. finally, this study conducted % bootstrap confidence intervals (ci) based on bootstrapped samples, with the effects being significant when the results did not include zero. a significance level of p < . was used for all variables. as the result, the demographic characteristics of participants are shown in table this study used multiple liner regression analysis (baron and kenny, ) to test whether ncs mediate the association between the psychological distress and ptsd. in this study, the direct path coefficient from the psychological distress to ptsd was significant (b = . , β = . , p < . ), and the psychological distress was also significantly associated with ncs (b = . , β = . , p < . ). when we considered both the psychological distress and ncs as predictors of ptsd in the regression model, the path coefficients of the psychological distress on ptsd remained significant (b = . , β = . , p < . ). in addition, we used the process macro (model ) in spss and perform the bootstrap method to test the indirect effect (preacher and hayes, ) . the results indicated that the psychological distress on ptsd through ncs was significant ( % ci = [ . , . ]; excluding ). thus, this study indicated that ncs mediated the association between psychological distress and ptsd. before examining the moderated mediation analysis, all the variables were mean centered to minimize multicollinearity. table showed the detailed results. in model , the psychological distress was positively related to ptsd (β = . , p < . ). gender did not relate to ptsd (β = - . , p > . ), but the interaction term between the psychological distress and gender was positively related to ptsd (β = - . , p < . ), which indicated that gender could moderate the association between psychological distress and ptsd. in model , the main effect of psychological distress on ncs was significant (β = . , p < . ), but this effect could not be moderated by the gender (β = - . , p > . ). in model , the main effect of ncs on ptsd was significant (β = . , p < . ), however, this effect could not be moderated by the gender (β = - . , p > . ). simple slope analyses were used to further analyze the moderate effect of gender on the relationship between psychological distress and ptsd (see figure ). the results indicated that psychological distress can be significantly associated with ptsd in males (β simple = . , t = . , p < . ) and females (β simple = . , t = . , p < . ). the effect of psychological distress on ptsd was higher in males than females. in addition, this study conducted the process macro method (model ) to further analyze the moderation mediation, which was able to verify the above assumptions. the index of moderated mediation was - . (se = . , %ci = [- . , - . ]). analysis of the moderation effect indicated that this path was significantly for males ( % ci = [ . , . ]; excluding ) and females gender was coded so that = male and = female. *p < . ; **p < . . ( % ci = [ . , . ]; excluding ), which tested the above assumption. in this study, we found that within month after the occurrence of covid- outbreak in china, the prevalence of ptsd was . %, which was lower than a cross-sectional study of the prevalence of ptsd ( . %) month after the earthquake in chengdu, sichuan province, china (lau et al., ) and also lower than ptsd ( %) reported by sars patients months after discharge (kwek et al., ) . however, in a -year follow-up study of discharged sars patients, the result shows the reported cases of ptsd was . % among all patients (hong et al., ) . and in a report from italy, the prevalence of ptsd years after the earthquake is only . % (priebe et al., ) . the above differences in ptsd prevalence after a traumatic event may be due to the differences in research methods, culture, type and severity of the disaster, time interval measured after the disaster and diagnostic criteria (liu et al., ) . in addition, a systematic review demonstrated that the ptsd rate declined after disaster , but studies also pointed out that adolescents affected by traumatic events were prone to invasive thoughts such as sleep disorders, nightmares, and separation anxiety (yule, ) . thus, this emphasizes that . . . f . *** . ** . *** *p < . ; **p < . ; ***p < . . relevant government agencies should take measures aimed at the mental health of youths as soon as a public health emergency occurs. in addition, related preventive and clinical measures should also be applied to prevent and treat the damage of covid- to participants' health. a recent study suggested that covid- can cause nervous system damage (wu et al., ) , and also indicated that the negative mental states (such as depression and anxiety) are relate to changes in the immune system (rajkumar, ) . thus, from the perspective of psychoneuroimmunology, the immune system can be improved by eliminating daily psychological distress, maintaining good sleep quality, balancing nutrition intake, keeping a healthy lifestyle and exercising regularly. as the result, if people have strong immune systems, it can reduce the risk of covid- infection (kim and su, ; matias et al., ; ng et al., ) . also, this study provides references that are significant for relevant clinical researches, and they can help psychiatrists to effectively identify the groups with mental health issues due to the covid- outbreak (zhou et al., ) . after picking out people in need, psychological professionals can provide remote services like telephone and internet, which can speed up the development of technologies along the way, such as electronic consent forms and telemedicine (smith et al., ) . as expected, the effect of psychological distress on ptsd was mediated by ncs, which supported the initial hypothesis. in the study, the mediation analysis indicates that psychologically distressed adolescents are more likely to engage in negative coping strategies, which ultimately lead to ptsd (vlahov et al., ) . in addition, traumatic experiences cause people to experience more negative emotions, which in turn results in ptsd (quan et al., ) . people overwhelmed with negative emotions tend to choose negative behaviors like self-blame or avoid problems (xiang et al., ) , this may be because negative emotions have been theorized as an obstacle mechanism to affect ncs (folkman and lazarus, ) . such actions can further weaken people's capability to deal with psychological distresses, which will eventually lead to mental illnesses like ptsd (d'amico et al., ) . moreover, studies have also shown that the symptoms of ptsd and psychological distress have overlapping characteristics (hurlocker et al., ) , sharing common characteristics such as inattention, hypervigilance, and emotional disorders (pacella et al., ) , in which may be because the related symptoms didn't occur in isolation (borsboom and cramer, ) . therefore, these results may help psychiatrists and psychologists to develop or take interventions that target specific symptoms of this relationship. when a public health emergency occurs, the local government should immediately provide relevant psychological interventions to help young people overcome negative emotional experiences, because early psychological interventions can help reduce the prevalence of ptsd (zhou et al., ) . on the other hand, during the covid- outbreak, the government and other relevant agencies should encourage adolescents to take active coping styles, enhance their ability of learning from difficult situations and actively seek help from others who can protect them from ptsd (liu et al., ) . our study indicated that gender played a moderating role in the direct effect between the psychological distress and ptsd, which supported the hypothesis. with the increase of psychological distress, the prevalence of women ptsd increased significantly, but the prevalence of men ptsd increase more. from a biological perspective, gender is an important biological determinant of the vulnerability of psychological distress, and gender differences have been identified in the brains' activation of stress. this may be because by examine the brain activity in response to physiological stresses, significant differences appear between men and women. when people try to cope with psychological distress, the activities of prefrontal lobe in males' brains are asymmetric, meanwhile, the activities are mainly focus on limbic system for females. in brief, the results show men and women will choose different actions and coping strategies in response to when people try to cope with psychological distress (wang et al., ) . the reason may also be caused by the different coping styles during the study time, or it may be because women are more likely to show symptoms during emergencies, which can effectively reduce the chance of get ptsd (du et al., ) . in addition, social expectations related to gender roles may lead to differences (tolin and foa, ) . in china, there may be such a basic rule that men are normally perceived as powerful figures who are dominant in status and rights (chen et al., ) , but this social trend may also bring more psychological distresses to men. during the occurrence of covid- , the chinese government has implemented the strictest prevention and control measures, people need isolation at home to prevent infection, on the other hand, adult males will experience more psychological distress due to increasing financial pressures and loss of job opportunities. such high stress situations can increase chances of getting ptsd in males. therefore, this study suggests that corresponding measures should be taken based on the gender differences in the ptsd. certain limitations of this study should be recognized. we examined only general psychopathology using the ghq- rather than a specific mental health problem (such as depression and fear). our study used a cross-sectional design, which cannot provide strong evidence for causality. thus, further research should use a longitudinal design. in addition, our study is limited by sample size. in order to get more detailed results, larger and more universal sample groups are needed. this study was conducted within month of the covid- emergency in china. in this study, . % of participants were diagnosed with ptsd, which indicates the significance of the public health emergency. government and other relevant agencies must take swift and systematic action to improve the mental health of youth. this study found that general mental health can be affected by ptsd through ncs, highlighting the moderating effect of gender on this association. the prevalence of ptsd in women increased significantly with psychological distress, but the prevalence of men ptsd increased even more. this study provides a reference for formulating psychological intervention measures to improve people's mental health and psychological adaptability during the occurrence of covid- and any similar pandemics in the future. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this study was funded by international innovation team of jilin university ( gjtd ); research plan of youth development in jilin province-the effect of covid- on adolescent mental health ( jqy- ); research on the problems of covid- of jilin university ( xgzx ). leilei liang https://orcid.org/ - - - violent assault, posttraumatic stress disorder, and depression-risk factors for cigarette use among adult women social support moderates posttraumatic stress and general distress after disaster the moderatormediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations network analysis: an integrative approach to the structure of 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stress symptoms among chinese adolescents exposed to wenchuan earthquake, china prevalence and risk factors of post-traumatic stress disorder among adult survivors six months after the wenchuan earthquake risk factors of severity of post-traumatic stress disorder among survivors with physical disabilities one year after the wenchuan earthquake the author wish to thank his collaborators for their contribution to this study. key: cord- -d yv mcl authors: hori, arinobu; takebayashi, yoshitake; tsubokura, masaharu; kim, yoshiharu title: ptsd and bipolar ii disorder in fukushima disaster relief workers after the nuclear accident date: - - journal: bmj case rep doi: . /bcr- - sha: doc_id: cord_uid: d yv mcl the global threat posed by the covid- pandemic has highlighted the need to accurately identify the immediate and long-term postdisaster impacts on disaster-relief workers. we examined the case of a local government employee suffering from post-traumatic stress disorder (ptsd) and bipolar ii disorder following the great east japan earthquake. the complex and harsh experience provoked a hypomanic response such as elated feelings with increased energy, decreased need for sleep and an increase in goal-directed activity, which allowed him to continue working, even though he was adversely affected by the disaster. however, . years later, when he suffered further psychological damage, his ptsd symptoms became evident. in addition to treating mood disorders, trauma-focused psychotherapy was required for his recovery. thereafter, we considered the characteristics of mental health problems that emerge in disaster-relief workers, a long time after the disaster, and the conditions and treatments necessary for recovery. the global threat posed by the covid- pandemic has highlighted the need to accurately identify the immediate and long-term postdisaster impacts on disaster-relief workers. we examined the case of a local government employee suffering from post-traumatic stress disorder (ptsd) and bipolar ii disorder following the great east japan earthquake. the complex and harsh experience provoked a hypomanic response such as elated feelings with increased energy, decreased need for sleep and an increase in goal-directed activity, which allowed him to continue working, even though he was adversely affected by the disaster. however, . years later, when he suffered further psychological damage, his ptsd symptoms became evident. in addition to treating mood disorders, trauma-focused psychotherapy was required for his recovery. thereafter, we considered the characteristics of mental health problems that emerge in disaster-relief workers, a long time after the disaster, and the conditions and treatments necessary for recovery. disasters continue to affect people not only in the moment of a disaster but also throughout the long-term recovery process. post-traumatic stress disorder (ptsd) and depression significantly impair the social functioning of those affected and are often recognised as the most visible mental health effects on survivors, as was the case with the great east japan earthquake (geje) of . [ ] [ ] [ ] [ ] in the present study, however, we would like to focus on manic and hypomanic episodes that occurred in the victims of the geje. while bipolar disorder requires medical treatment, social functioning of the patient tends to be maintained during the hypomanic episode. hypomanic patients show symptoms such as elated feelings with increased energy, decreased need for sleep and an increase in goaldirected activity. they could continue to contribute to the community as disaster-relief workers in the disaster-recovery process, which delays the recognition of their treatment needs by healthcare providers. the geje, which was followed by the nuclear accidents, left the affected areas severely damaged and required the victims to contribute as disaster-relief workers for a long period. therefore, after the geje, not a few of the people involved may have continued to work as disasterrelief workers while exhibiting hypomania. in the general postdisaster context, relief workers are considered to be a group vulnerable to mental health problems and have a higher incidence of late-onset ptsd. this may be partly due to the fact that there are many opportunities for relief workers to come into contact with the misery of victims of disasters or adverse situations. in the case of the chernobyl disaster, the long-term effects on the mental health of the population who lived through the events are known. the risk of mental disorder was particularly high among the workers involved in the clean-up efforts after the disaster because they were in constant fear of being exposed to radiation. [ ] [ ] [ ] from this, one can infer the magnitude of the burdens borne by those engaged in the work of providing support to a community during any disaster. in the geje, the risk of mental disorder was also shown to be higher among disaster-relief workers, such as local government employees and tokyo electric power company officials. [ ] [ ] [ ] in this case, being the target of blame and attacks from victims was a major factor contributing to increased risks. in this study, we observed the emergence of bipolar ii disorder and symptoms of ptsd in a local government employee who experienced almost all the events of the geje disaster. even after the acute phase of the disaster, he continued to work diligently as a local government employee for more than years. while he was forced to deal with social conflict caused by aspects of his job, he came across reports of floods in other parts of japan. consequently, he began experiencing symptoms of ptsd and major depressive episodes. the covid- pandemic is, at the time of writing, wreaking havoc around the globe in what is a major health disaster. during the pandemic, many people, including healthcare workers, are expected to work in appalling conditions for extended periods. therefore, understanding how the experience of a long-term, complex and severe disaster affects the mental health of essential responders (who are engaged in essential services) is important in guiding future policies and practices. the patient was a male in his s when he first visited our clinic. he was born and grew up in a town in fukushima prefecture (within km of the nuclear power plant). after he graduated from a college in another city, he returned to his hometown and started working in a town office. he has no medical history of note. after the accident at the nuclear power plant in , an evacuation global health order covering his hometown was issued. the order was lifted in july . he was working at the town office at the time of the earthquake. later, while conducting a tour of the coastal area to check for earthquake damage and to ensure that people had evacuated, he experienced the tsunami near his childhood home. he and his colleague evacuated the lower floor of the house, moved upstairs with his family and watched as the surrounding houses were swept away, fearing that, along with his family and his colleague, he would also be swept away at any moment. eventually, the water receded, but the area around the house was flooded, preventing any movement. mobile phone services collapsed. in the evening, he carried his grandmother on his back and waded through the waters to take refuge on a nearby hill, where about people had gathered. he barely slept during the night. at daylight the next day, he was rescued-along with the other people who were with him-by a self-defence forces helicopter. on the afternoon of the second day, he began engaging in relief work throughout the area. among the tasks and efforts he undertook was aiding the local fire brigade and he was involved in housing the corpse of a man whom he had known since childhood. he would go on to help recover six or seven bodies in half a day. with nowhere to go, he slept that night wrapped in a blanket by his desk in his office. he heard a rumour of a nuclear power plant being in danger and fell asleep in a daze. by the morning of the third day, it was clear that the nuclear power plant was in danger. evacuation orders for everyone within a km radius, followed by a km radius, from the nuclear power plant, were conveyed. on the night of the fourth day, the town office was closed. on the morning of the fifth day, he told his family to flee, although he decided to stay and aid in the relief work being carried out. on the morning of the seventh day, - people-taking refuge at a junior high schoolwere transported to another prefecture aboard seven or eight buses. there were only three staff members remaining, including himself. initially, he felt a strong sense of urgency and was in high spirits. he carried on working for months with the local authorities, which included visiting evacuees. one of the evacuees once made him kneel for hours, scolding him and saying, 'you're here too late'. even after he returned to his hometown, he continued to work as a local government employee. he was involved in a lot of heartbreaking work-such as catching and slaughtering the growing number of untended or escaped cattle and pigs within the evacuation area. in august , after watching the news of the flood damage in another area of japan, he experienced flashbacks of scenes from the tsunami during the geje; these flashbacks made him anxious and made sleeping difficult. this affected his work severely. at that time, he was working in a department of the town and frequently attended briefings in his hometown. he notes that there was a lot of shouting at these briefings. in the same month, he visited a clinic in the city and was diagnosed with ptsd and depression. he was given leave from the time of his initial visit for a duration of about months. his symptoms subsequently improved, and he decided to discontinue treatment. during this time, while taking antidepressant medication, he experienced an uptick in his mood and spent a lot of money on mail order goods besides elated feelings with increased energy, decreased need for sleep and an increase in goal-directed activity. two-and-a-half years later, he became depressed again and visited another psychiatric hospital in the city. this visit began a second leave of absence from his work; he returned to work after months. three months later, he took a third leave of absence after suffering a worsening of his anxiety and depression. his physician, at the time, determined that he needed specialised treatment for ptsd and referred him to our clinic for the purpose of implementing trauma-focused psychotherapy. his first visit to our clinic was years and months after the geje. although outwardly he appeared well groomed, his speech was sluggish. his alcohol consumption increased after the disaster, but he had been abstaining from alcohol for a month and a half before his visit, so we told him to continue. the previous doctor's prescriptions were escitalopram ( mg), mirtazapine ( mg), ethyl loflazepate ( mg) and diazepam ( mg). although we considered this prescription inappropriate for a bipolar patient, we continued this treatment first then started to taper it down. after two general outpatient meetings, a total of sessions of trauma-focused psychotherapy were conducted twice a week. weekly outpatient visits continued for a month. whenever he heard news about an earthquake on the tv, he became anxious; however, he had learnt to respond by practising breathing techniques. the psychotropic drugs were gradually reduced. he returned to work the next month, on a half-day basis, and began working full time after weeks. at that time, he was still taking escitalopram ( mg) and ethyl loflazepate ( mg). we conducted prolonged exposure therapy. in the first session, we listened in detail to comprehend all aspects of his trauma. because he had experienced multiple traumatic events, we asked him to evaluate the degree of subjective distress he felt about the different events. he expressed the following: ( ) on the tsunami: 'i feel like blaming nature, wondering why this once-in-a-thousand-year event happened at this time'; ( ) in reference to the harsh complaints emanating from residents after the disaster: 'it's not just my fault' and 'there's only so much i can do'; and ( ) concerning the scene where corpses were taken: 'why did it have to be this way?' in the second session, he expressed survivors' guilt: 'there was some fear in the trauma part, but i wondered if the loss of an acquaintance was greater. the village where i was born and raised was gone. the person i told immediately after the earthquake to "get out of here fast" also died. i am wondering why i didn't tell them more forcefully. images of the disaster and [the sound of] sirens on fire trucks and ambulances trigger my anxiety. there were other times when we were all talking about the disaster and everyone was normal, and i was the only one who froze'. in the third session, he recalled that he was near his childhood home soon after the earthquake when the tsunami hit and how he had escaped by taking shelter on the second floor. he further recalled that he was left with others on high ground until the following day. in the fourth session, he described the first few days in detail. the moment the tsunami came, he was told: 'there's a tsunami coming, run away quickly'. he recalled that 'the waves were really black, and [that] the water was extremely powerful', and that he 'was rescued by a helicopter with [his] colleagues and [that he] went back to the town office crying'. in addition, on the afternoon of the th , he was tasked with helping recover the deceased; the first person he found and carried was a fire brigade worker who he knew. in the fifth session, he remembered that, after recovering bodies on the afternoon of the th, he received the news that the nuclear power plant was in danger. in addition, after the evacuation order was issued, he had to help evacuate local residents while his family was evacuated to another area. there were times when he was subjected to abuse. he stated that: 'there's so much going on, so much work, it makes me just laugh'. in the sixth session, he was asked to explain, in detail, the scenes when the lifeless body of someone he knew was recovered. he had received a call from the fire brigade, telling him that a body had been found; subsequently, he was sent to pick it up. on recognising the corpse as someone he knew, he thought, 'i could have been dead, that could well have been me rather than him'. in the seventh session, he could recall and express his memories more easily than previously. he said, 'it's over, but why did it take so long?' in the eighth session, we dealt with the tsunami scene again and he recalled the episodes in greater detail. in the ninth session, he was asked to speak about his recollections of the first months after the earthquake and how he lost kg of weight during that period, resulting in a colleague telling him that he looked completely different. in the tenth session, he was asked to repeat his recollections of those first months. he responded by saying that 'it's great that i've been able to organize the memories in my head. before, they were all jumbled up. i have been able to cut out some of the worst traumatic experiences, organize others, and accept the result. so, i've come to understand that it's all in the past'. the patient continued his visits to the outpatient clinic as well as his medication-mainly the mood stabiliser lamotrigine ( mg: in japan, the dosage of each psychotropic drug is usually set lower than in western countries) used for the treatment of bipolar disorder. he voluntarily practised coping techniques, such as breathing exercises, in situations where he felt stressed. every year, emotional instability emerged around march, the day the earthquake struck. in october , the area where the disaster occurred suffered from flooding and water damage due to a major typhoon. he was involved in the management and operation of the evacuation centre that was set up at that time, but later became unwell and needed to take a leave of absence for about a month. trauma-focused psychological interview sessions were conducted following this event, and two traumatic memories were treated, which were left unaddressed in the prolonged exposure method interviews conducted. one recollection concerned the times when he was angrily abused by some evacuees during the period after the geje. the second was about the scene when he was verbally abused at his job. after the two sessions, he recovered and has returned to work and continues to be well. the covid- outbreak, which began in january, has caused intense and extensive fear and anxiety. the patient has reported that the outbreak has brought back memories of the geje, as well as that of the atmosphere of the people at the time, causing him to experience some heightened emotions of fear. he has also realised, however, that for a long time he was too absorbed in and preoccupied by his geje experiences; because of this awareness and acceptance, he was mindful not to be like that this time round. how do the complex and harsh experiences of the geje disaster and its aftermath affect disaster-relief workers? the geje was a complex disaster that involved an earthquake, tsunami and nuclear power plant accident, followed by a series of compulsory evacuations. what are the crucial aspects of the trauma caused by complex disasters? what kind of response does such trauma provoke in the short term and what are the long-term consequences? what kind of measures should be taken to deal with mental health problems caused by complex disasters, including nuclear disasters? important characteristics of the traumatic events experienced by disaster-relief workers in complex disasters, including nuclear accidents, and as demonstrated throughout this case, are as follows: . they intermittently experience multiple traumatic events over an extended period. . the impact of being caught up in social conflicts over nuclear power and radiation exposure is significant, as is receiving strong condemnation and attacks from residents. considering these two points, two further observations can be made: . in addition to the magnitude of the trauma or loss experienced, there may be a mildly manic reaction to dealing with persistent crisis situations in the community at large. in this psychological defence reaction, there is a risk that mental health problems, such as depression and ptsd, would appear or develop a few years after the disaster. . anxiety concerning the health effects of radiation exposure, which is generally considered to be a problem following nuclear disasters, might be neglected. this patient experienced the geje as a local government employee and had an extremely harsh and traumatic time in the months following the disaster. these included the recovery operations, a fear of exposure to radiation, harsh living conditions following the evacuation, separation from his family, and strong condemnation and reprimands as a result of postdisaster social strife and conflicts. despite this strong psychological burden, this individual continued to work diligently for the recovery and reconstruction of the community, which illustrated the strength of his resilience. it is believed that participation in the altruistic activity of contributing to the recovery of the community boosted that resilience. at the same time, it is worth noting that in the present case, the patient demonstrated a hypomanic state. the hypomanic state is pathological, as it involves the avoidance of realistic anxiety. denial of self-damage or fatigue can make selfcare more difficult to implement. however, in the short term, it produces desirable effects by maintaining social activity, which can protect people from being overwhelmed by practical challenges in a disaster situation. this may be an adaptive response which enhances resilience. we would like to draw attention to the fact that the patient did not complain of anxiety concerning the adverse health effects of radiation exposure, which is generally expected in mental health problems associated with nuclear disasters. as in the present case, this may be due to the fact that residents who choose to live in relatively close proximity to the accident site can be seen as a biassed group that does not take the possible global health damage of radiation exposure seriously. it is also possible to think that a manic avoidance of anxiety may be at work here. alternatively, it could be an outcome of the risk communication that took place after the disaster. people living in the area had learnt that the levels of radiation that they were exposed to while living in close proximity to the plant were not the kind that would actually have serious consequences. three years and months after the disaster, the ptsd symptoms-including flashbacks-suddenly flared up after the patient was exposed to news of another disaster in japan. in addition, during this period, the patient endured a situation in which he was required to negotiate, as a representative of the local government (being an employee himself), with residents who were affected by the nuclear accident. however, communication and negotiations did not go well, resulting in strong admonishment. in the case of an elderly woman with symptoms of ptsd caused by the tsunami, as reported by hori et al, the recurrence was also caused by being involuntarily blamed for being involved in a severe conflict among residents in the communal dwelling where she was living. although our patient recovered from his mood disorder by using medication, he had two repeated flare-ups which led to the implementation of prolonged exposure therapy -a psychotherapy focused on ptsd. north and pfefferbaum have argued that less invasive treatments should be prioritised in the immediate aftermath of a disaster as an intervention for post-disaster ptsd, and specialised trauma-focused treatments should be provided only when depression and ptsd symptoms persist. our treatment is consistent with this argument. the actual psychotherapy process involved sorting out a situation in which multiple traumatic events were intricately intertwined, in addition to habituation through the recall of traumatic memories. we also discussed the destruction of his hometown and the loss of his relatives and acquaintances. although improvement was observed following the treatment described previously, emotional instability was sometimes caused by increased stress in daily life; as such, it was necessary to continue the outpatient treatment, including the prescription of lamotrigine ( mg). we also provided psychological education about stress coping. although trauma reactions and feelings of depression may intensify on the anniversary of the geje, he gradually became able to care for himself. in addition, we discussed his tendency to be manically uplifted in crisis situations and overly immersed in his community contributions. however, the traumatic experience of receiving strong condemnation from residents -that could not be addressed in the initial ptsd treatment-necessitated additional psychotherapeutic interviews later on. on the other hand, we should not rely solely on improving the coping skills of patients. because experiencing multiple disasters would increase the suicide rate, the same person should not be repeatedly burdened as a relief worker. the following lessons can be drawn from this case: . the recovery and reconstruction of the community, including a medical system that allows general psychiatric treatment, such as treatment for mood disorders, should be ensured as quickly as possible after a disaster. . it is not easy for those who have an important role in the affected community to reduce their responsibilities in the community during the postdisaster phase. there is also a prejudice against psychiatric issues. awareness-raising activities related to mental health, including psychoeducation about symptoms of mood disorders and ptsd, should be carried out widely in the community, even though this could be difficult after the disaster. the medical facilities where the cur-rent treatment was provided also existed in the areas affected by the disaster. . a system that allows access to specialised treatment focused on ptsd should be developed when necessary. . the public should be made aware that they should refrain from unwarranted severe criticism of local government officials in the wake of a disaster, as it would increase the risk of mental health problems for those who are criticised. ► for the victims of the great east japan earthquake who experienced the earthquake, tsunami, nuclear accident and subsequent evacuation, there are two highly significant points: ( ) the persistence of the crisis situation over a long period (weeks, months or even years) and ( ) the emergence of social conflicts over radiation exposure from an early stage. ► in particular, disaster-relief workers are at a high risk of mental health problems because they are repeatedly exposed to other victims' tragic situations and are prone to be strongly criticised or attacked, even though they themselves are victims of the disaster. ► with respect to postdisaster mental health, both depression and hypomania may emerge. since hypomania is a partial disavowal of difficult realities, decrease in anxiety and increasing physical activity can represent an adaptive response to difficult situations arising after a complex disaster, including a nuclear disaster where the threat is invisible. ► exposure to radiation after a nuclear accident can damage mental as well as physical health, both or either of which may not manifest for some considerable time after the initial disaster, or which may appear following various trigger events. ► in postdisaster patients, mood disorders that are combined with post-traumatic stress disorder (ptsd) may not be controlled without ptsd-focused treatment. psychological distress after the great east japan earthquake and fukushima daiichi nuclear power plant accident: results of a mental health and lifestyle survey through the fukushima health management survey in fy and fy severe psychological distress of evacuees in evacuation zone caused by the fukushima daiichi nuclear power plant accident: the fukushima health management survey mental health and psychological impacts from the great east japan earthquake disaster: a systematic literature review psychiatric outpatients after the . complex disaster in fukushima mental disorders that exacerbated due to the fukushima disaster, a complex radioactive contamination disaster newly admitted psychiatric inpatients after the . disaster in fukushima report from minamisoma city: diversity and complexity of psychological distress in local residents after a nuclear power plant accident a 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patient with late-onset ptsd affected by evacuation due to the fukushima nuclear power plant accident longitudinal associations of radiation risk perceptions and mental health among non-evacuee residents of fukushima prefecture seven years after the nuclear power plant disaster changes in risk perception of the health effects of radiation and mental health status: the fukushima health management survey keys to resilience for ptsd and everyday stress coping styles of outpatients with a bipolar disorder building risk communication capabilities among professionals: seven essential characteristics of risk communication enhancement of ptsd treatment through social support in idobata-nagaya community housing after fukushima's triple disaster mental health response to community disasters: a systematic review suicidality risk and (repeat) disaster exposure: findings from a nationally representative population survey hospital staff shortage after the triple disaster in fukushima, japan-an earthquake, tsunamis, and nuclear power plant accident: a case of the soso district mental health crisis in northeast fukushima after the earthquake, tsunami and nuclear disaster acknowledgements we thank all those who contributed to the recovery from the great east japan earthquake.contributors ah was the main therapist of the case and wrote the initial manuscript. yt and mt critically revised the manuscript. yk supervised the case. all authors contributed to the refinement of the paper and approved the final manuscript. key: cord- -oi l f f authors: shevlin, mark; mcbride, orla; murphy, jamie; miller, jilly gibson; hartman, todd k.; levita, liat; mason, liam; martinez, anton p.; mckay, ryan; stocks, thomas v. a.; bennett, kate m.; hyland, philip; karatzias, thanos; bentall, richard p. title: anxiety, depression, traumatic stress and covid- -related anxiety in the uk general population during the covid- pandemic date: - - journal: bjpsych open doi: . /bjo. . sha: doc_id: cord_uid: oi l f f background: the covid- pandemic has created an unprecedented global crisis, necessitating drastic changes to living conditions, social life, personal freedom and economic activity. no study has yet examined the presence of psychiatric symptoms in the uk population under similar conditions. aims: we investigated the prevalence of covid- -related anxiety, generalised anxiety, depression and trauma symptoms in the uk population during an early phase of the pandemic, and estimated associations with variables likely to influence these symptoms. method: between and march , a quota sample of uk adults aged years and older, stratified by age, gender and household income, was recruited by online survey company qualtrics. participants completed standardised measures of depression, generalised anxiety and trauma symptoms relating to the pandemic. bivariate and multivariate associations were calculated for demographic and health-related variables. results: higher levels of anxiety, depression and trauma symptoms were reported compared with previous population studies, but not dramatically so. anxiety or depression and trauma symptoms were predicted by young age, presence of children in the home, and high estimates of personal risk. anxiety and depression were also predicted by low income, loss of income and pre-existing health conditions in self and others. specific anxiety about covid- was greater in older participants. conclusions: this study showed a modest increase in the prevalence of mental health problems in the early stages of the pandemic, and these problems were predicted by several specific covid-related variables. further similar surveys, particularly of those with children at home, are required as the pandemic progresses. severe acute respiratory syndrome coronavirus (sars-cov- ) was first detected in wuhan, china, on december . the disease it causes has been named covid- . the first uk coronavirus case was confirmed on january , and on march the world health organization declared the global spread of covid- to be a pandemic. since then there have been rapidly increasing cases and deaths associated with the virus globally and in the uk. on the evening of march , the uk prime minister announced extensive restrictions on freedom of movement, the closure of non-essential businesses and the requirement to stay at home except for limited purposes. the mental health consequences for the population of an existential threat on the scale of the current pandemic, and of the associated restrictions on movement and social gatherings, are not well understood. there has been research on the psychological effects of other infectious respiratory diseases (irds) such as sars, the h n flu pandemic and mers. however, with a few exceptions, which are mostly from the far east and have focused largely on anxiety and its influence on risk perception and health behaviours rather than mental health more broadly, , these studies have predominantly considered healthcare workers , and patients. this absence of knowledge is troubling because there is plausible evidence from modelling that emotional and behavioural responses to a pandemic may affect its course, and because the burden of population mental ill-health may have implications for resources during the pandemic and national recovery afterwards. in , the canadian national advisory committee on sars and public health, proposed that a 'systemic perspective', which focused not only on medical staff and patients but also on the general population, should be prioritised by all those engaged in ird psychosocial research. a similar approach was advocated in a recent uk expert panel convened by the academy of medical sciences and the mental health research charity mq. here, we report initial findings from the first wave of a longitudinal, multi-wave survey of the social and psychological effects of covid- on the uk population, conducted by researchers in seven uk and irish universities (the covid- psychological research consortium). of note, in a mirror study with similar methodology, we recently reported the social and psychological effects of covid- on the population of the republic of ireland. the primary aim of this study was to assess the levels of anxiety, depression and traumatic stress, based on validated selfreport measures, in a large, representative community sample during an early stage of the pandemic, between and march . based on the scant previous studies and given the dramatic restrictions imposed because of covid- , we expected higher levels of common psychological and stress symptoms compared with previous population estimates. our secondary aim was to identify groups that are psychologically vulnerable during the pandemic, by assessing the relationship between levels of anxiety, depression and traumatic stress and (a) age; (b) household income; (c) economic threat due to covid- ; (d) health-related risk factors (being male, self or close friend or relative having a pre-existing serious health condition); (e) covid- infection status; (f) anxiety specifically related to covid- ; (g) perceived risk of covid- infection; (h) living in an urban area; (i) living as a lone adult and (j) living with children in the home. data collection started on march , days after the first confirmed covid- case in the uk and on the same day that the uk prime minister announced at . pm the 'lockdown' that required all people in the uk to stay at home except for very limited purposes, and was completed on march . the fieldwork was conducted by the survey company qualtrics. the uk adult population aged years and older was the target population, and quota sampling methods were used to ensure that the sample was representative of this population in terms of age and gender, based on population estimates from eurostat, and household income based on the office for national statistics household income bands. qualtrics provides an online platform to securely house data and leverages partners to connect with potential participants who could have been alerted to the study in one of two ways: (a) they opted to enter studies they were eligible for themselves by signing up to a panel platform; or (b) they received automatic notification through a partner router which alerted them to studies for which they were eligible (via email, sms or in-app notifications). importantly, to avoid self-selection bias, survey invitations to eligible participants only provided general information and did not include specific details about the contents of the survey. participants were required to be an adult (aged years or older), able to read and write in english, and a resident of the uk. no other exclusion criteria were applied. panel members were not obliged to take part in the study. for purposes of quota sampling for age, gender and household income, qualtrics proceeded as follows during the days of fieldwork: (a) respondents in 'hard to reach' quota groups (e.g. young adults in the highest income bands) were prioritised and targeted first; (b) next, the focus shifted to allow the quotas to 'fill up' naturally, without specific targeting; and (c) finally, a switch back to targeting respondents to fill incomplete quotas ensued. participants followed a link to a secure website and completed all surveys online. the invite link was active for a participant until a quota they would have qualified for was reached but after the quota was filled; previously eligible respondents were prevented from taking part in this study. participants were informed about the purpose of the study, that their data would be treated in confidence, that geolocation would be used to determine the area in which they lived, and of the right to terminate the study at any time without giving a reason. all participants provided informed consent prior to completing the survey and were directed to contact the national health service covid- helpline at the end of the survey if they experienced any distress or had additional concerns about covid- . ethical approval for the study was granted by the ethical review board of sheffield university (the reference number for ethical approval is ). qualtrics employed checks to identify and remove potential duplicate respondents or any participants who completed the survey in less than the minimum completion time (half the median time of the 'soft-launch' with participants) to ensure responses were trustworthy. the pre-recruitment quotas were achieved with a high level of accuracy; the quotas were obtained to within % for gender, . - . % for age bands and . - % for household income bands. the adult psychiatric morbidity survey in england estimated the rate of post-traumatic stress disorder (ptsd) to be . %; this was lower than the rates for anxiety and depression. to detect a disorder with a prevalence of %, with precision of % and a % confidence level, a sample size of was required. however, estimating the prevalence of disorders with a low prevalence (< %) may result in a small number of 'cases' being identified. for instance, a sample size of and prevalence of % will identify approximately cases and, if follow-up analyses are based only on these cases, tests may be underpowered. to detect a correlation of . , with alpha = . and power of . , cases are required (or an overall sample size of ). as a compromise between ensuring adequate sampling to reliably estimate prevalence and adequate power for subgroup analysis, a target sample size of participants was set. given the dual processes used by qualtrics and partners to recruit respondents to quotas, it was not possible to determine the number of survey invitations that were distributed to panel members, or indeed the number of panellists who were alerted to the survey and who did or did not complete the survey (i.e. the response rate). qualtrics did provide some metrics for the study, as follows: respondents did not provide full informed consent and were screened out; respondents who completed the survey from outside the uk or were aged under years were also screened out; and, to ensure responses were trustworthy, participants who completed the survey in less than the minimum completion time were removed, as were potential duplicate respondents. this resulted in a sample of participants who completed the survey over days of fieldwork. subsequent checks ensured that the participants were also representative of the population in terms of voting history, number of people in household and other important demographic characteristics. participants were recruited from the four countries of the uk, proportional to their relative population sizes: england ( . %), wales . % (n = ) were in part-time employment, . % (n = ) were retired, . % (n = ) were students, . % (n = ) were currently unemployed and seeking work, . % (n = ) were not working owing to disability, and . % (n = ) were unemployed and not seeking work. self-reported gender and age were recorded, and age was also categorised into a six-level variable for the regression analysis. participants were asked 'do you consider yourself to live in:' and were required to choose one of the options provided: 'city', 'suburb', 'town' or 'rural'. lone adult: participants were asked 'how many adults ( years or above) live in your household (including yourself)?' and were provided with options ranging from ' ' to ' or more'. the data were recoded into a binary variable to represent living alone. participants were asked 'how many children (below the age of ) live in your household?' and were provided with options ranging from ' ' to ' or more'. the scores were categorised into four groups ( , , , or more children). participants were asked 'please choose from the following options to indicate your approximate gross (before tax is taken away) house- participants were asked 'some people have lost income because of the coronavirus covid- pandemic, for example because they have not been able to work as much or because business contracts have been cancelled or delayed. please indicate whether your household has been affected in this way', and the response options were 'my household has lost income because of the coronavirus covid- pandemic', 'my household has not lost income because of the coronavirus covid- pandemic, and 'i do not know whether my household has lost income because of the coronavirus covid- pandemic'. the first option was considered as 'yes' ( ) and the other options were collapsed to represent 'no'. participants were asked 'do you have diabetes, lung disease, or heart disease?', and the response options were 'yes' ( ) and 'no' ( ). they were also asked 'do any of your immediate family have diabetes, lung disease, or heart disease?', and the response options were 'yes' ( ) and 'no' ( ). participants were asked 'have you been infected by the coronavirus covid- ?', and six responses were provided. these were collapsed into a binary variable representing 'perceived infection status'. positive perceived infection status was based on the selection of either, 'i have the symptoms of the covid- virus and think i may have been infected' or 'i have been infected by the covid- virus and this has been confirmed by a test'. negative perceived infection status was based on the selection of either, 'no. i have been tested for covid- and the test was negative', 'no, i do not have any symptoms of covid- ', 'i have a few symptoms of cold or flu but i do not think i am infected with the covid- virus' or 'i may have previously been infected by covid- but this was not confirmed by a test and i have since recovered'. positive status (self) was coded ' ' and negative status was coded as ' '. participants were also asked 'has someone close to you (a family member or friend) been infected by the coronavirus covid- ?', and four responses were provided. these were collapsed into a binary variable representing 'perceived infection statussomeone close'. positive perceived infection status was based on the selection of either, 'someone close to me has symptoms, and i suspect that person has been infected' or 'someone who is close to me has had a covid- virus infection confirmed by a doctor'. negative perceived infection status was based on the selection of either, 'no' or 'someone close to me has symptoms, but i am not sure if that person is infected'. positive status (other) was coded ' ' and negative status was coded as ' '. participants were asked 'what do you think is your personal percentage risk of being infected with the covid- virus over the following time periods?', and three sliders were presented, one for each time period: ( ) 'in the next month', ( ) 'in the next three months', ( ) 'in the next six months'? the slider had ' ' and ' ' at the left-and right-hand extremes, respectively, with point increments, and the labels 'no risk', 'moderate risk' and 'great risk' were shown on the left-hand, middle and right-hand parts of the scale, respectively. these produced continuous scores for each time period, ranging from to , with higher scores reflecting higher levels of perceived risk of being infected by covid- . the scores were recoded into 'low' ( - ), 'moderate' ( - ) and 'high' ( - ). nine symptoms of depression were measured using the patient health questionnaire- (phq- ). participants indicated how often they had been bothered by each symptom over the past weeks using a four-point likert scale ranging from (not at all) to (nearly every day). possible scores ranged from to , with higher scores indicative of higher levels of depression. to identify participants likely to meet the criteria for depressive disorder, a cut-off score of was used. this cut-off produces adequate sensitivity ( . ) and specificity ( . ), corresponds to 'moderate' levels of depression and is used to identify a level of depression that may require psychological intervention. the psychometric properties of the phq- scores have been widely supported, and the reliability of the scale among the current sample was excellent (α = . ). symptoms of generalised anxiety were measured using the generalized anxiety disorder -item scale (gad- ). participants indicated how often they had been bothered by each symptom over the past weeks on a four-point likert scale ( = not at all, to = nearly every day). possible scores ranged from to , with higher scores indicative of higher levels of anxiety. a cut-off score of was used; this has been shown to result in sensitivity of % and a specificity of %. the gad- has been shown to produce reliable and valid scores in community studies, and the reliability in the current sample was high (α = . ). the international trauma questionnaire (itq) is a self-report measure of icd- ptsd based on a total of six symptoms across the three symptom clusters of re-experiencing, avoidance and sense of threat: each symptom cluster comprises two symptoms. participants were asked to complete the itq '… in relation to uk population mental health and covid- your experience of the covid- pandemic. please read each item carefully, then select one of the answers to indicate how much you have been bothered by that problem in the past month'. the ptsd symptoms are accompanied by three items measuring functional impairment caused by these symptoms. all items are answered on a five-point likert scale, ranging from (not at all) to (extremely), with possible scores ranging from to . a score of ≥ (moderately) is considered 'endorsement' of that symptom. a ptsd diagnosis requires traumatic exposure and at least one symptom to be endorsed from each ptsd symptom cluster (re-experiencing, avoidance and sense of threat), and endorsement of at least one indicator of functional impairment. the psychometric properties of the itq scores have been demonstrated in multiple general populations , and in clinical and high-risk samples. , the reliability of the ptsd items was high (α = . ). the survey included a question 'how anxious are you about the coronavirus covid- pandemic?', and the participants were provided with a 'slider' (electronic visual analogue scale) to indicate their degree of anxiety with ' ' and ' ' at the left-and righthand extremes, respectively, and point increments. this produced continuous scores ranging from to , with higher scores reflecting higher levels of covid- -related anxiety. the scores were recoded into quintiles, and the upper quintile was considered to be indicative of 'covid- anxiety'. similar recruitment strategies and measures have been used by international collaborators in other countries, including ireland, italy, spain, saudi arabia and the united arab emirates. the analyses were conducted in three linked phases. first, the prevalences of generalised anxiety, depression and traumatic stress were estimated using the established cut-off scores. second, the bivariate associations between the predictor variables and the mental health variables were calculated using logistic regression, and the associations were reported as odds ratios (ors) with % confidence intervals. third, all predictor variables were entered simultaneously into multivariate binary logistic regression models to estimate the unique effect of each predictor variable, and the associations were reported as ors. based on the cut-off scores for the gad- and the phq- , the prevalence of depression was . % ( % ci . - . %) and that of anxiety was . % ( % ci . - . %). there was no significant difference between prevalence of depression for males and females (χ ( ) = . , p = . ), but significantly more females ( . %) screened positive for anxiety than males ( . %: χ ( ) = . , p < . ). a variable was computed to represent participants who screened positive for the most common mental health disorders (anxiety/depression), either anxiety or depression; the prevalence for this was . % ( % ci . - . %), and the prevalence was higher for females ( . %) than for males ( . %: (χ ( ) = . , p < . ). using the diagnostic algorithm for the itq, the prevalence of traumatic stress was . % ( % ci . - . %). there was a significant gender difference, with a higher prevalence of traumatic stress for males ( . %) compared with females ( . %: χ ( ) = . , p < . ). the covid- anxiety prevalence was . % ( % ci . - . %), and there was a significant gender difference, with a higher prevalence of covid- anxiety for females ( . %) compared with males ( . %: χ ( ) = . , p < . ). three binary logistic regression models were used to predict caseness on covid- -related anxiety, anxiety/depression and traumatic stress. the predictor variables were age, gender, living location, lone adult status, number of children, income, loss of income, pre-existing health condition (self and other), covid- infection status (self and other) and personal risk of infection over the following month. table shows the findings for covid- -related anxiety, stratified by the predictor variables, with bivariate associations (unadjusted) presented as ors, and ors from the multivariate (adjusted) model with all predictors entered. the multivariate model was significant (χ ( ) = . , p < . ). when the unadjusted ors were calculated, only female gender, the presence of children in the household and estimates of personal risks of infection were predictive of covid-related anxiety. however, when the adjusted effects were calculated, the effect for the presence of children became stronger; there was an effect for history of infection, which should be interpreted with caution in the light of the small numbers involved; and there was a very strong effect for age, with older participants reporting more anxiety about the virus. the multivariate regression models for both anxiety/depression (χ ( ) = . , p < . ), and traumatic stress (χ ( ) = . , p < . ) were statistically significant; the unadjusted and adjusted ors are shown in tables and . for anxiety/depression, there was a strong effect for age, contrary to the effect observed for covidrelated anxiety, with very high levels of psychological symptoms in the youngest participants and low levels in those over years of age. a bivariate effect for urban location did not survive in the multivariate model, and the effect of having children in the house was much muted in the multivariate model. participants who had lost income in the pandemic and those in the lower-income categories showed markedly higher risk for anxiety/depression. higher levels of anxiety/depression were also reported by those who had pre-existing health conditions, knew someone who had a pre-existing health condition, had become infected themselves, and/or gave a high estimate of their personal risk of infection. finally, in the case of traumatic stress, there was again a higher prevalence in younger participants, but the gender effect was reversed compared with anxiety/depression, with more symptoms being reported by males. the influence of the presence of children was marked for both the bivariate associations and the multivariate model, but there was little effect for income or loss of income when other variables were controlled for. the lack of an association for being infected by covid- in the multivariate model should be interpreted with caution, given the small numbers involved and the wide confidence intervals. trauma symptoms were also associated with the perception of a high risk of infection. this study was one of the first to measure psychological disorders in a representative sample of the uk population during a pandemic. the study had the additional virtues of recruiting participants early in the crisis and using standardised measures, allowing follow-up at later stages. we found higher levels of anxiety, depression and traumatic stress than those previously reported by general population-based studies. although previous studies have investigated the psychological effects of past pandemics, particularly the sars and h n pandemics in the far east, they mostly considered the effects on pandemic survivors and health professionals, and the only population-based studies did not use standardised instruments. for example, a study in taiwan following the sars pandemic used a five-item symptom-rating scale, and found that poorer mental health was related to personal experience of sars shevlin et al or knowing people who had been affected. in a chinese study that employed a short questionnaire during the same pandemic, respondents reported increased fear, anxiety and panic. however, a longitudinal study of citizens of hong kong during the h n pandemic found low levels of anxiety throughout, but anxiety levels were associated with compliance with social distancing advice. our primary aim was to assess the levels of anxiety, depression and traumatic stress in the population during the early stages of the covid- pandemic. the prevalence of anxiety ( . %) and depression ( . %) found in this study appear to be higher than those previously reported, but not markedly so. the english adult psychiatric morbidity survey (apms) reported that . % of the sample experienced symptoms of common mental health disorders, based on a cut-off score of on the clinical interview schedule-revised, with a higher prevalence for women ( . %) than for men ( . %). the prevalence of anxiety or depression in the understanding society study in was . % ( . % for females, . % for males), based on the general health questionnaire (ghq). the closest comparable study is probably the national institute for health research applied research collaboration north west coast household health survey, which administered the phq and gad (face-to-face) to people in the north-west of england, mainly living in deprived areas; in this study, % were depressed and % were anxious. a recently published study used data from the understanding society covid- web survey, and reported the population prevalence of clinically significant levels of mental distress to be . %. the study used the ghq to identify clinically significant distress, and data collection was approximately month after our data collection period, but despite these differences the ghq prevalence was similar to that based on meeting the criteria for either anxiety or depression in this study, which was . %. this may be indicative of a stable psychological response during the first month of lockdown, although longitudinal studies will be required to determine the longitudinal change during lockdown. the prevalence of ptsd in this current study was . %, similar to the combined prevalence of ptsd and complex ptsd in a uk trauma-exposed sample (prevalence of . % for ptsd and . % for complex ptsd ), and much higher than that reported by the apms ( . %, with no gender differences found ). however, these comparisons should be treated with caution, as the status of covid- as a traumatic stressor is not clear. unexpectedly, the prevalence for males was higher than that for females; most epidemiological studies report a higher prevalence of ptsd for females. the reasons for this are not immediately clear, but the health and economic threats that covid- poses may be undermining traditional male gender roles, or the higher prevalence of mortality for males during the british covid- pandemic may play a part. the unadjusted estimates for the model predicting anxiety/ depression revealed that younger age, being female, living in a city, pre-existing health conditions, covid- status and perceived risk of covid- infection all significantly increased the likelihood of screening positive for anxiety or depression. contrary to expectations, the oldest age group and being male were associated with a lower likelihood of anxiety or depression, despite these factors being associated with higher covid- related mortality. in the adult psychiatric morbidity survey, a much lower prevalence of common psychological disorders was observed in those over compared with those of working age, although the effect was nonlinear and the high prevalence observed for those under in this study were not evident there. strikingly, the opposite relationship with age was observed for anxiety specifically about the covid- pandemic, which was related to mortality risk in a logical way. the adjusted estimates were generally attenuated, but the same pattern of associations was found. the unadjusted estimates for the model predicting traumatic stress differed in that being male was a significant risk factor, and there was a large effect for living in an urban area. this study had both strengths and limitations. on the strengths side, the sample was highly representative of the uk population, was recruited early in the progress of the pandemic, and used standardised measures, allowing comparisons with findings from later stages of the covid- crisis. however, despite the sampling frame and large sample size, and although the participants in this study were representative of the uk population in terms of demographic, economic and social factors, as well as voting history, it was not a true random probability sample (which would have been very difficult to obtain under the current circumstances), and it is possible that individuals' decisions about whether to participate were affected by psychological factors, creating the possibility of sampling bias. second, all mental health assessments were based on self-report and not clinician-administered interviews; this may have resulted in overestimation of prevalence. third, the validity of the assessment of traumatic stress may be questioned, as it is not clear whether the covid- pandemic meets the icd- criteria ('an extremely threatening or horrific event or series of events') or dsm- criteria (direct exposure, witnessing the trauma, learning that a relative or close friend was exposed to a trauma, indirect exposure to aversive details of the trauma, usually in the course of professional duties) for a traumatic event for the entire population. this question is already being debated, with arguments being made that the global nature of the threat, its wide ranging effects (i.e. health, economic and social), and the widespread reports of behaviours and cognitions modelling studies have suggested that the influence of pandemics on psychological disorders in the general population may affect the progress of a pandemic and, therefore, indirectly affect mortality. furthermore, the development of psychological disorders in the population may create a burden that impedes national social and economic recovery once the pandemic ends. the fact that the prevalence of psychological problems observed in the present study was not dramatically higher than those reported in previous studies suggests that the population, at an early stage of the pandemic, has successfully adapted to the unprecedented changes that have been forced on their lifestyles. however, we have identified certain key groups who may be more vulnerable to the social and economic challenges of the pandemic, particularly those whose income has been affected, who have children living in the home and who have pre-existing health conditions that make them vulnerable to the more devastating effects of the covid- virus. further research is needed to track whether these groups show higher levels of psychological problems at later stages in the pandemic and whether specific interventions and policies should be developed to address their needs. the datasets generated during and/or analysed during the current study will be archived with the uk data service (https://ukdataservice.ac.uk/) within months of the study ending. community psychological and behavioral responses through the first wave of the influenza a (h n ) pandemic in hong kong changes in emotion of the chinese public in regard to the sars period psychological impact of severe acute respiratory 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contribution to the design of the study; drafting or revising manuscript; final approval of the version to be published; project administration. r.p.b.: conception of study; contribution to the design of the study; drafting or revising manuscript; final approval of the version to be published; project administration. this research received no specific grant from any funding agency, commercial or not-for-profit sectors. none. key: cord- - dhwggn authors: hong, xia; currier, glenn w.; zhao, xiaohui; jiang, yinan; zhou, wei; wei, jing title: posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: a -year follow-up study() date: - - journal: gen hosp psychiatry doi: . /j.genhosppsych. . . sha: doc_id: cord_uid: dhwggn objective: to measure the incidence and impact of posttraumatic stress disorder (ptsd) in a cohort of subjects with severe acute respiratory syndrome (sars). methods: clinical assessments of ptsd were conducted at , , , and months after discharge from medical hospitalization for treatment of sars. diagnoses of ptsd were established by a trained psychiatrist using the chinese classification of mental disorders (ccmd-iii) and diagnostic and statistical manual of mental disorders, th edition (dsm-iv) criteria. to study the impact of ptsd, we used the impact of event scale (ies), zung self-rating anxiety scale (sas), zung self-rating depression scale (sds), symptom checklist (scl- ), short form- (sf- health survey) and social disability screening schedule (sdss). results: of the subjects who finished at least two follow-up interviews, developed ptsd over the study period ( . %). scores on ies, sas, sds and scl- (p<. ) were higher, and functional impairment as measured by sf- (p<. ) and sdss was more severe (p=. ) for subjects with ptsd. conclusion: ptsd occurs in a significant percentage of subjects who recover from sars, and the occurrence of ptsd predicts persistent psychological distress and diminished social functioning in the years after sars treatment. severe acute respiratory syndrome (sars) was the first severe and readily transmissible new infectious disease to emerge in the st century. sars initially developed in southern china, where the first cases are now known to have occurred in late november [ ] . since then, the cumulative number of reported probable cases of sars worldwide for the period november , , to august , , was [ ] . the largest outbreak of sars struck beijing in spring . infected individuals from several outlying provinces sought clinical care in beijing, resulting in viral dissemination to local health care facilities. beijing's outbreak began in march ; by late april, daily hospital admissions for sars exceeded for several days, with the onset of the last probable case on may , [ , ] . in total, cases of probable sars occurred, with total of deaths and a case fatality rate of . % [ ] . initial public health management of the outbreak relied heavily on quarantine. patients diagnosed with sars were isolated in several hospitals, with specific secondary referral hospitals serving as central receiving facilities as the outbreak emerged. unaffected individuals with known contact with sars patients were isolated in their own homes to interrupt the transmission of the syndrome. the public was terrified, with widespread media attention concerning the severity of the epidemic. sars is normally transmitted through droplet spread from one person to another, clustered among family groups. the transmission rate among close contacts was . % (range by beijing local government districts, . - . %). transmission increased with the age of close contacts, from . % in children younger than years to . % in adults aged to years. the attack rate was highest among spouses ( . %), other household members ( . %) and nonhousehold relatives ( . %) [ ] . posttraumatic stress disorder (ptsd) is a stress-related disorder that can occur after the experience of a traumatic event. the estimated lifetime prevalence of ptsd is . % in the us population [ ] . the -month prevalence of ptsd was . % in metropolitan population in china (beijing and shanghai) [ ] . several studies report the incidence of ptsd in victims of natural disaster ( . % to . %) or traumatic accident ( . %) in china [ ] [ ] [ ] . however, differences in study design, outcome measures and clinical populations provided make it difficult to compare these results. the psychosocial and functional impact of ptsd can be severe. individuals with ptsd often manifest greater psychological and social impairment. ptsd can damage interpersonal relationships and functional capacity, leading to increased depression and related impairment [ ] . more generally, chronic stress has been associated with a variety of adverse medical outcomes, including chronic diseases such as diabetes, hypertension and heart disease [ ] . one specific serious medical outcome of treatment related to sars can adversely affect long-term functional capacity. as a side-effect of drugs (such as glucocorticoids) used in treatment, femoral head necrosis (fhn) was reported to occur in % to % of chinese sars patients in follow-up studies [ , ] . there were articles published after examining the psychological impact of sars on survivors [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] . in one study of survivors of sars at months postdischarge from hospital in singapore, the rate of possible ptsd, inferred from an impact of event scale (ies) score of n , was . % [ ] . in a study of survivors of sars at month postdischarge from hospital in hong kong, % to % of them reported symptoms related to ptsd [ ] . in another study in hong kong, among survivors, % at month and % at months postdischarge endorsed symptoms consistent with ptsd [ ] . however, these articles were limited by use of self-reported ratings of ptsd, and no specific ptsd measures were included. several studies suggest that sars survivors still had elevated levels of general psychological distress , , and months after hospital discharge, but the rate of ptsd is unspecified in these studies [ ] [ ] [ ] [ ] [ ] [ ] [ ] . the increased psychological burden of fhn in conjunction with sars has not been evaluated. furthermore, several articles published in chinese focused on the incidence of ptsd on sars survivors in beijing, shanxi and tianjin in mainland china, and the incidence rate of ptsd was reported to be . %, . % and . % at months postdischarge [ ] [ ] [ ] . the aim of our study was therefore to determine the incidence of ptsd in survivors of sars up to years after initial medical treatment. we aimed to describe changes in psychological and functional outcomes for subjects with and without ptsd diagnoses over the same time frame and to consider the impact of fhn on severity of ptsd. participants were recruited from the free outpatient medical clinic for convalescent patients of sars at peking union medical college hospital (pumch). infectious, respiratory and psychological services were available in the clinic. subjects from several inpatient sars treatment facilities received subsequent care at pumch on a voluntary basis. the study sample was enrolled between june , , and november , . all subjects qualifying for the study had received a sars diagnosis in accordance with the ministry of health of the people's republic of china criteria for "infectious atypical pneumonia" and were determined to be adequately treated, appropriate for discharge and isolated for week in their own home after hospital discharge [ ] . the protocol of this study was approved by the pumch ethics committee, and written informed consent was obtained from all participants. all adult subjects who came to the free outpatient clinic for convalescent patients of sars at pumch were consecutively screened over a period of months. all subjects who were approached agreed to participate. the initial interview (t ) was performed an average of days (s.d.= , range= to days) after hospital discharge. follow-up interviews were conducted approximately months (t , average= days, s.d.= days), months (t , average= days, s.d.= days), months (t , average= days, s.d.= days) and months (t , average= days, s.d.= days) after discharge from hospital. interviews consisted of a variety of rater-administered, self-report measures and open interview, and lasted on average approximately min. all rater-administered and self-report measures were translated into chinese and have been published. . sociodemographic data, including age, sex, marital status, occupation, employment status prior to sars, educational level, living status, number of relatives who contracted or died from sars. . medical and psychiatric history, as well family history of psychiatric disorder, was included. "if you were found to suffer from femoral head necrosis" and "if you have any body discomfort" were added in t , t and t . chest computed tomography (ct) was available in t . the abnormality of chest radiography was scored from (not at all) to (very severe) by a radiologist. magnetic resonance imaging (mri) of the hip joint was available in t . self-reported fhn and results of mri were used together to judge whether subjects suffered from fhn. . scales used to assess the impact of ptsd: a. the impact of event scale (ies) is a -item self-report questionnaire designed to assess symptoms of intrusive thoughts and avoidance resulting from traumatic life events. the scale measured frequency with which each of the ptsd symptom has occurred over the past week; scores of , , and correspond with responses of "not at all," "rarely," "sometimes" and "often," respectively; and a summed score ranges from to [ , ] . b. zung's self-rating depression scale (sds [ ] ) and zung's self-rating anxiety scale (sas [ ] ) are two -item self-report questionnaires designed to assess symptoms of depression and anxiety, with scores ranging from to [ ] [ ] [ ] [ ] . c. symptom checklist (scl- ) is a -item selfreport inventory designed to screen for psychopathological symptoms. each item is scored from (not at all) to (extremely). it includes nine symptom dimensions: somatization, obsessivecompulsiveness, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism [ , ] . d. short form- (sf- ) health survey was conducted in t to t . the sf- includes eight subscales: physical functioning (pf), role limitation due to reduced physical functioning (rp), body pain (bp), general health (gh), vitality (vt), social functioning (sf), mental health (mh) and role limitation due to emotional problems (re). scale scores were transformed and standardized on a scale ranging from to , with lower scores representing poorer health functioning [ ] . sf- has been translated into chinese and normed on chinese populations [ ] . e. social disability screening schedule (sdss) was conducted in t to t . sdss is a -item rateradministered scale used to access the function in a variety of occupational, social, marital and family roles. item scores of , and correspond with absent, moderate or serious dysfunction, respectively. this scale was translated into chinese and modified according to the disability assessment schedule [ , ] . t interviews were conducted at the outpatient clinic. t to t interviews were completed in a variety of venues, including at pumch, the patient's home or by mail with telephone follow-up if live interviews were not possible. self-rating scales were finished by the subjects themselves according to written direction. other rating scales were conducted by the same interviewer during each visit. the diagnosis of ptsd was made by a senior psychiatric doctor according to ccmd-iii [ ] criteria. the ccmd-iii differs from the dsm-iv classification [ ] by requiring a longer duration for symptoms, and therefore all subjects met dsm-iv criteria as well. diagnoses were classified into four types: . current ptsd: subjects fulfilled the criteria of ptsd at the follow-up interview. . prior ptsd: subjects endorsed past symptoms consistent with ptsd and met the diagnostic criteria, but the symptoms were alleviated and did not meet the criteria at the current follow-up interview. . no ptsd. . unable to confirm: insufficient data available to make ptsd diagnosis. statistical analyses were conducted with sas . /spss . . group comparisons of dimensional variables were performed with independent-samples t tests. for categorical variables, chi-squared tests were used, including fisher's exact test if the expected count was less than five in more than % of cells. for ordinal variable (chest ct), nonparametric wilcoxon signed-rank test was used. linear mixed-effects models were used to examine whether the impact of ptsd as measured by ies, sas, sds, scl- , sf- and sdss was different with no-ptsd subjects, and whether there were some changes over time. the models contained scores on ies, sass, sds, scl- , sf- and sdss as response variables (y), and ptsd (x) and follow-up time (years postdischarge, t) as the primary fixed effects of interest. ptsd was included as a time variant variable with a value of for any time point before and a value of after diagnosis. the models included x, t and the interaction between x and t (model of y on x, t, x⁎t). sociodemographic characteristics and medical condition of the sample are presented in table . the majority of subjects were females, and the mean age was . years. the age distribution did not differ from overall beijing sars cases [ ] (chi-square= . , p=. ). one subject had a positive history of depression and had been prescribed fluoxetine for year, although he/she was not taking antidepressants before the onset of sars. subjects with ptsd were more likely to be older, female, married, have higher numbers of close relatives who suffered and/or died from sars, and to have fhn. there was no significant difference between those with ptsd and those without ptsd on chest ct findings in t (p=. ). follow-up status is shown in fig. . seventy, , and subjects finished at least one, two, three and four interviews, respectively. forty-three finished all five interviews. some subjects who missed earlier interviews were captured in later assessments. among all visits, . % were finished at the outpatient clinic, . % via home interviews and . % via mailing and telephone. as shown in fig. , met the criteria initially; one subject who did not demonstrate ptsd in t to t developed onset of ptsd at t but recovered at t , and one subject who did not demonstrate ptsd in t to t developed onset of ptsd at t . two subjects who fulfilled the symptom criteria, severity criteria, but not the course criteria for ptsd in the t visit (interval between t and hospital discharge was and days, respectively), were then dropped. therefore we were unable to confirm the diagnoses of these two subjects. three subjects, whose diagnosis was ptsd in both the t and t visits, did not fulfill the diagnostic criteria thereafter, suggesting recovery from ptsd. thirty-eight subjects never met the diagnostic criteria. one participant, who went abroad at t , did respond to questionnaires while unavailable for interview; the diagnosis was unable to confirm at t and t . upon return to china at t , this subject did not meet the criteria for ptsd. no other subject who missed an assessment changed his/her ptsd status on the next available assessment. table . twenty-three ( . %) of the cases of ptsd established at t still met the diagnostic criteria at t . compared with subjects with no ptsd, subjects given a diagnosis of ptsd had significantly higher scores on ies, sas, sds, scl- and sdss, and a significantly lower score on sf- at all time points (table ) . table shows the differences in mean score on scales from linear mixed models for the ptsd vs. the no-ptsd group. all ptsd terms were significant (pb. ), indicating that there were significant differences in the scores on scales for the ptsd vs. the no-ptsd group. time terms were significant in ies (− . , p=. ), sds (− . , pb. ) and vt ( . , p=. ), suggesting that there was a significant decrease in scores on ies and sds, and an increase in scores on vt as follow-up time increased for both the ptsd and the no-ptsd groups. ptsd×time interaction terms were not significant (pn. ), indicating that there were no significant differences in the changes over time in the scores on scales for the ptsd vs. the no-ptsd group. the incidence of ptsd is . % in sars survivors in our -year follow-up study, suggesting ptsd is common in sars survivors. this incidence rate is similar to that reported for survivors of sars at months after discharge from hospital in singapore, where the rate of possible ptsd was . % [ ] . great variations in rates of ptsd have been reported after impersonal events such as serious motor vehicle accidents and natural disasters, with reported ranges of % to % [ ] [ ] [ ] . focusing on another life-threatening condition, davydow et al. [ ] reviewed observational studies among survivors of acute respiratory distress syndrome and found that the psychiatrist-diagnosed ptsd prevalence at hospital discharge, years and years was %, % and %, respectively. in this study, we use the ccmd-iii criteria [ ] , which is a more conservative measure of ptsd than dsm-iv [ ] , with a -month vs. a -month requirement for symptom duration. in the survey, two subjects fulfilled the symptom criteria, severity criteria, but not the course criteria for ccmd-iii in the t visit (interval between t and hospital discharge was and days, respectively) and were not located thereafter. had we used dsm-iv criteria only, the latter subject (interviewed at days after hospital discharge) would have been diagnosed with ptsd. it is unlikely that we overestimated the incidence of ptsd by using stricter diagnostic criteria. a critical question is whether the survivors enrolled in the study are representative of the sars survivors in beijing. the average age in our cohort was . years, which is close to the median age of beijing sars cases ( years), with no significant difference in age distribution between those two groups (p=. ). females were overrepresented in our sample ( . %), which may reflect differences in help-seeking behavior between genders [ , ] . females with mental health problems are more likely to seek help from medical professionals [ ] , although in the current study, participants also sought help from departments of infectious disease and respiratory medicine. four ( / , . %) sars survivors who exhibited ptsd in our cohort recovered during follow-up. most subjects ( / , . %) who were diagnosed with ptsd at the beginning of our study retained the diagnosis through the end of the study, suggesting that the median recovery time of this cohort is more than months. the score on ies in subjects with ptsd showed the same trends, with only a slight decrease over time (tables and ). this is consistent with other studies, including the detroit area survey of trauma, where the median time for ptsd to remit was . months and where in more than one third of cases ptsd persisted for more than months. previous research suggests that ptsd persists longer in women (median duration is . months) than in men ( . months) and persists longer in cases resulting from traumas experienced directly (median duration is . months) compared with learning about traumas to a loved one or the sudden unexpected death of a loved one ( . months) [ ] . subjects in our study were sars survivors who experienced the trauma directly, and . % were females, possibly explaining the long duration of ptsd in our group. as shown by linear mixed-effects modeling, after excluding the effect of time and ptsd×time interaction variables, compared with subjects with no ptsd, subjects given a diagnosis of ptsd had significantly higher scores on ies, sas, sds, scl- and sdss and a significantly lower score on sf- (table ). these findings suggest that the impact of ptsd was severe and persistent in our cohort, adversely affecting not only mental but also physical health. these results are consistent with findings in the studies of survivors of acute respiratory distress syndrome [ ] and of general intensive care unit survivors [ ] . symptoms of ptsd in those survivors were associated with lower quality of life, and physical outcomes were significantly impacted by the presence of ptsd [ , ] . a traumatic event's severity, duration and physical proximity are the most important factors affecting the likelihood of developing ptsd [ ] . in our cohort, while subjects from several inpatient sars treatment facilities were enrolled, we have no data about their clinical course during active sars infection. chest radiography postdischarge may be an indirect indicator for the clinical severity of the disease. there was no significant difference between those with ptsd and those without ptsd on chest ct findings in t . but the marginal significance (p=. ) suggested the necessity of larger sample size to clarify the correlation. the number of close relatives who suffered or died from sars may be an important indicator of the event severity. fhn, a specific serious adverse medical outcome related to sars treatment, may be a chronic stressor to these survivors. subjects with ptsd were more likely to have fhn and to have higher numbers of close relatives who suffered and/or died from sars than the no-ptsd group. these results supported the hypothesis we mentioned above. this study has several potential limitations, including primarily a limited sample size. the diagnosis of ptsd according to the criteria of dsm-iv [ ] by a trained psychiatrist using a standardized interview technique may be regarded as the clinical "gold standard" for the measurement of ptsd. therefore, the subjects were interviewed by an experienced psychiatrist in our cohort. had we employed the structured clinical interview for dsm-iv to establish the ptsd diagnosis, the criterion validity would have been greater. third, our subjects came from several inpatient sars treatment facilities, and data about subject's severity of sars, treatment method and drug dose were unavailable for analysis. ptsd could be detected in almost half of sars survivors in the years after successful medical treatment. once established, ptsd tended to endure and had a significant deleterious impact in terms of both psychiatric symptoms and function. these findings suggest that attention to the psychological aftermath of severe infectious disease is warranted. world health organization. severe acute respiratory syndrome (sars): over days into the outbreak world health organization. summary table of sars cases by country severe acute respiratory syndrome hindsight: a reanalysis of the severe acute respiratory syndrome outbreak in beijing evaluation of control measures implemented in the severe acute respiratory syndrome outbreak on beijing posttraumatic stress disorder in the national comorbidity survey twelve-month prevalence, severity, and unmet need for treatment of mental disorders in metropolitan china longitudinal study of earthquake-related ptsd in a randomly selected community sample in north china an epidemiologic study of posttraumatic stress disorder in flood victims in hunan china prevalence and characteristics of trauma and posttraumatic stress disorder in female prisoners in china quality of life in the anxiety disorders: a meta-analytic review health disparities in military veterans with ptsd: influential sociocultural factors dynamic changes of serum sars-coronavirus igg, pulmonary function and radiography in patients recovering from sars after hospital discharge factors of avascular necrosis of femoral head and osteoporosis in sars patients' convalescence quality of life and psychological status in survivors of severe acute respiratory syndrome at months postdischarge posttraumatic stress, anxiety, and depression in 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disorder ethnicity, culture, and disaster response: identifying and explaining ethnic differences in ptsd six months after hurricane andrew post-traumatic stress disorder and comorbid depression among survivors of the earthquake in turkey psychiatric morbidity in survivors of the acute respiratory distress syndrome: a systematic review beliefs about mental health problems and helpseeking behavior in dutch young adults gender, race-ethnicity, and psychosocial barriers to mental health care: an examination of perceptions and attitudes among adults reporting unmet need trauma and posttraumatic stress disorder in the community: the detroit area survey of trauma posttraumatic stress disorder in general intensive care unit survivors: a systematic review physical and psychological sequelae of critical illness social support during intensive care unit stay might improve mental impairment and consequently health-related quality of life in survivors of severe acute respiratory distress syndrome we would like to thank dr. naiji lu from the university of rochester medical center for his statistical support. key: cord- - ciukd authors: jalloh, mohamed f; li, wenshu; bunnell, rebecca e; ethier, kathleen a; o’leary, ann; hageman, kathy m; sengeh, paul; jalloh, mohammad b; morgan, oliver; hersey, sara; marston, barbara j; dafae, foday; redd, john t title: impact of ebola experiences and risk perceptions on mental health in sierra leone, july date: - - journal: bmj glob health doi: . /bmjgh- - sha: doc_id: cord_uid: ciukd background: the mental health impact of the – ebola epidemic has been described among survivors, family members and healthcare workers, but little is known about its impact on the general population of affected countries. we assessed symptoms of anxiety, depression and post-traumatic stress disorder (ptsd) in the general population in sierra leone after over a year of outbreak response. methods: we administered a cross-sectional survey in july to a national sample of consenting participants selected through multistaged cluster sampling. symptoms of anxiety and depression were measured by patient health questionnaire- . ptsd symptoms were measured by six items from the impact of events scale-revised. relationships among ebola experience, perceived ebola threat and mental health symptoms were examined through binary logistic regression. results: prevalence of any anxiety-depression symptom was % ( % ci . % to . %), and of any ptsd symptom % ( % ci . % to . %). in addition, % ( % ci . % to . %) met the clinical cut-off for anxiety-depression, % ( % ci . % to . %) met levels of clinical concern for ptsd and % ( % ci . % to . %) met levels of probable ptsd diagnosis. factors associated with higher reporting of any symptoms in bivariate analysis included region of residence, experiences with ebola and perceived ebola threat. knowing someone quarantined for ebola was independently associated with anxiety-depression (adjusted or (aor) . , % ci . to . ) and ptsd (aor . % ci . to . ) symptoms. perceiving ebola as a threat was independently associated with anxiety-depression (aor . % ci . to . ) and ptsd (aor . % ci . to . ) symptoms. conclusion: symptoms of ptsd and anxiety-depression were common after one year of ebola response; psychosocial support may be needed for people with ebola-related experiences. preventing, detecting, and responding to mental health conditions should be an important component of global health security efforts. what are the new findings? ► to the best of our knowledge, the assessment was the first national survey that examined the impact of the devastating ebola epidemic on populationlevel mental health using globally validated scales, and conducted after more than a year of ongoing transmission of ebola in the country. ► we found that symptoms of ptsd and anxietydepression were common after one year of the outbreak, especially among those with ebolarelated experiences. ► furthermore, we have demonstrated the ability to rapidly administer brief mental health screeners at the population level to identify factors associated with mental health symptomology towards the end of an unprecedented infectious disease epidemic. recommendations for policy ► preventing, detecting and responding to mental health conditions should be an important component of global health security efforts. ► use of brief mental health screeners during outbreak response could increase the ability to identify and address the needs of at-risk groups. ► so doing could help avert the substantial short-term and long-term effects of mental health disorders on individual health and on national health systems, societies and economies. primarily in sierra leone, liberia and guinea. in sierra leone alone, there were reports of more than ebola cases, resulting in over deaths, and more than individuals were quarantined due to possible ebola exposure. little is known about the epidemic's effects on the mental health of the general population in the affected countries. numerous studies have examined the mental health effects associated with other infectious disease outbreaks including the severe acute respiratory syndrome (sars) epidemic [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] and novel influenza a (h n ) pandemic. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] the mental health impact of other emergencies, such as bioterrorism, have also been documented among survivors. psychological distress, anxiety, depression and post-traumatic stress disorder (ptsd) have been recorded among populations exposed to mass conflict and displacement including those affected by the civil conflict in sierra leone between and . known risk factors for anxiety, depression and ptsdincluding experience with ill individuals, perceptions of threat, high levels of mortality, food and resource insecurity, stigma and discrimination, and intolerance of uncertainty-may have been experienced by people in sierra leone during the ebola epidemic. adverse mental health outcomes could be expected in the general population given the magnitude of the epidemic. high levels of distress have been documented among ebola survivors in guinea and sierra leone and healthcare workers (hcws) in all three affected countries. there are few mental health resources in sierra leone; for example, when the ebola outbreak began, there was only one trained psychiatrist for the population of over million. assessments of mental health and of risk factors for mental illness can support policy efforts to improve resources to address mental health and inform how resources can be targeted most efficiently-especially in the aftermath of a devastating ebola epidemic. the sierra leone ministry of health and sanitation and the us centers for disease control and prevention collaborated with focus and other stakeholders to implement a national, household-based ebola knowledge, attitudes and practices (kap) survey in july . the survey assessed respondents' ebola-related kap, perceptions of ongoing ebola threat, ebola-related experiences, and anxiety-depression and ptsd symptoms. the present analysis aimed to estimate prevalence of mental health symptoms and factors associated with having symptoms in the general population. the national survey employed a multistage cluster sampling procedure with primary sampling units selected with probability relative to their size. in order to attain % confidence levels and cis of ± % estimates of the national population, individuals were approached across the regions and districts of sierra leone. using sierra leone's most recent census list ( ) of enumeration areas as the sampling frame, enumeration areas were randomly selected across all districts. within each cluster, households were selected using systematic random sampling. to generate reliable district-level estimates for key districts, we oversampled in the three districts still experiencing active ebola transmission. a weighting factor was applied to each record to adjust for the different sample sizes taken in different districts. within each household, the household head and another individual (aged between years and years) or a woman were approached for consent and interviewed. survey questions included sociodemographic characteristics, ebola experience, perceived ebola threat, anxiety-depression symptomology and ptsd symptomology (supplementary file ). ebola experience variables included whether participants knew someone who had died from ebola and whether they knew someone who had been quarantined due to ebola exposure. participants whose only reported experience with ebola-related death ( . %, n= ) or quarantine was related to public figures ( . % of sample, n= ), such as well-known medical doctors who died from ebola, were excluded from this analysis. these two variables were also combined into a two-level composite item which included: ( ) no experience with ebola-related death or quarantine; ( ) knowing others who had been quarantined or had died from ebola. participants' perceptions of ebola as a threat were measured by four items that asked whether they perceived that ebola was no longer a threat to ( ) sierra leone; ( ) their district; ( ) their community; and ( ) their household. participants responded using -point likert scale items ranging from (strongly agree) to (strongly disagree). responses were further dichotomised into 'agree' and 'disagree,' and the scores reversed so that higher scores represented more perceived risk. we also created a composite score across all four domains with representing 'any perceived ebola threat' and representing 'no perceived ebola threat. ' symptoms of anxiety and depression were measured by patient health questionnaire- (phq- ). phq- was developed by combining two ultrabrief screeners, the phq- and the generalised anxiety disorder scale, that have been demonstrated to reliably measure depression and anxiety symptoms. participants were asked to report their symptoms of depression and anxiety in the past weeks on a likert scale from (not at all) to (nearly every day) for a maximum score of . the sample was further dichotomised into those who expressed any symptoms compared with those who did not by creating a new composite variable. we also examined the prevalence of anxiety and depression using the established clinical cut-off total score of , which represents the proportion of people who would be considered as having clinical bmj global health levels of depression or anxiety if the screener were used for diagnostic purposes. symptoms of ptsd were measured by the impact of event scale- (ies- ), which is a validated, shortened version of the full ies-revised (ies-r). the full scale contains items (scored from to ) with demonstrated reliability and validity to measure ptsd symptoms across different cultures and settings. while ies-r is generally not used to diagnose ptsd in clinical settings, it is widely used for screening at-risk patients with ptsd. the ies- includes a total of six items-two items from each of the three subscales of the measure, namely intrusion, hyperarousal and avoidance. participants were asked to report their ptsd symptoms in the past days on a likert scale ranging from (not at all) to (extremely). we dichotomised the sample into those who expressed any symptoms versus those who did not by creating a new composite variable. we evaluated respondents for whom ptsd may be a 'clinical concern' using an inputted . mean item cut-off score (equivalent to / on ies-r). in addition, we assessed respondents who met 'probable diagnosis' of ptsd using an inputted . mean item cut-off score (equivalent to / total score in ies-r). data collection in june , focus recruited experienced data collectors, team supervisors and regional supervisors. they were trained for a week on overall assessment protocols and guidelines, informed consent, safety and security precautions, administration of questionnaire, and quality control and assurance. the training included oral translation of each item into local languages (krio, mende, temne and limba), back translations (orally), group discussions of the translations for accuracy in meaning, role plays to reflect possible range of responses, and group consensus on the final translations to ensure consistent and accurate use of each item. in july , the trained data collectors used open data kit for digital data collection at the household level. nearly all interviews (> %) were conducted in krio. in july , when the ebola kap was administered, % of the cumulative confirmed ebola cases in the country had been reported. control activities continued, including provision of prevention messages, case detection, contact identification, quarantine and monitoring, and management of cases and deaths. quarantine involved days of home-based isolation with armed uniformed police dispatched to enforce restriction of movement in and out of the household. quarantined individuals were clinically monitored, and if ebola was suspected, they were transferred to a holding centre for testing. the data were analysed using spss v. . statistical significance was defined as a two-tailed p-value less than . . for reliability, internal consistency was assessed by calculating cronbach's α values. for factorial validity, the factor structures of the phq- and ies- scales were examined with confirmatory factor analysis (cfa). the relationships between demographic variables (gender, age, education and region of residence), ebola experience, perceived ebola threat and mental health symptoms were examined. frequencies, proportions, % ci of proportions, as well as χ tests were generated to examine the relationships between sample characteristics and mental health symptoms. univariate and multivariate binary logistic regression analyses were conducted to examine the relationship between ebola experience, perceived ebola threat and mental health symptoms. we further examined the effect of ebola experience, perceived ebola threat and interaction between those two variables on mental health status by conducting a multivariable logistic regression controlling for potential confounders. to avoid multicollinearity, only composite scores were entered as predictors into the model. sex, age, education and region were included because they have been associated with mental health symptoms in other studies. goodness of fit index (gfi), comparative fit index (cfi) and root mean square error of approximation (rmsea) were calculated to measure the cfa model. weighted cell count, percentages and ors with % cis are presented in the logistic regression tables. of individuals approached, ( %) consented to participate in the assessment. sample characteristics by mental health symptoms are presented in table . the median age of respondents was years (sd= ); ( %) were male. the sample comprised respondents from all four geographical regions in sierra leone: ( %) from the west, north ( %), east ( %) and south ( %). boosted district samples in kambia and port loko, where cases were still being identified, resulted in a larger sample from the north. of all respondents, % had no formal education, % had some primary school education and % had secondary or higher education. nearly a third ( %) of respondents knew at least one person who died from ebola. similarly, participants ( %) knew at least one person who was quarantined. about a quarter ( %) of respondents knew someone who died from ebola and someone who was quarantined. nearly three quarters ( %) of respondents perceived an ebola threat at one or more levels: in sierra leone ( %), their district ( %), their community ( %) or their household ( %). prevalence of symptoms figure shows % ( % ci . % to . %) of respondents reported at least one symptom of anxiety or depression, with % ( % ci . % to . %) meeting the clinical cut-off definition. of all respondents, % ( % ci . % to . %) reported one or more ptsd bmj global health table a ,b describes respondents' experiences with ebola and the association with anxiety and depression and ptsd symptoms, controlling for age, gender, region and education level. the experience of knowing someone who died from ebola alone was not independently associated with anxiety and depression symptoms (adjusted or (aor) . % ci . to . , p= . ) but was independently associated with ptsd symptoms (aor . % ci . to . , p= . ). those participants who knew someone quarantined due to ebola exposure alone were more likely to report symptoms of anxiety and depression (aor . % ci . to . , p< . ) and ptsd (aor . % ci . to . , p< . ) than those who did not. respondents who had both experiences (that is, they knew at least one person who died from ebola and someone quarantined) were also more likely to report symptoms of anxiety and depression (aor . % ci . to . , p< . ) and ptsd (aor . % ci . to . , p< . ) compared with those who did not report both. those with any ebola experience were more likely to report anxiety and depression symptoms than those who had no ebola experience (aor . % ci . to . , p< . ) and were more likely to report ptsd symptoms than those with no ebola experience (aor . % ci . to . , p< . ). table presents the relationship between perceived ebola threat and reported symptoms of anxiety and depression and ptsd. respondents who perceived some ongoing threat of ebola were more likely to report symptoms of anxiety-depression (aor . % ci . to . , p< . ) and ptsd (aor . % ci . to . , p< . ) compared with those who did not. table presents multivariate analyses of the associations between ebola experience and perceived ebola threat and symptoms of anxiety and depression and ptsd, adjusting for gender, age, region and education levels. ebola experience and perceived ebola threat were independently associated with anxiety and depression symptoms as well as ptsd symptoms. in addition, the interaction between ebola related experience and risk perception was independently associated with both anxiety-depression and ptsd symptoms: participants who had ebola experience and also perceived ongoing ebola threat were more likely to report symptoms of anxiety-depression (aor · % ci · to · , p= . ) and ptsd symptoms (aor · % ci · to · , p= . ). in a national sample of sierra leoneans after more than a year of the unprecedented ebola epidemic, nearly half of all respondents reported at least one symptom of anxiety or depression and three quarters expressed ptsd symptoms. most respondents reported between one and four symptoms. after adjusting for sociodemographic variables, we found that persons with any level of ebola experience were more likely to report symptoms of anxiety-depression and ptsd. even though expression of one or more symptoms was widespread among our sample, a lower proportion of respondents met the clinical cut-off scores for anxiety-depression ( %- %) and probable diagnosis for ptsd ( %- %). the proportion of respondents who exhibited clinical level symptoms of anxiety-depression may be considered 'lower than expected' given the magnitude and duration of the epidemic, but may also point to a culture of resiliency among sierra leoneans. on the other hand, we documented substantial ptsd, which is a public health concern that may require targeted mental health interventions at the individual level and community level for those with some personal ebola experience. a national assessment of the mental health impact of the sars epidemic in taiwan, using a different scale than in our current study, found % prevalence of depression after the epidemic ended. another population-based survey in taiwan revealed % prevalence of psychiatric morbidity following sars. in singapore, a community-based sample detected that a quarter of all respondents had clinical levels of ptsd symptoms. other mental health assessments with sars survivors and hcws documented similar or higher clinical ptsd levels compared with our current assessment. one study found that hcws with a history of mental illness before sars were more likely to report new onset following the epidemic. in our assessment, we cannot determine how past mental health history of ptsd in sierra leone, especially due to the prolonged civil war from to , may have influenced the levels of clinical ptsd concern we detected. similar to sars, the h n pandemic was associated with psychological distress among the general population, family members of hospitalised patients with h n and hcws. in some instances, prevalence of h n -related anxiety was higher among those who had greater intolerance of uncertainty. additional research is required to better understand the relationship between intolerance of uncertainty and quarantine experience during large-scale infectious disease outbreaks. an assessment with hcws in china found that being quarantined and having perceived threat of sars were associated with high depressive symptoms several years after bmj global health the epidemic ended. in a separate study, h n quarantine experience did not predict elevated ptsd levels while dissatisfaction with control measures was a better predictor. to the best of our knowledge, no prior study has assessed the mental health impact of the protracted ebola epidemic at population levels in sierra leone, liberia or guinea. a limited number of studies have examined population-level mental health in other african countries. one such study in a predominantly rural community in ethiopia found that % of the population expressed clinical levels of mild depressive, anxiety and somatic symptoms. on the other hand, a wide variety of studies have examined anxiety and depression in highrisk populations in africa, including patients with tuberculosis in ethiopia and angola, rwandans who had experienced genocide, and nigerian prison inmates. findings of varying levels of mental health symptomology from these studies suggest that further investigations may be required to better understand specific mental health impact of the ebola epidemic on directly affected persons such as ebola survivors. in a systematic review, adverse mental health impact has been documented among conflict-affected persons. in sierra leone, during protracted civil conflict, exposure to traumatic events was associated with non-specific physical ailments. high prevalence of traumatic experiences and psychiatric sequelae has also been documented among sierra leonean refugees. among war affected youth in sierra leone, social disorder and perceived stigma contributed to both externalising and internalising problems. former child soldiers in sierra leone saw reliable improvement in ptsd symptoms over time, suggesting that a supportive environment may encourage resilience. a key recommendation in previous studies and who guidance is to integrate mental health into primary healthcare services. one study found global return on investments for scaling up treatment for depression and anxiety. an example of such effort is in progress in sierra leone wherein public health nurses are trained to screen patients for possible mental health needs. the who mental health gap action programme emphasises that scaling up mental health services is a joint responsibility that requires collaboration from governments, health professionals, donors, civil society, communities and families. limitations although a random national sample was obtained, our sample is not necessarily nationally representative. the sample had a higher proportion of respondents with any education compared with the general population. however, we did not find any association between education level and mental health symptoms, suggesting that this may not have influenced our findings. we acknowledge the necessity of validating survey instruments before using them in a new cultural context. although phq- and ies-r have been widely used globally, - neither has been validated nor used in sierra leone prior to this study. we therefore do not know the validity of clinical cut-off scores for our sample. to the best of our knowledge, phq- and ies-r (or the shortened form in this assessment) have not been used to measure population-level symptoms of mental health in any similar setting; making it impossible to compare our results to similar populations elsewhere. however, we found both had acceptable internal reliability and factorial validity. in the current survey, the phq- instrument demonstrated acceptable internal reliability (cronbach's α= . ) and good factorial validity (gfi= . , cfi= . , rmsea= · ). the shortened ies- scale used in the present study demonstrated acceptable internal reliability (cronbach's α= . ) and good factorial validity (gfi= · , cfi= · , rmsea= . ). in addition, the national sample was not designed to produce specific estimates for directly affected persons such as ebola survivors, families of ebola victims and quarantined persons. moreover, there are no baseline/historical data available for comparisons. we also did not measure the effects of exposure to sierra leone's civil conflict on long-term ptsd outcomes on the population prior to ebola. overall, our findings underscore the feasibility and importance of monitoring and addressing mental health during public health outbreaks as well as building capacity to do so as part of preparedness efforts. use of brief mental health screeners during outbreak response could increase the ability to identify and address the needs of high-risk groups. we have demonstrated the ability to rapidly administer phq- and ies- at a population-level to 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use disorders demographic and health survey psychometric evaluation of the indonesian version of the impact of event scale-revised the global burden of mental disorders: an update from the who world mental health (wmh) surveys global health security: the wider lessons from the west african ebola virus disease epidemic acknowledgements the authors thank the sierra leoneans who participated in this assessment and provided responses in the midst of an unprecedented epidemic. the authors also thank the data collection team from focus for their diligent efforts in ensuring data quality and the government of sierra leone and their national and international partners in the response. finally, we dedicate this article to the memory of our co-author, dr. foday dafae, the late director of disease prevention and control in sierra leone ministry of health and sanitation, in honor of his years of service to the people of sierra leone. contributors mfj, rb, aol and ps led the overall study design with substantial contributions made by the other coauthors. ps, mfj and mbj were responsible for training the data collectors and supervised all data collection and data management efforts. wl led all data analyses. all authors contributed equally to the iterative interpretation of the results and the writing and preparation of the manuscript.funding this study was funded by the centers for disease control and prevention ( . / ).disclaimer the findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the us centers for disease control and prevention or the sierra leone ministry of health and sanitation.competing interests none declared. key: cord- -i iugwz authors: wang, ya-xi; guo, hong-tao; du, xue-wei; song, wen; lu, chang; hao, wen-nv title: factors associated with post-traumatic stress disorder of nurses exposed to corona virus disease in china date: - - journal: medicine (baltimore) doi: . /md. sha: doc_id: cord_uid: i iugwz quantitative studies using validated questionnaires on post-traumatic stress disorder (ptsd) of nurses exposed to corona virus disease (covid- ) in china are rare and the baseline ptsd must first be evaluated before prevention. this study aimed to investigate the factors potentially involved in the level of ptsd of nurses exposed to covid- in china. in this cross-sectional study, male and female nurses (n = ) exposed to covid- from hubei china were included in the final sample. the ptsd checklist-civilian (pcl-c) questionnaire and simplified coping style questionnaire (scsq) were used for evaluation. multivariate stepwise linear regression analysis and spearman correlation test were performed to assess the association between various factors associated with ptsd. the incidence of ptsd in nurses exposed to covid- was . %, the pcl-c score was . ( . – . ), and the highest score in the three dimensions was avoidance dimension . ( . – . ); multivariable stepwise linear regression analysis showed that job satisfaction and gender were independently associated with lower pcl-c scores (both p < . ); pcl-c scores were correlated with positive coping (r = − . , p = . ), negative coping (r = . , p = . ). nurses exposed to covid- from hubei china with job satisfaction, male and positive coping had low pcl-c scores which necessitate reducing the ptsd level by ways of improving job satisfaction, positive response, and strengthening the psychological counseling of female nurses in order to reduce the risk of psychological impairment. post-traumatic stress disorder (ptsd) is a mental disorder that may develop after exposure to exceptionally threatening or horrifying events. its main features are re-experience, avoiding traumatic memory and the feeling of continuous threat to be vigilant or over vigilant. [ ] a south african study that investigated the relationship between exposure to critical incidents and prevalence of mental health problems among emergency medical care personnel (including traffic police, fire services, ambulance staff, and sea and air rescue workers) found that symptoms of anxiety, depression, or ptsd intensified when exposure to critical incidents increased. [ ] research shows that paramedics are more prone to develop ptsd symptoms than general population, and positive coping style plays an important role in ptsd symptom relief. [ ] many people show remarkable resilience and capacity to recover following exposure to trauma. [ ] in december , an outbreak of severe acute respiratory syndrome coronavirus (sars-cov- ) infection occurred in wuhan, hubei province. on february , , who officially named the disease caused by the novel coronavirus as corona virus disease (covid- ) , which has the characteristics of fast transmission, wide transmission, and strong infectious. droplets, close contact, aerosols, as well as fecal and oral transmission are all routes of transmission of the virus. [ ] most of the patients infected with the virus have fever, dry cough, dyspnea, and other symptoms, and even acute respiratory distress syndrome, septic shock, metabolic acidosis, bleeding, and coagulation dysfunction. [ ] covid- is a highly contagious disease, and nurses are at the front lines of care and are thus more susceptible to infection. [ ] this makes the nurses' physiological and psychological state highly stressed and even ptsd. in order to reduce the incidence of ptsd, reduce the clinical symptoms of ptsd and improve the prognosis, it is necessary to understand the influencing factors of ptsd and make early and effective intervention. the purpose of this study was to investigate pcl-c scores and the incidence of ptsd in nurses exposed to covid- in china; to analysis of influencing factors of ptsd; and to explore the correlation between the pcl-c scores, positive coping and negative coping. this study was approved by the ethics committee of the affiliated hospital of the inner mongolia medical university (approval number: ). all the participants provided a informed consent. this cross-sectional and correlational study was conducted between february and march , and male and female nurses filled out the questionnaire. three tertiary hospitals (west district of wuhan union hospital, the first people's hospital of jingmen city, the people's hospital of zhongxiang city) were randomly selected from hubei provinces in china for participation. only tertiary hospitals were selected because they offer high-level specialized health care services. the inclusion criteria were: . registered nurses with designations of staff nurse; and . nurses exposed to covid- . the exclusion criteria were: . nurses unwilling to be surveyed; or . assistant nurse. . . outcome measurements . . . ptsd checklist-civilian (pcl-c). the ptsd checklistcivilian version (pcl-c) was translated to chinese language by professor shi tieying and others. [ ] the questionnaire was used to assess the severity of ptsd symptoms. the cronbach's alpha coefficient for the total scale was . . the item validity was . . the pcl-c comprises of a total of three dimensions (reexperiencing dimension, avoidance dimension, hyperarousal dimension). the intensity and frequency of ptsd symptoms are rated as levels. total ptsd scores were calculated by summing the scores for all items, with higher scores indicating more severe ptsd symptoms. study participants with total scores ranging from to were defined as having some degree of ptsd and ranging from to were definitively diagnosed with ptsd. [ ] . . . simplified coping style questionnaire. the simplified coping style questionnaire (scsq) was designed by yaning xie to evaluate coping style in chinese. [ ] it is a self-rating scale in which a total of items are measured, including positive coping and negative coping. multilevel scoring was used for each coping (range - ), and the results of the scsq are the overall positive and negative coping scores. higher scores indicate higher frequencies of relevant coping. the cronbach's alpha of the total score is . . it shows that the scale has good reliability. the results of validity analysis show that the coping style can indeed be divided into two factors: "negative coping" and "positive coping," which is in line with the theoretical concept. socio-demographic information such as age, gender, nationality, professional title (based on the national unified examination, with appropriate certificates), work experience, education (based on certificates), average monthly income (rmb), marital status, degree of family support, degree of job satisfaction, training or learning methods protection knowledge, and have you participated in severe acute respiratory syndrome (sars) prevention and control were collected from all the participants. this survey uses the form of a questionnaire star. before issuing the questionnaire, the participant were informed of the purpose of this research and were assured of their right to refuse to participate or to withdraw from the study at any stage. researcher issued instructions about filling the questionnaire and a unified guidance language is used to explain the research purpose to the research subjects, thereby ensuring that there was no ambiguity for answering the questions. participants answered the questionnaire anonymously and hence there was no infringement on patient privacy. the confidentiality of all participants was guaranteed. a questionnaire was considered invalid if more than % of the items were not answered. data were analyzed using spss . (spss inc, usa). categorical data were presented as frequencies. the shapiro-wilk test and a histogram normal curve were used to test the normal distribution of the pcl-c scores, scores in three dimensions of pcl-c and the two dimensions of scsq (positive coping and negative coping). the results of the shapiro-wilk test showed that p < . and that histogram normal curve does not meet the concentration and symmetry. this indicated that the data did not follow a normal distribution pattern. therefore, m(iqr)median (inter quartile range) were used to describe the data in this study. two independent samples were tested using the non-parametric mann-whitney u test, and multiple independent samples were tested using the non-parametric kruskal-wallis h test. multivariate stepwise linear regression analysis was conducted using the pcl-c score as the dependent variable. the independent variables were those with p-values <. in univariate analyses. spearman correlation test was used for the correlations between the pcl-c scores, positive coping and negative coping. twosided p-values <. were considered statistically significant. out of the total of participants contacted for the study, questionnaires was deemed as being disqualified due to inadequate responses and hence were excluded. finally questionnaires were included in the final sample, and the effective response rate was . %. socio-demographic data, job characteristics and pcl-c scores of the participants are presented in table and in figure . when data did not follow a normal distribution pattern, m(iqr)were used to describe the data and the mann-whitney u test and kruskal-wallis h test was applied. the mean age of the participants was . ( . - . ) years (p < . ). the majority of the participants were females and male had lower pcl-c scores than female (p < . ). work experience was . ( . - . ) years (p < . ). nurses satisfied with their career had lower pcl-c scores than those who were unsatisfied (p < . ). nationality, professional title, education, average monthly income (rmb), marital status, degree of family support, training or learning methods protection knowledge, and have you participated in sars prevention and control were not associated with pcl-c scores. the specifics of these results are provided in tables and were used to describe the data. pcl-c scores were . ( . - . ) points. the minimum value was points ( cases in total) and the maximum value was points ( cases in total). pcl-c score between to points accounted for . % (ptsd incidence rate). the highest score in three dimensions was avoidance dimension . ( . - . ). three dimensions score from high to low, it was the avoidance dimension, reexperiencing dimension, and hyperarousal dimension. positive coping and negative coping scores were . ( . - . ) and . ( . - . ). details are shown in table . multivariate stepwise linear regression analysis was conducted using the pcl-c score as the table socio-demographic data, job characteristics and pcl-c scores of nurses (n = ) exposed to covid- in tertiary hospitals in china. the specifics of these results are provided in table , figures - . the two dimensions of scsq were positive coping and negative coping. the data for the pcl-c scores, positive coping and negative coping were not normally distributed and adopted spearman correlation analysis. the results showed that pcl-c was negatively correlated with positive coping (r = À. , p < . ), and pcl-c was positively correlated with negative coping (r = . , p < . ). this study showed that pcl-c scores were . ( . - . ) points. the minimum value was points ( cases in total) and the maximum value was points ( cases in total). pcl-c score between and points accounted for . % (ptsd incidence rate). since the covid- outbreak was a bio-disaster with profound psychological effects on health workers. [ ] medical and paramedical staff, particularly in service in emergency planning, are frequently exposed to situations of great physical and psychological stress. [ ] this study focused on its psychiatric consequences in nurses. the findings of li et al were not consistent with the results of this study. the positive detection rate and highest score of ptsd are higher than this study. [ ] many previous studies had shown that emergency rescuers were likely to suffer from ptsd after participating in emergency. the prevalence of ptsd among medical staff after table pcl-c scores and scores in the dimensions of scsq among nurses (n = ) exposed to covid- in tertiary hospitals in china. wenchuan earthquake was %. [ ] the prevalence of ptsd among search and rescue workers in months after the binge earthquake was %. [ ] during the sars epidemic in , the detection rate of ptsd among medical staff at the first line was high up to . %. [ ] the findings of pompili et al have reported that almost half of the psychologists reported post-traumatic stress symptoms that did not subside until at least months had elapsed. [ ] therefore, social should focus on the supportive and therapeutic resources available for nurses. there is a need for urgent intervention after crisis to identify and treat those with ptsd as such approach can reduce the risk of psychological impairment. [ ] the study showed that the highest score in three dimensions was avoidance dimension . ( . - . ); three dimensions score from high to low, it was the avoidance dimension, reexperiencing dimension, and hyperarousal dimension. the findings of li et al have reported that the highest score in three dimensions was avoidance dimension. [ ] however, other occupational exposures existing studies have found the opposite. regarding medical staff members exposed to h n patients and disaster relief medical staff, previous studies have reported that the highest score in three dimensions was re-experiencing dimension. [ , ] the reason may be that different occupational exposures caused different pressures on medical staff. the results showed that job satisfaction and gender were influencing factors of ptsd. some studies reported results similar to our findings and indicated that mental health is highly relevant to work satisfaction. [ ] [ ] [ ] nurses who are dissatisfied with their jobs often feel that they are working in a dysfunctional system which affects the quality of their tasks and their self-esteem, [ ] which are associated with higher ptsd scores. the findings of pompili et al have reported that patients with mood disorders were . times more likely to be women than patients with psychosis. [ ] several other studies have reported that women exposed to traumatic events are more likely to develop ptsd than men. [ , [ ] [ ] [ ] however, other existing studies have found the opposite. [ ] this phenomenon might be attributable to the fact that the injuries sustained by the men after experiencing physical violence were more severe than those of the women. [ ] this discrepancy also may be explained by the fact that males display a higher basal cortisol level (during fertility years) associated with lower prevalence of stress-related psychopathology. [ ] . . correlation between the pcl-c scores, positive coping and negative coping the results showed that pcl-c was negatively correlated with positive coping, and pcl-c was positively correlated with negative coping. active coping is "process of taking active steps to try to remove or circumvent the stressor or to ameliorate its effects." [ ] negative coping is marked by avoidance (e.g., ignoring the problem) or other maladaptive efforts (e.g., self-blame, venting) that worsen rather than resolve the challenge. [ , ] the results is consistent with previous research results. when medical staff encounter traumatic events, negative coping styles are more likely to increase their tendency to develop ptsd symptoms, and active coping can help prevent or alleviate ptsd symptoms. [ , [ ] [ ] [ ] [ ] [ ] the innovations of this study can be summarized as the factors potentially involved in the level of ptsd of nurses exposed to covid- in china. nurses exposed to covid- from hubei china with job satisfaction, male and positive coping had low pcl-c scores. which necessitates empowering the nurses by way of education and training programs, reach their goals at the individual and team level, getting career progression thereby ensuring their job satisfaction. effective and sustainable psychological counseling should be directed particularly to the female nurses in order to reduce the risk of psychological impairment. active coping includes initiating direct action, increasing one's efforts, and trying to execute a coping attempt in stepwise fashion. this study has several limitations. first, the self-assessment method may be relatively subjective. a third-party evaluation should be used in future studies and to validate the self-assessments. second, the study covered only tertiary hospitals in hubei provinces of china, thus limiting the generality of the conclusions. future research should be conducted nation-wide. third, confounding factors such as stress, work conflict, time management, and team work had not assessed. fourth, due to flaws in the study design, table multivariate stepwise linear regression analysis of factors influencing the pcl-c scores among nurses (n = ) exposed to covid- in tertiary hospitals in china. <. * * * f = . , p < . , r = . , r = . . b = standard regression coefficient, b = partial regression coefficient, se = standard error. * p < . . * * * p < . . associations between pcl-c scores and scores in the dimensions of scsq in nurses (n = ) exposed to covid- in tertiary hospitals in china. positive coping negative coping we failed to calculate the sample size by power analysis before the study. alternatively, we calculated the sample size according to the number of variables ( times of the variables), and taking a % attrition rate into consideration, the total sample size was determined to be . in the present study, there are a total of valid questionnaires, we believe the participant's number is sufficient. despite these limitations, the present research is meaningful. diagnosis and classification of disorders specifically associated with stress: proposals for icd- trauma exposure, posttraumatic stress disorder and the effect of explanatory variables in paramedic trainees coping styles and dispositional optimism as predictors of post-traumatic stress disorder (ptsd) symptoms intensity in paramedics. style radzenia sobie ze stresem i dyspozycyjny optymizm jako predyktory nasilenia objawów ptsd w grupie ratowników medycznych post-traumatic stress disorder the epidemic of -novel-coronavirus ( -ncov) pneumonia and insights for emerging infectious diseases in the future clinical features of patients infected with novel coronavirus in wuhan, china special attention to nurses' protection during the 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respiratory syndrome outbreak prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured sars caring unit during outbreak: a prospective and periodic assessment study in taiwan increased prevalence of posttraumatic stress disorder symptoms in critical care nurses key: cord- -kksivbh authors: lahav, yael title: psychological distress related to covid- – the contribution of continuous traumatic stress date: - - journal: j affect disord doi: . /j.jad. . . sha: doc_id: cord_uid: kksivbh objective: the novel coronavirus (covid- ) is a substantial stressor that could eventuate in psychological distress. evidence suggests that individuals previously exposed to traumatic events, and particularly to continuous traumatic stress (cts), might be more vulnerable to distress when facing additional stressors. this study aimed to investigate these suppositions in the context of the ongoing shelling of israel from the israel-gaza border, which continues even amidst the covid- crisis. method: an online survey was conducted among israel's general population. the sample included participants. seven-hundred-and-ninety-three participants had been exposed to traumatic events, with participants reporting cts. trauma exposure, covid- -related stressors, and psychological distress related to covid- (anxiety, depression, and peritraumatic stress symptoms) were assessed. results: most participants reported experiencing at least one psychiatric symptom related to covid- . being younger, female, not in a relationship, having a below-average income, being diagnosed with the disease, living alone during the outbreak, having a close other in a high-risk group, and negatively self-rating one's health status were associated with elevated distress. individuals who had been exposed to trauma, and to cts in particular, had elevated anxiety, depression, and peritraumatic stress symptoms compared to individuals without such a history or to survivors of non-ongoing traumatic events. cts moderated the relations between ptsd symptoms, anxiety symptoms, and peritraumatic stress symptoms, with significantly stronger relations found among individuals exposed to cts. limitations: this study relied on convenience sampling. conclusions: trauma survivors, and particularly traumatized individuals exposed to cts, seem at risk for psychological distress related to covid- . in december , the novel coronavirus (covid- ) appeared in wuhan, china. early stages of covid- include severe acute respiratory infection, with some patients developing acute respiratory distress syndrome, acute respiratory failure, and other severe complications . this disease is highly infectious (ryu et al., ) , and after it was identified in wuhan, it was identified in other parts of the world. on january , , the world health organization (who) declared covid- a "public health emergency of international concern." in february , the virus was identified in israel, and by april th , the number of individuals diagnosed with the virus was , , with people deceased (world health organization). to slow down the spread of this highly contagious and potentially fatal virus, strict measures were taken in israel, including restricting outdoor activities, cancelling gatherings, closing schools and institutes of higher learning, shutting down all "nonessential" businesses, minimizing public transportation, etc. the outbreak itself and the measures taken to bring it under control have likely been highly stressful for many individuals. as such, it is reasonable to suggest that the covid- pandemic will have implications not only for physical health, but also for mental health and well-being (brooks et al., ; lai et al., ; mcewen et al., ; shigemura et al., ) . furthermore, as with the sars outbreak (hawryluck et al., ; wu et al., ) , it would not be surprising to find that the covid- pandemic has been experienced by many as a traumatic event, leading to trauma-related symptoms, namely peritraumatic stress reactions. although research exploring psychological distress related to covid- is only in its initial stages, recent studies have provided support for this view. a recent cross-sectional study of , healthcare workers in hospitals equipped with clinics/wards for patients with in china found that a considerable proportion of these workers reported experiencing symptoms of depression, anxiety, insomnia, and distress (lai et al., ) . a longitudinal study conducted among the general population in china during the initial outbreak of covid- , and the epidemic's peak four weeks later, indicated clinically significant peritraumatic stress symptoms as well as moderate-to-severe stress, anxiety, and depression, which did not change significantly over time . a study among , chinese individuals ranging from - years of age uncovered three profiles of peritraumatic stress symptoms: mild ( . %), moderate ( . %), and high ( . %; jiang, nan, lv, & yang, ) . lastly, a nationwide large-scale survey of psychological distress in the general population of china indicated that almost % of respondents experienced psychological distress during the covid- pandemic . the severity of an individual's psychological distress in response to covid- may be related to specific covid- -related stressors. being diagnosed with covid- , belonging to a risk group for covid- complications, and perceiving one's physical health in a negative fashion may all raise substantial concerns during the pandemic and might intensify one's emotional plight (e.g., shi et al., ) . having family members or close others who belong to a risk group for covid- might also increase worries and generate or exacerbate psychological distress. lastly, being quarantined or living alone during the pandemic might also have detrimental effects. reduced social interactions and loneliness are well-known risk factors for psychopathology (nolen-hoeksema and ahrens, ) and might increase individuals' vulnerability, particularly under conditions of exposure to stressors. indeed, a recent review which included studies, found posttraumatic stress symptoms, confusion, and anger among quarantined children and adults (brooks et al., ) . that said, there are some individuals who might be even more vulnerable than others to the implications of the covid- crisis. according to the ''sensitization'' hypothesis, individuals who have previously been exposed to traumatic events might react more severely to additional stressors due to heightened sensitivity to stress or depleted coping capacities (resnick et al., ; yehuda et al., ) . research has supported this claim. a metaanalysis that was based on studies indicated that previous exposure to a traumatic event was related to an elevated risk for ptsd following a later trauma (ozer et al., ) . this association seems to be applicable when the additional stressor is a physical illness; for example, previous exposure to a traumatic event was found to be associated with psychiatric symptomatology, depression, and ptsd symptoms in women with breast cancer (green et al., ) . this heightened vulnerability of individuals previously exposed to trauma might be rooted in posttraumatic distress subsequent to trauma exposure. during its follow-up periods, a longitudinal study revealed that traumatized individuals with ptsd were at a higher risk for ptsd than were individuals with no history of trauma exposure (breslau et al., ) . despite the evidence regarding the effects of prior trauma and posttraumatic distress on the distress of individuals who are facing an additional stressor, to the best of my knowledge no study to date has explored this subject with regard to a worldwide pandemic such as covid- . furthermore, to date the research has been focused on the effects of additional stressors on survivors of past traumatic events (i.e., events that came to an end), and not on survivors of continuous traumatic stress. continuous traumatic stress (cts) or type iii trauma exposure (kira et al., ) reflects a situation in which individuals repeatedly face an ongoing and protracted threat, typically lasting several years (straker, ) . continuous traumatic stress is a common phenomenon worldwide (heidelberg institute for international conflict research, ), and can result from various traumatic situations, such as living under conditions of constant urban violence (roach, ) , or being exposed to continuous rocket shellings (greene et al., ) , the latter of which was the focus of the current study. living under conditions of ongoing exposure to traumatic events involves constant uncertainty, as well as constant alertness and preparedness (ruby, ) . recurrent exposure to traumatic stress impairs people's ability to maintain a stable routine and creates a sense of threat, vulnerability, anxiety, confusion, uncertainty, and helplessness (zimbardo, ) . research has indeed documented elevated distress among individuals exposed to cts situations, including ptsd symptomatology, anxiety, depression, and helplessness, as well as somatization (hobfoll et al., ; itzhaky et al., ) . the ramifications of ongoing and unceasing exposure to trauma might not be limited to cts-related psychological distress; rather, cts may very well affect one's ability to adjust to new challenges and stressors, such as the covid- threat. given that cts demands an ongoing effort to cope, individuals in cts situations might be worn down and depleted of coping capacities, and thus particularly vulnerable to covid- -related stressors. furthermore, it is reasonable to assume that suffering from posttraumatic distress would be particularly difficult and painful when one continues to be exposed to the trauma, with such continuous exposure heightening one's vulnerability in the context of new challenges. thus, the negative effects of ptsd symptoms on psychological distress related to covid- might be particularly prominent among individuals exposed to cts, and more so than among individuals who were exposed to traumatic events that came to an end. sadly, the situation in southern israel today allows us to examine the aforementioned postulations. for the past almost two decades, as part of the israeli-palestinian conflict, individuals living in this region have been subjected to frequent rocket shelling from the gaza side of the border, with more than , rockets and mortars fired (israel ministry of foreign affairs, ). although there have been some relatively quiet periods, there have also been several intensive armed conflicts, each interspersed with varying amounts of shelling, right before and during the conflicts. these attacks have resulted in death, injury, damage, and disruption to the everyday life of israelis living in the "gaza envelope." these attacks have continued, even now, at a time when israelis are also contending with the covid- disaster. the present study aimed to explore whether individuals previously exposed to traumatic events, and particularly those previously and currently exposed to cts as part of their living in the "gaza envelope," suffer from increased vulnerability when facing covid- . specifically, the current investigation strove to explore the contribution of ptsd symptoms as a result of past trauma exposure versus as a result of cts in explaining psychological distress (peritraumatic stress symptoms, anxiety symptoms, and depression symptoms) in the face of covid- . being the first, presumably, to address this subject matter, the current study was exploratory in nature. three main objectives were set: . to describe the prevalence of covid- -related stressors as well as the levels of psychological distress (peritraumatic stress symptoms, anxiety symptoms and depression symptoms) related to covid- . . to explore the contribution of trauma exposure in explaining psychological distress related to covid- , above and beyond demographic characteristics and covid- related stressors. . to explore the moderating role of trauma type (cts versus past trauma exposure) in the associations between ptsd symptoms and psychological distress related to covid- , above and beyond demographic characteristics and covid- -related stressors. participants and procedure. an online survey was conducted among a convenience sample of israeli adults. the survey was accessible through qualtrics, a secure web-based survey data collection system. the survey took an average of minutes to complete and was open from april , to april , . it was anonymous, and no data were collected that linked participants to recruitment sources. the [masked for review] institutional review board (irb) approved all procedures and instruments. clicking on the link to the survey guided potential respondents to a page that provided information about the purpose of the study, the nature of the questions, and a consent form (i.e., the survey was voluntary; respondents could quit at any time; responses would be anonymous). the first page also offered researcher contact information. each participant was given the opportunity to take part in a lottery that included four $ gift vouchers. a total of , people participated in the survey. of them, only ( . %) participants who provided data regarding the study variables were included. no differences were found between participants who were included in the study and those who were not in terms of relationship status, education, or income (p s >. ). yet there were significant differences between the groups in terms of age, t( )= - . , p = . ; gender, χ ( , n= ) = . , p = . ; and religiosity, χ ( , n= ) = . , p = . . the average age among the current sample was higher (m = . , sd = . ) than among the group of participants who were not included in the study (m = . , sd = . ), and the proportion of women and secular individuals among the current sample was higher ( . %, . %, respectively) than among the group of participants who were not included in the study ( . %, . %, respectively). participants' ages ranged from to (m = . , sd = . ), with the majority of the sample being below the age of ( . %). most of the participants were jewish ( . %) women ( . %); were secular ( . %); had a high school degree or under ( . %); were in a relationship ( . %); and had an average or above-average income ( . %). of the total sample, participants ( . %) were classified as having been exposed to traumatic events based on the trauma history screen (ths; carlson et al., ). the average age of this subgroup was . (sd = . ). most of this sub-group were women ( . %); were secular ( . %); had a high school degree or under ( . %); and had an above-average income ( . %). regarding type of traumatic event, participants ( . %) reported continuous exposure to rocket attacks (thus, cts), and the rest of the participants reported exposure to a traumatic event that had ended. the latter category (i.e., a traumatic event that had ended) included accidents ( . %), a physical or sexual assault during childhood ( . %), natural disasters ( . %), a physical or sexual assault in adulthood ( . %), being attacked with a gun, knife, or weapon ( . %), the sudden death of a family member or close friend ( . %), seeing someone die or get badly hurt or killed ( . %), and seeing something horrible during military service ( . %). the vast majority of participants reported two traumatic events or more ( . %). background variables. participants completed a brief demographic questionnaire that assessed age, gender, education, relational status, religiosity, and income. specific stressors related to the covid- pandemic were measured via nine items designed by the research team. participants were asked ) how they perceived their own physical health, ) whether they were diagnosed with the disease, ) whether they were quarantined, ) whether they were living alone during the outbreak, ) whether they belonged to a high-risk group for covid- , ) whether they had close others who belonged to a high-risk group, ) whether they had close others who had been diagnosed with the disease, ) whether they had close others who had been hospitalized due to the disease, and ) whether they had experienced the loss of close others as a result of the disease. given that only four participants reported experiencing the last three stressors (having close others who were diagnosed with the disease, having close others who were hospitalized due to the disease, experiencing a loss of close others due to the disease), these specific stressors were not included in the present analyses. anxiety and depression symptoms related to covid- . levels of anxiety and depression symptoms in response to covid- were assessed by the anxiety and depression subscales of the brief symptom inventory- (bsi- ; derogatis, ) . the bsi- is a self-report symptom checklist measure consisting of items, each describing a psychiatric symptom. anxiety and depression subscales consist of six items each. participants were asked to indicate the extent to which they had been bothered by the symptom in the prior week, on a -point likert scale ranging from (not at all) to (extremely). mean scores on each subscale reflect the respondent's level of anxiety or depression symptoms, with higher scores reflecting greater symptoms. the raw scores are converted to t scores, with an accepted cutoff point of for psychopathology on depression and anxiety subscales (derogatis, ) . the bsi- has been found to have adequate convergent and discriminant validity and good reliability (derogatis, ) . internal consistency reliabilities in this study were good for both the depression (α = . ) and anxiety subscale (α = . ). peritraumatic stress symptoms related to covid- . peritraumatic stress symptoms in response to covid- were measured via a modified version of the ptsd checklist (pcl- ) (weathers et al., ). this -item self-report measure asks participants to indicate the extent to which they experienced each ptsd symptom, on a -point likert scale ranging from (not at all) to (extremely). items correspond to the newly approved ptsd symptom criteria in the diagnostic and statistical manual of mental disorders ( th ed., dsm- ; american psychiatric association, ). the original version was adapted so that the timeframe for experiencing each symptom was changed from "in the past month" to "since the outbreak of the covid- pandemic," and the index event was the covid- pandemic. a total score of peritraumatic stress symptoms was calculated by summing all items. although not a definitive diagnostic measure, preliminary research suggests a cutoff score of is a useful threshold to indicate symptomatology which may be at clinical levels (bovin et al., ) . the pcl- demonstrates high internal consistency and test-retest reliability (bovin et al., ) . internal consistency reliabilities in this study for the pcl- total score was excellent (α = . ). trauma exposure. exposure to traumatic events was measured via a modified version of the trauma history screen (ths; carlson et al., ) . the ths was developed as a brief, easyto-complete self-report measure of exposure to high-magnitude stressor events that could be traumatic. only items (of the original items) which reflect traumatic events according to the dsm- criteria were included. in addition, "continuous exposure to rocket attacks" was added to the list of events. for each event, respondents are asked to indicate whether the event occurred ("yes" or "no"). ptsd symptoms as a result of trauma exposure. ptsd symptoms were measured via the pcl- (weathers et al., ) . participants were asked to anchor responses to "stressful life experiences" on a scale ranging from (not at all) to (extremely). a total score is also calculated to assess the overall ptsd severity. internal consistency reliability in this study for the pcl- total score subscales was excellent (α = . ). the current analyses were conducted using spss and process computational macro (hayes, ) . to assess the univariate associations between background characteristics and covid- -related stressors, on the one hand, and psychological distress outcomes (i.e., anxiety symptoms, depression symptoms, and peritraumatic stress symptoms) on the other, linear regressions were conducted. to explore the unique contribution of trauma exposure in explaining psychological distress related to the covid- pandemic above and beyond background characteristics and covid- -related stressors, three multiple regression analyses were conducted. anxiety symptoms, depression symptoms, and peritraumatic stress symptoms were treated as dependent variables. trauma exposure, covid- -related stressors, and the background variables of age, gender, relationship status, and incomeall four of which variables had the largest contribution in explaining psychological distress outcomes compared to the other background variableswere treated as independent variables. to explore the moderating role of trauma type (cts versus previous non-ongoing trauma exposure) in the associations between ptsd symptoms and psychological distress related to the covid- pandemic, moderation analyses were conducted via process (model ) computational macro (hayes, ) . these analyses were conducted only among participants who reported a trauma history and had data regarding ptsd symptoms (n = , . %). scores of all the variables were standardized. significant interactions were probed using the process (model ) computational macro (hayes, ) . to determine whether including the independent variable and covariates in the current analyses was adequate, we assessed for multicollinearity, and examined the variance inflation factors (vifs) for the study variables. findings indicated that all were within the acceptable range (all vifs were smaller than ), indicating that multicollinearity was not a problem in our analyses. respondents reported several covid- -related stressors. these consisted of being diagnosed with the disease (n = , . %), being quarantined (n = , . %), living alone during the outbreak (n = , . %), belonging to a high-risk group for covid- (n = , . %), perceiving one's physical health in a negative fashion (n = , . %), having a close other who was diagnosed with covid- (n = , . %), and having a close other who belonged to a high-risk group (n = , . %). the majority of the sample (n = , . %) reported experiencing at least one anxiety symptom since the outbreak of the pandemic, and the average of the levels of anxiety symptoms was . (±. ). moreover, ( . %) participants met the anxiety criteria. similarly, the majority of the sample (n = , . %) reported experiencing at least one depression symptom since the outbreak of the pandemic. the average of the levels of depression symptoms was . (±. ), and ( . %) participants met the depression criteria. among participants who suffered from clinically significant anxiety symptoms since the outbreak of the pandemic, . % had a history of exposure to prior trauma; among participants who suffered from clinically significant depression symptoms since the pandemic's outbreak, . % had a history of exposure to prior trauma. the vast majority of the sample (n = , . %) reported experiencing at least one peritraumatic stress symptom specifically related to covid- , and the average of the levels of peritraumatic stress symptoms was . (±. . ). furthermore, . % (n = ) of the participants had a peritraumatic stress symptom total score of and above, indicating that their symptoms were clinically significant. among participants who suffered from clinically significant peritraumatic stress symptoms in relation to covid- , . % had a history of exposure to prior trauma. table presents the association between demographic characteristics and covid- -related stressors, on the one hand, and psychological distress on the other. as can be seen in the table, age, gender, relationship status, and income were related to all outcomes. being younger was associated with higher anxiety, depression, and peritraumatic stress symptoms related to the pandemic. it should be noted that the current study's exploration of psychological distress among the different age groups ( - , - , - , - ) corroborated the existence of this trend, indicating higher distress among younger people. being female, not being in a relationship, and having a below-average income were also associated with higher anxiety, depression, and peritraumatic stress symptoms related to covid- . having a high school degree or below was related to elevated peritraumatic stress symptoms only, and religiosity was unrelated to any of the psychological distress outcomes. covid- -related stressors were associated with psychological distress as well. negative perceived health was related to elevated anxiety, depression, and peritraumatic stress symptoms. being diagnosed with the disease was related to elevated anxiety and peritraumatic stress symptoms, and living alone during the outbreak was related to elevated depression and anxiety symptoms. being quarantined and belonging to a high-risk group for covid- were both related to elevated peritraumatic stress symptoms. lastly, having a close other who belonged to a high-risk group was associated with elevated anxiety and depression symptoms. three multiple linear regressions exploring the contribution of trauma exposure history in explaining psychological distress, above and beyond demographic characteristics (age, gender, relationship status, income) and covid- related stressors, were conducted. results of the analyses are presented in table . as can be seen in the table, younger age, being female, and having a lower-than-average income were related to elevated anxiety, depression, and peritraumatic stress symptoms during the pandemic. not having a relationship was related to elevated depression symptoms. being diagnosed with covid- was related to increased anxiety symptoms, and living alone during the outbreak was associated with elevated depression symptoms. negative perceived health was associated with elevated anxiety, depression, and peritraumatic stress symptoms. more importantly, a history of exposure to a traumatic event had a significant effect in explaining anxiety, depression, and peritraumatic stress symptoms, above and beyond the other variables in the model, so that individuals who were classified as having been exposed to traumatic events had higher levels of anxiety, depression, and peritraumatic stress symptoms during the covid- pandemic than did individuals who had not previously been exposed to traumatic events. of the participants who were classified as having been exposed to traumatic events, only participants ( . %) provided data regarding ptsd symptoms subsequent to these events. of them, participants ( . %) reported continuous exposure to rocket attacks, whereas the rest (n = , . %) reported exposure to traumatic events that had ended. the average of the levels of ptsd symptoms subsequent to prior trauma was . (±. . ), and . % (n = ) of the participants had a ptsd symptom score of and above, indicating that their symptoms were clinically significant. among participants who had clinically significant peritraumatic stress symptoms in relation to covid- , . % had clinically significant ptsd symptoms subsequent to prior trauma. the proportion of clinically significant peritraumatic stress symptoms in relation to covid- was higher among participants who had ptsd symptoms at a clinical level subsequent to prior trauma than among participants with ptsd symptoms below a clinical level ( . % vs. . %). a supplementary logistic analysis indicated that the risk for clinically significant peritraumatic stress symptoms in relation to covid- was more than times higher among participants with clinically significant ptsd symptoms subsequent to prior trauma than among participants with ptsd symptoms below a clinical level (odds ratio = . , % confidence interval: . - . ). to explore the moderating role of trauma type in the relations between ptsd symptoms and psychological distress during the pandemic, moderation analyses were conducted among this group of participants (n = ). results of the moderation analyses are presented in table . as can be seen in the table, younger age was associated with higher levels of anxiety, depression, and peritraumatic stress symptoms. being female was associated with elevated anxiety symptoms, and not having a relationship was associated with elevated depression symptoms. negative perceived health was associated with elevated anxiety, depression, and peritraumatic stress symptoms, and living alone during the outbreak was associated with elevated depression symptoms. trauma type and ptsd symptoms had a significant effect in explaining anxiety, depression, and peritraumatic stress symptoms. individuals exposed to cts had more elevated psychological distress during the covid- pandemic than did individuals exposed to traumatic stress that had ended. additionally, higher levels of ptsd symptoms subsequent to trauma exposure were related to elevated psychological distress manifested in anxiety, depression, and peritraumatic stress symptoms during the covid- pandemic. furthermore, trauma type significantly moderated the relations between ptsd symptoms on the one hand, and anxiety and peritraumatic stress symptoms during the covid- pandemic on the other. probing these interactions revealed a similar trend which is depicted in figures & : although ptsd symptoms subsequent to trauma exposure had a significant effect in explaining anxiety and peritraumatic stress symptoms during the pandemic among participants exposed to cts as well as participants exposed to traumatic events that had ended, this effect was significantly stronger among participants exposed to cts (β = . , p<. ; . , p<. , respectively) than among participants exposed to traumatic events that had ended (β = . , p<. ; . , p<. , respectively). this study described the impact of the covid- outbreak on the mental health of israel's general population. the study's results indicated that the majority of the sample reported experiencing at least one symptom of anxiety, depression, or peritraumatic stress. furthermore, around one tenth of the sample had peritraumatic stress symptoms above the cutoff of , and another % of the sample met the criteria for anxiety or depression. these findings demonstrate the potential negative implications of covid- for mental health and are in line with recent studies that were conducted in china revealing anxiety, depression, and peritraumatic stress symptoms among general population samples as a result of covid- (jiang et al., ; qiu et al., ; wang et al., ) . several demographic characteristics were associated with elevated distress. consistent with a previous study , the present results indicated that female participants had a higher degree of psychological distress related to covid- than did male participants. this finding coincides with previous studies that found women to be at an elevated risk for depression and anxiety (bekker and van mens-verhulst, ; lim et al., ) , findings which might be rooted in biological and socioeconomic factors (albert, ) . the lack of being in a relationship and having a below-average income were also associated with intensified distress. in terms of explaining these associations, the lack of being in a relationship might have limited social support and exacerbated loneliness, particularly under the current circumstances of social distancing, and having a below-average income might have increased financial worries and concerns stemming from the covid- crisis, and potentially exacerbating distress. the current results, indicating a relation between younger age and elevated distress, are also consistent with a previous study that found respondents aged - . years to suffer from a higher psychological impact of covid- than did older respondents . this finding suggests that although people in the + age group are actually the ones most at risk of suffering from covid- complications, they might not be particularly susceptible to potential psychopathology. young adults, on the other hand, showed elevated vulnerability, which may have been rooted in obtaining a large amount of information via social media (roberts et al., ) . exploring the univariate relations between covid- -related stressors and the psychological distress connected with the pandemic revealed significant associations between all of the stressors and psychological distress outcomes. nevertheless, when demographic characteristics and trauma exposure were also included in the analyses, only four stressors had a significant effect in explaining the levels of psychological distress. specifically, being diagnosed with the disease, living alone during the outbreak, having a close other who belonged to a high-risk group, and negatively self-rating one's health statusall of which have been documented in previous studies (e.g., fiorillo & gorwood, ; wang et al., )were found to significantly explain the levels of psychological distress. whereas negatively self-rating one's health status was related to all psychological distress outcomes, the other three covid- -related stressors were associated with specific types of symptomatology. namely, being diagnosed with the disease and having a close other who belonged to a high-risk group, which could intensify tension and worries, were related to anxiety symptoms. living alone during the outbreak, a condition that could deepen feelings of loneliness, was linked to elevated depression. the importance of this study, however, lies in its discovery of the effects of previous trauma exposure in the context of the covid- pandemic. the present findings indicated that individuals who had previously been exposed to traumatic events had elevated levels of anxiety, depression, and peritraumatic stress symptoms as related to covid- , compared to individuals who had not previously been exposed to traumatic events, even after taking into account demographic characteristics and covid- -related stressors. going a step further, the present study demonstrated that the impact of trauma exposure on the psychological distress connected with covid- depended upon the nature of the exposure. in comparison to exposure to traumatic events that had ended, exposure to cts was related to elevated levels of anxiety, depression, and peritraumatic stress symptoms. furthermore, exposure to cts moderated the relations between ptsd symptoms on the one hand, and anxiety and peritraumatic stress symptoms during the covid- pandemic, on the other. although ptsd symptoms had a significant effect in explaining anxiety and peritraumatic stress symptoms during the pandemic among trauma survivors in general, its effect was significantly stronger among participants who were exposed to cts than among participants who had been exposed to traumatic events that had ended. suffering from ptsd symptoms is highly debilitating. vivid intrusive recollections, emotional numbness, and hyperreactivity in response to trauma reminders severely interfere with the daily lives of affected individuals (american psychiatric association, ) and are likely to take a toll when such individuals are exposed to an additional stressor (breslau et al., ; kessler et al., ) . that said, coping with such difficulties while still being exposed to an ongoing trauma could be even more devastating. unceasing exposure to trauma leads to a substantial degradation of individuals' psychological, social, and economic resources (e.g., hobfoll et al., ) , and this degradation could in turn limit one's capacity to handle a new stressor. furthermore, the reality of ongoing threat/danger not only deprives one of the opportunity to experience recovery in a safe and protected environment (lahad and leykin, ; nuttman-shwartz and shoval-zuckerman, ), but also repeatedly confirms a sense of threat and helplessness. as such, the negative effects of the ongoing trauma and subsequent ptsd symptoms on coping with an additional stressor might be particularly potent. although the current study contributes to the understanding of psychological distress related to the covid- pandemic among individuals previously exposed to trauma and cts, it has several limitations. first, the cross-sectional design precludes any conclusions regarding causal relations between the study variables. second, this study relied on convenience sampling and, similar to other surveys conducted during the covid- pandemic (lai et al., ; wang et al., ), suffered from an overrepresentation of the female gender which might be reflected in higher response rates in surveys among women (underwood et al., ) . furthermore, only participants who provided data regarding the study variables were included in this study: a group that was characterized by greater proportions of female and secular individuals as well as by a higher average age compared to participants who were not included in the study. although religiosity was not associated with psychological distress outcomes, and gender and age were controlled for in the present analyses, this limitation should be acknowledged prior to generalizing from the results to the population at large. third, this study did not include measures of potential protective factors, such as social support. lastly, this study was based on self-reported data which may be subject to response biases and shared method variance. future studies among a variety of populations, and specifically among gender-balanced samples, should include data from clinical interviews. despite these limitations, this study represents a step towards understanding the relations between trauma exposure and psychological distress in the face of an additional stressor. the present findings suggest that trauma survivors might be at risk for elevated distress following covid- , and that individuals who are exposed to ongoing traumatic stress and who suffer from ptsd symptoms might be the most vulnerable to psychiatric symptomatology related to covid- . the present study has important clinical implications. its results point to the need to provide clinical interventions to trauma survivors during this pandemic, and particularly to individuals exposed to cts. survivors of previous traumatic events (that are not ongoing) might benefit from evidence-based treatments such as trauma-focused cognitive behavior therapy (tf-cbt; hobfoll et al., ) , which could be provided online and would tap specific challenges that survivors might experience when dealing with the pandemic. individuals exposed to cts, on the other hand, need specific clinical interventions that are tailored to the particular struggles that they face (nuttman-shwartz and shoval-zuckerman, ) . treatment for individuals exposed to cts should be directed towards managing anxiety and physical symptoms, and the acquisition of day-to-day coping skills, and not on a reprocessing of the trauma, as is generally done when treating survivors of traumatic events that are not ongoing (diamond et al., ) . one of the main goals of cts treatment is to teach patients to differentiate between adapting to an actual danger versus symptomatic reactions to trauma reminders. core elements of stress management therapy such as relaxation, breathing exercises, and mindfulness-based practices might be beneficial (e.g., nuttman-shwartz & shoval-zuckerman, ) and a biopsychosocial approach, which is based on cognitive behavioral methods (hamblen et al., ) , might also be effective for individuals exposed to cts. given that numerous populations around the world are exposed to cts, providing these clinical tools via online mental health services during the ongoing covid- pandemic is of substantial value. although some nations are beginning to see the end of the pandemic's first wave, it is generally believed that another and potentially worse second wave will return in the fall, a situation which calls urgently for preparation and precautions. the author does not have any conflict of interests to disclose. . *** . *** . *** ptsd symptoms . *** . ** . *** trauma type x ptsd symptoms . ** . . ** why is depression more prevalent in women? diagnostic and statistical manual of mental health disorders: dsm- anxiety disorders: sex differences in prevalence, degree, and background, but gender-neutral treatment psychometric properties of the ptsd checklist for diagnostic and statistical manual of mental disorders-fifth edition (pcl- ) in veterans a second look at prior trauma and the posttraumatic stress disorder effects of subsequent trauma: a prospective epidemiological study the psychological impact of quarantine and how to reduce it: rapid review of the evidence epidemiological and clinical characteristics of cases of novel coronavirus pneumonia in wuhan, china: a descriptive study bsi , brief symptom inventory : administration, scoring and procedures manual ongoing traumatic stress response (otsr) in sderot, israel the consequences of the covid- pandemic on mental health and implications for clinical practice trauma history as a predictor of psychologic symptoms in women with breast cancer psychopathology, risk, and resilience under exposure to continuous traumatic stress: a systematic review of studies among adults living in southern israel ptsd treatment research: an overview and evaluation sars control and psychological effects of quarantine process: a versatile computational tool for observed variable moderation, mediation, and conditional process modeling [white paper exposure to terrorism, stress-related mental health symptoms, and defensive coping among jews and arabs in israel the association of exposure, risk, and resiliency factors with ptsd among jews and arabs exposed to repeated acts of terrorism in israel psychiatric reactions to continuous traumatic stress: a 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mental health of general population during the covid- epidemic in china the ptsd checklist for dsm- (pcl- ). scale available from the nationalcenter for ptsd at www world health organization situation report - the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk impact of cumulative lifetime trauma and recent stress on current posttraumatic stress disorder symptoms in holocaust survivors the political psychology of terrorist alarms -. *** - . *** -. *** - . *** -. *** - . *** genderfemale . *** . *** . ** . ** . ** . ** male reference reference reference in relationship -. *** - . *** -. *** - . *** -. *** - . key: cord- -z rupgfo authors: di crosta, adolfo; palumbo, rocco; marchetti, daniela; ceccato, irene; la malva, pasquale; maiella, roberta; cipi, mario; roma, paolo; mammarella, nicola; verrocchio, maria cristina; di domenico, alberto title: individual differences, economic stability, and fear of contagion as risk factors for ptsd symptoms in the covid- emergency date: - - journal: front psychol doi: . /fpsyg. . sha: doc_id: cord_uid: z rupgfo on january th , the world health organization (who) declared the covid- pandemic a public health emergency of international concern (pheic). italy has been one of the most affected countries in the world. to contain further spread of the virus, the italian government has imposed an unprecedented long-period lockdown for the entire country. this dramatic scenario may have caused a strong psychological distress, with potential negative long-term mental health consequences. the aim of the present study is to report the prevalence of high psychological distress due to the covid- pandemic on the general population, especially considering that this aspect is consistently associated with ptsd symptoms. furthermore, the present study aims to identify the risk factors for high ptsd symptoms, including individual differences and subjective perception of both economic and psychological aspects. we administered an online survey to participants during the peak period of the contagion in italy. a logistic regression on the impact of event scale – revised (ies-r) scores was used to test the risk factors that predict the possibility to develop ptsd symptoms due to the covid- pandemic. gender (female), lower perceived economic stability, higher neuroticism, and fear and consequences of contagion were predictors of high ptsd symptomatology. the results, highlighted in the present study, extend our understanding of the covid- pandemic’s impact on the population’s mental health, by identifying individuals at high-risk of developing ptsd. this may help with the implementation of specific protocols to prevent the possibility of developing symptoms of ptsd in target populations. coronavirus disease arises from sars-cov- , which is an infection that affects the lower respiratory tracts (ashour et al., ; wölfel et al., ) . specifically, covid- symptoms range from asymptomatic infections to mild-severe respiratory symptoms, often accompanied by fever and dry cough, and in some cases, a severe lethal form of pneumonia, acute respiratory distress, and fatality (rothan and byrareddy, ) . it has been estimated that around % of covid- patient symptoms will show a severe form of the disease (zhong et al., ) . at this time, there is no specific vaccine or treatment for this disease and the elective clinical procedures consist in isolating patients to manage their clinical symptoms. in early december , several cases of this new acute respiratory infection were reported in wuhan, hubei province, china. on january th , the world health organization (who) declared the covid- outbreak as a public health emergency of international concern (pheic) (mahase, ) . although china has been relatively successful in containing its outbreak by reducing new cases of infection by more than %, the number of infections spread in other countries, especially italy, iran, and united states (callaway, ) . currently, to contain further spread of the virus, governments are implementing unprecedented strict restrictive measures to reduce person-toperson transmission of covid- . consequently, entire nations in different parts of the world have been lockdown, with a full or partial lockdown. the implementation of restrictive measures, such as "social distancing" or "social isolation, " have caused an inevitable readjustment in the daily life of modern societies causing limitations in traveling, social interactions, and work life. although the psychological impact of covid- pandemic has not yet been well-documented, based on previous experience with coronavirus infections (e.g., mers-cov and sars-cov), it has been hypothesized that the pandemic is leading to several health problems such as stress, anxiety, depressive symptoms, insomnia, denial, anger, and fear (torales et al., ) . in support of this, a study on the psychological impact of the covid- , found that more than half of the respondents reported a moderateto-severe psychological impact, and approximately one-third reported moderate-to-severe anxiety during the initial phase of the outbreak in china (wang et al., a) . specifically, anxiety levels seem to be related to the fear for contagion of covid- , as assessed on an iranian sample using a new validated selfreport questionnaire (ahorsu et al., ) . furthermore, a study on the psychological impact of the lockdown in italy showed a high increase of distress levels associated to several factors including gender, personality traits, depression and anxiety levels (mazza et al., ) . beyond the direct effects on mental health, the spread of the pandemic and the consequent restrictive measures are significantly impacting the world economy, resulting in a sharp decline in major financial indices and prompting fear of a global recession (uddin et al., ) . crucially, the ilo monitor (ilo, ), published on april th , reports that full or partial lockdown measures, adopted to contain the spread of the virus, are affecting almost . billion workers globally, which represents around % of the entire world's workforce. many families are experiencing higher financial distress because of the uncertainty of their incomes. as a result, consumers are reducing spending and are avoiding making new investments (fernandes, ) . although the psychological and economical long-term effects of the covid- are not yet predictable at this time, it is possible to hypothesize that the covid- emergency is causing drastic changes in the daily life of individuals, causing levels of distress similar to those found in response to traumatic events. post-traumatic stress disorder (ptsd) refers to the development of specific negative symptoms after exposure to one or more traumatic events. this symptomatologic presentation may include fear-based re-experiencing, emotional and behavioral changes, dysphoric moods, and negative effects on cognition (american psychiatric association, ). a self-report questionnaire often used to measure the subjective response to a specific traumatic event, related to the consequent development of ptsd symptoms, is the impact of event scale -revised (ies-r) (horowitz et al., ) . in previous studies, ies-r has been used to evaluate the traumatic impact of past epidemics (sars, h n ) during previous cases of lockdown (hawryluck et al., ; wu et al., wu et al., , wang et al., ; liu et al., ) . furthermore, two recent studies used ies-r to measure the psychological distress caused by the covid- pandemic (wang et al., a,b) . these studies highlighted a significant impact of the covid- pandemic in determining high levels of psychological distress, showing, also, differences related to gender with females reporting higher ies-r scores. several studies have highlighted a similar link between ptsd and gender (carmassi et al., ; gilmoor et al., ) . furthermore, symptoms of ptsd have also been associated to additional variables such as personality traits, socio-economic level, and educational level. regarding personality traits, the role of neuroticism (alias emotional stability at the opposite end of the continuum) has been widely studied in ptsd. neuroticism is characterized by aspects of affective negativity (watson and tellegen, ; mccrae and costa, ) and is constituted by a negative emotional response to frustration, or loss, that often overlaps with specific aspects of arousal symptoms (yin et al., ) . authors have investigated the relationship between neuroticism and stressful events, highlighting the significant correlation between neuroticism, risk of developing ptsd symptoms, and worsening in mental health conditions following a stressful/traumatic event (holeva and tarrier, ; engelhard et al., ; frazier et al., ) . furthermore, a longitudinal study using ies-r to measure ptsd symptoms, due to the tsunami, highlighted that neuroticism was negatively related to ptsd symptoms improvement ( - months post-disaster) (hussain et al., ) . people who reported high levels of neuroticism tend to react with strong emotions to stressful events. the literature has also highlighted that lower education may be a risk factor in developing ptsd (carmassi et al., ; kvestad et al., ) . for instance, education level was associated with the ies-r avoidance score (wu et al., ) . furthermore, a recent meta-analysis highlighted that lower socioeconomic status, lower education level, and gender (female) were predictors of ptsd (tang et al., ) . finally, research highlighted that fear is one of the main factors involved in ptsd (blechert et al., ; beckers et al., ) . notably, during a health crisis the degree of fear can be influenced by the probability of contracting the disease and the consequences derived by it (yuen et al., ) . in the present study we specifically focus on the role of individual differences, perception of economic stability, and psychological factors (including neuroticism and fear for the covid- pandemic) in predicting symptoms of ptsd. we conducted a nationwide survey on a large sample of the italian population in the period starting from april st, to april th, (the peak of the contagion in italy, see supplementary material). as of may , official data showed that italy represents one of the most affected countries in the world with approximately , confirmed cases and more than , deaths. furthermore, since march th, , the entire country has been experiencing an unprecedented long-term period of lockdown with strict measures including the impossibility for people to leave their home for non-essential reasons, the closure of shops and public spaces, and the ban on gatherings and traveling. this is a crucial aspect considering that a recent review study, on the psychological effects of the lockdown during previous outbreaks, pointed out that individuals experiencing the lockdown showed higher levels of psychological distress compared to their counterparts (brooks et al., ) . we recruited participants using a web-based survey. economic stability was one of the variables considered for this study. for this reason, we identified individuals who receive a stable income and those who do not receive an income by selecting only unemployed and full-time workers. other categories such as students, stay-at-home individuals, and retirees were excluded. a total of ( female) italian adults between -and -years-old (m = . , sd = . ) were included in the present study (see table for all sample characteristics). the entire survey lasted approximately min. the study was approved by the board of the department of human neuroscience, faculty of medicine and dentistry, sapienza university of rome and all participants provided their consent to participate. the study was administered as a battery of questionnaires using the qualtrics survey software. the entire survey consisted of two ad hoc questionnaires and two standardized measures, described below. also, a set of socio-demographic questions were presented. specifically, based on the study hypothesis, we examined gender (male vs. female), work status (full-time worker vs. unemployed), education level (high school degree or less vs. more than high school degree), and home-living condition (not alone vs. alone). socio-demographic data are shown in table . the eight items in the questionnaire were specifically created for the covid- emergency and referred to either self or loved ones' health. these items are presented in table . participants answered on a scale from (not at all) to (extremely). the component structure and reliability of the questionnaire was explored in a larger sample (n = ), using principal component analysis (pca) and cronbach's alpha. the results from these analyses revealed two factors, with four items per factor. a first factor, "belief of contagion, " reflects the conviction of being infected, either in the past or in the future. the second factor, "consequences of contagion, " reflects the possibility of suffering severe consequences due to the contagion (i.e., to be hospitalized or to die). two scores ranging from to were computed by averaging the items in each scale. the factor structure of the questionnaire was evaluated using pca. an oblique (promax) rotation was used. the scree plot, eigenvalues, and parallel analysis (with replications) were used to guide the retention of components. the results showed a structure of two moderately correlated factors, r = . . the pattern matrix is reported in table . four items showed satisfactory loadings (i.e., > . ) on the first factor. these items reflected the conviction to be infected, either in the past or in the future, as well as the beliefs that a loved one has been/will be infected. we labeled this factor "belief of contagion." the second factor comprises four items regarding the possibility of suffering severe consequences following contagion (i.e., to be hospitalized, to die), both for her/himself and for a loved one. this factor was labeled "consequences of contagion." only one item showed cross-loadings (i.e., a difference < . between the loadings on two or more components), which was excluded from the final measure (howard, ) . internal consistency of the final -item measure was tested with cronbach's alpha. the results showed excellent values for both the belief of contagion scale, α = . , and consequences of contagion scale, α = . . two of the questions in the survey dealt with perceived economic stability, either before or during the pandemic. specifically, the questions were presented as follows: "before the emergency, i considered my family and i to be economically stable"; and: "during the emergency, i consider my family and i to be economically stable." answers were given on a scale from (not at all), to (extremely). to determine the change in the perceived economic stability, we computed a difference score, labeled as "economic stability, " between these two items (before the emergency -during the emergency). therefore, higher scores on this variable should reflect severe decline in perceived economic stability, while scores approaching zero indicated no changes in personal economic stability. negative scores, possible but not likely, indicated an improvement in economic stability during the pandemic. the big five inventory -item (bfi- ) the big five inventory -item (bfi- ) is a short scale (rammstedt and john, ) measuring the big five personality traits: agreeableness/antagonism, conscientiousness/lack of direction, emotional stability/neuroticism, extraversion/introversion, and openness/closedness to experience. the bfi- has two bidirectional items for each of the big five personality factors. participants are asked to respond to each item indicating whether they agree or disagree with the statement, using a -point likert-type scale, ranging from (not agree at all) to (totally agree). the scale was developed based on the item big five inventory (rammstedt, ) and designed for contexts in which respondents' time is severely limited. a previously validated italian version was used in this study (guido et al., ) . in the current study, we focused on neuroticism (anxiety, angry hostility, depression, self-consciousness, impulsiveness, vulnerability). the impact of event scale -revised (ies-r) (christianson and marren, ) assesses the intensity of post-traumatic symptoms pertaining to intrusion, avoidance, and hyper-arousal on a likert-type scale ranging from (not at all) to (extremely). the ies-r was designed and validated providing a specific traumatic event and a specific time frame, as a reference for the subjects. the scale has been found to successfully discriminate between subjects with probable diagnosis of ptsd and subjects with non-probable diagnosis of ptsd. a cut-off score of was found to provide the best accuracy for detection of high levels of ptsd symptoms (creamer et al., ) . in this study "covid- epidemic" and "during the emergency" are respectively used for the subjects as a reference of a traumatic event and a specific time frame. first, we categorized participants in two groups based on their ies-r total raw score. specifically, we adopted the optimal cut-off of (creamer et al., ) to distinguish between low ptsd symptoms (low-ptsds) and high ptsd symptoms (high-ptsds). we compared the ptsds groups in terms of individual differences (gender, work status, education, and home-living conditions) performing two-by-two tables chi-squared tests (campbell, ) . based on correlation analysis, we performed a binary logistic regression to predict people's belonging to low-ptsds or high-ptsds group. specifically, we entered individual differences, perceived change in economic stability, and psychological factors (i.e., neuroticism and fear for covid- ) as predictors. our aim was to examine the factors leading to high ptsd symptoms related to covid- pandemic. the first striking result was that . % (n = ) of our sample belonged to the high-ptsds group, reporting a score on ies-r above the cut-off. furthermore, the low-ptsds and high-ptsds groups differed on all individual differences. specifically, women, full time workers, individuals with high school degree or less, and individuals who did not live alone were more inclined to develop ptsd symptoms compared to men, unemployed individuals, subjects with a higher level of education, and individuals who lived alone respectively. all values are reported in table . results of the point-biserial correlations indicated that there was a significant positive association between the ies-r group and "belief of contagion, " "consequences of contagion, " and "economic stability." therefore, all these variables could further impact the development of high ptsd symptoms. furthermore, a significant negative association was found between the "ies-r group" and "neuroticism, " therefore this personality trait is related to a greater probability of developing ptsd symptoms due to the covid- pandemic. detailed results of correlations, including means and standard deviations for all variables, are shown in table . finally, results of the binary logistic regression analysis showed that all entered variables predict the belonging on ies-r groups (see table ). specifically, in the first step gender, work status, education, and home-living conditions were entered. this model explained . % of the variance and only gender resulted as a significant predictor, suggesting that women report higher scores on ies-r. neuroticism was entered in step . the resulting model explained a significant amount of further variance, leading to a total explained variance of . %. step included perceived change in economic stability, and the effect of this variable was also significant. specifically, as economic stability goes up, which represents a greater perception of economic instability during the covid- emergency compared to before, the ptsd symptomatology measured by ies-r increases. the total explained variance in step was . %. finally, in step "belief of contagion" and "consequences of contagion" were entered, and both variables resulted as significant predictors. hence, increased fear of covid- expressed as the "belief of contagion" and the "consequences of the contagion" also increase the likelihood of being in the high-ptsds group. the variance explained by the final model was equal to . %. the covid- epidemic has caused a largescale lockdown worldwide. this pandemic is already showing a high negative impact on physical and mental health. consequences at the socio-economic level will also be significant which, in turn, will possibly negatively affect mental and emotional stability amongst all individuals. little is known about the long-term psychological impact of this pandemic which is characterized by the implementation of public health measures of immense unprecedented magnitude. it appears reasonable to expect an increase of acute stress disorders, ptsds, emotional, sleep, and depressive disorders because of the emerging effect of several factors, such as the fear of being personally infected or that someone close could be infected (mucci et al., ) , and the experience of very negative economic consequences (marazziti and stahl, ) . furthermore, the impact of all these factors may occur in relation to individual differences. several studies have been conducted in china; the first country affected by the covid- epidemic. a longitudinal study conducted on respondents reported the average mean ies-r scores of respondents was above the cut-off score, suggesting a substantial presence of ptsd symptoms among the population (wang et al., b) . moreover, comparing two-time responses, they found that a prolonged lockdown had an incremental psychological impact on mental health, especially among younger respondents. drawing from these findings and considerations, the current study has investigated multiple factors that would influence the step step step step psychological impact of covid- among the italian general population. our hypothesis about the relation among individual factors, economic stability, and fear of contagion as risk factors for pstd symptoms related to covid- was supported. the main striking result of the present study is that, during the peak of the covid- epidemic, more than one-third of the respondents ( . %; n = ) reported high ptsd symptoms. the rate of individuals with ptsd symptomatology on the italian population was two times the rate shown in spain (gonzález-sanguino et al., ) . we may hypothesize that higher rates of contagion registered in italy, at the time of data collection, have caused higher psychological distress in the italian population. also, our results are in line with literature which recognizes the female gender as a risk factor for ptsd symptoms (christiansen and elklit, ; ditlevsen and elklit, ) . a study reported that women are . times more likely to have ptsd than men (pyari et al., ) . biological factors are expected to play a role in these differences. for example, women are reported to be more sensitive to stress hormones and threats, less likely to use adaptive coping strategies, and more likely to provide negative appraisal to emergency situations than men (zhou et al., ; tang et al., ) . it has also been reported that women tend to assume more caregiving responsibilities. having to balance work and/or household tasks makes them a group at risk in highly demanding situations (gonzález-sanguino et al., ) . it has also been showed that higher ptsd rates were reported among people with a lower education compared to those with a higher education. despite conflicting results about the potential relationship between education level and ptsd (perrin et al., ) , the strongest evidence seems to suggest that lower levels of education were associated with a higher risk for ptsd (carmassi et al., ; kvestad et al., ) in previous epidemics as well (wu et al., ) . as recently highlighted, individuals with a higher level of education and socio-economic status might use better coping strategies because of greater social and economic resources, and ultimately be less impacted by environmental disaster, which in turn reduces the prevalence of ptsd (tang et al., ) . the findings regarding the role of individual factors increasing the risk for ptsd symptomatology, support the consideration that women with a lower educational level, not employed, with higher levels of neuroticism are more at risk to develop emergency trauma-related ptsd symptomatology. it is well known that individuals with higher levels of neuroticism tend to respond with strong emotions to stressful events, experience anxious and depressive affects, tend to appraise events more negatively, and have more difficulty in coping with stressful situations (suls and martin, ) . each of these factors have been previously considered to propose neuroticism as a risk factor for ptsd in several potential traumatic experiences such as earthquakes, terrorism, and domestic accidents (breslau and schultz, ; stevanoviae et al., ; yin et al., ) . following our regression results, all considered factors, excluding age, work status, education, and the living situation variables, appeared to be important factors in determining high ptsd symptoms due to covid- . specifically, the contributing factors to worsening psychological impact of covid- were gender, neuroticism trait, fear of contagion, and reduced economic stability. a similar study conducted at the time of sars on adult patients in hong kong found higher scores on the avoidance dimension of the ies-r among women (wu et al., ) . this evidence was also found among the spanish population in relation to covid- (gonzález-sanguino et al., ) . considering that ptsd is a fear-based disorder, belief of contagion and consequences of contagion were predictors of ptsd symptoms in italian adults. not surprisingly, neuroticism shows a consistent association with higher post-traumatic stress symptoms (holeva and tarrier, ) , and the present study contributes to this knowledge extending the evidence on a pandemic scenario. the results of the present cross-sectional survey provide relevant data about the post-traumatic psychological distress of covid- in italy, suggesting the need for greater psychological support in general and especially for highrisk groups. in addition to psychological support, cognitive behavioral therapy (cbt) and eye movement desensitization reprocessing (emdr) may provide positive effects on core ptsd symptoms. emdr treatment (lang, ; bower, ) seems to obtain greater results (moghadam et al., ) . reprocessing of eye movement desensitization leads people to overcome feelings of guilt, anxiety, and fear that are typical symptoms deriving from traumatic experiences in general. since fear of contagion of inappropriate magnitude may result in ptsd (rau et al., ) cbt may help to reduce the level of fear about the dangerousness of covid- and to encourage adaptive emotional responses (taylor et al., ) . furthermore, the practice of mindfulness is widely used in women (katz and toner, ; rojiani et al., ) in order to restore a sense of awareness of one's own experience. the mindfulness based stress reduction (mbsr) technique allows to increase the awareness of responses at a sensorial, affective, and cognitive level. mindfulness does not require direct exposure of the traumatic event as in most therapeutic strategies targeting ptsd but focuses on the here and now of the subject's experience (dutton et al., ) . assimilated mindfulness skills can reduce avoidant behaviors related to ptsd by promoting selfmanagement (gregg et al., ) and improving self-compassion (shapiro et al., ; thompson and waltz, ) . our results may be helpful to mental health professionals to recognize individuals who are at a higher risk and most in need of interventions, in order to prevent a possible rise of high posttraumatic stress for future infectious disease outbreaks. some caveats of the current study need to be acknowledged. first, the data were collected through an online survey, and this may result in participants' self-selection; hence, we cannot exclude a systematic sampling bias. second, we used a selfreported questionnaire to investigate ptsd symptoms, however, this administration format may have some biases. the ies-r is a widely used screening tool, scores should not be confused with a diagnosis, which can be obtained only by mental health professionals. also, the study was conducted during the initial stage of the covid- outbreak; hence, it is possible that we underestimated the actual occurrence of traumatic stress in the population, as delayed onset of ptsd symptoms is conceivable. third, our study allowed discriminating between people at risk and not at risk for high ptsd symptoms during the covid- pandemic, yet the use of a cross-sectional study design prevented to directly examine causal effects. notwithstanding these limitations, this study is a first attempt to elucidate the occurrence of ptsd symptoms in relation to covid- pandemic in the italian population. current results extend our knowledge of the links between individual and psychological factors and distress, with potential implication for the general populations' mental health. our results showed that the covid- pandemic has already had a great psychological impact on the italian population. crucially, in the present study more than one-third of the respondents reported ptsd symptoms during the peak of the covid- pandemic. moreover, it has been highlighted that several individual, economic, and psychological factors play a role in the development of higher levels of ptsd symptomatology. taken together, these results can provide a benchmark for future studies that aim to focus on the long-term effects of the covid- pandemic. furthermore, these data can be fundamental in identifying high-risk individuals to reduce the probability of developing ptsd. however, the most important aspect showed in the present study is the need to improve mental healthcare in the immediate future. therefore, the national health system and politicians must move in this direction to improve treatment for mental health problems and financial assistance. more professionals (i.e., psychologists, psychiatrists, nurses) should be hired in hospitals and clinics to cope with this emergency in the short and long term (mucci et al., ) . in this context, government institutions are called upon to make an effort to provide immediate and long-term financial support in order to fight the war against covid- and try to limit as much as possible the physical, mental, and economic burden. the raw data supporting the conclusions of this article will be made available by the authors, without 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mxmy authors: stangeland, paula a. title: disaster nursing: a retrospective review date: - - journal: critical care nursing clinics of north america doi: . /j.ccell. . . sha: doc_id: cord_uid: l mxmy this article presents a review of the literature related to disaster preparedness and nursing. a definition of disaster as set forth by the american red cross is provided. eight themes, including ( ) defining disaster, ( ) nursing during and after disaster, ( ) nursing education in disaster preparedness, ( ) military nurse preparedness, ( ) postdisaster stress, ( ) ethical issues and intent to respond, ( ) policy, and ( ) hospital emergency policy, were derived from the review and are explored in this article. although a plethora of disaster-related literature exists, the voice of the nurses who worked during these disasters is missing. areas of proposed research illuminated by current research are suggested. cinahl, medline (ovid), pubmed, and psycinfo. in , the robert t. stafford disaster relief act was signed into law, establishing the process by which presidents could declare disasters in states overwhelmed by catastrophic events. therefore, the literature review was limited to the past years. keywords entered into the databases were nursing, disaster, hurricane, posttraumatic stress, and preparedness. the search revealed a vast amount of disaster-related literature, which was categorized into thematic sections: (a) defining disaster, (b) nursing during and after disaster, (c) nursing education in disaster preparedness, (d) military nurse preparedness, (e) postdisaster stress, (f) ethical issues and intent to respond, (g) policy, and (h) hospital emergency policy. the association between disasters and human existence is indisputable, hence many definitions for disaster are found in the literature. a comprehensive definition for disaster is difficult to locate in the literature-most definitions are either too broad or too narrow, and many organizations have created their own definitions for the term. for the purpose of this review, the definition of the term that was deemed most appropriate was that used by the american red cross (arc), which defines disaster as: a threatening or occurring event of such destructive magnitude and force as to dislocate people, separate family members, damage or destroy homes, and injure or kill people. a disaster produces a range and level of immediate suffering and basic human needs that cannot be promptly or adequately addressed by the affected people, and impedes them from initiating and proceeding with their recovery efforts. natural disasters include floods, tornadoes, hurricanes, typhoons, winter storms, tsunamis, hail storms, wildfires, windstorms, epidemics, and earthquakes. human-caused disasters-whether intentional or unintentional-include residential fires, building collapses, transportation accidents, hazardous materials releases, explosions, and domestic acts of terrorism. common to all definitions of disaster is the characteristic that disasters are destructive events that more often than not require assistance from outside the community. researchers report that nurses are one of the largest groups of emergency responders during a disaster and are at risk for psychosocial problems that may need interventions to help them cope with exposure to disasters. , in the immediate aftermath of a disaster, the effects can be overwhelming to nurses working in the area, as there is a great deal of chaos and confusion that nurses must contend with and overcome. , [ ] [ ] [ ] studies indicate disaster emergencies create an atmosphere of pandemonium and uncertainty and that nurses perceive they have been or will be abandoned by leadership. , , , feelings of abandonment by management and a lack of communication play a major role in the decision-making processes of nurses and other hcps when deciding to work during a disaster. [ ] [ ] [ ] nurses state that they feel disaster plans are made by leaders or managers without input from the nurses who will actually be working and taking care of patients during and after the disaster. , giarratano and colleagues conducted an interpretive phenomenological study based on van manen's "lived experience" philosophy. the sample included perinatal nurses who worked during hurricane katrina. the purpose of the study was to stangeland make explicit the perinatal nurses' shared meanings of their lived experience of providing care in new orleans during hurricane katrina. major themes that emerged from the study include (a) duty to care, (b) conflicts in duty, (c) uncertain times, (d) strength to endure, (e) grief, (f) anger, and (g) feeling right again. findings demonstrated that nurses who work during disasters must live through the uncertainty of the situation and be prepared to adapt to the needs that arise in both patient care and self-preservation situations. this study revealed that primary resources needed by nurses while working during a disaster include excellent basic nursing skills, intuitive problem solving, and a sense of staff unity. researchers noted that the nurses exhibited a wide range of problems related to stress. these problems included changed sleep patterns, change in mood, eating problems, substance abuse, and avoidance behaviors. at the same time, it was recognized that the nurse participants practiced in harmony with duty to care values and demonstrated behaviors of strength, courage, and resilience. o'boyle and colleagues completed a qualitative study with a purposive sample of nurses who participated in focus groups ranging from to participants in each group. the sample of nurses was recruited from midwest hospitals that were designated as receiving sites for evacuees. the purpose of the study was to identify beliefs and concerns of nurses who worked in hospitals designated as receiving sites during public health emergencies. abandonment was the major theme that emerged from the focus group interviews. this theme was supported by subthemes including: chaos, unsafe environment, loss of freedom, and limited institutional commitment. nurses felt that policies were not well thought out, and that they were left out of the communication loop. in addition, the nurses stated that they did not receive any preparedness training to handle bioterrorist events. nurses believed that in the event of a bioterrorist attack, there would be a disruption in normal staffing resources. aware that nurse staffing under normal conditions is at times already strained, the nurses feared that they would not be free to leave the workplace. therefore, these researchers reported that the participants in the study believed that a shortage of nursing staff would be indirectly related to nurses who refused to work during a disaster. a limitation of this study is the small number of participants in some of the focus groups, which might have limited the discussions. a qualitative descriptive study completed by broussard and colleagues explored school nurses' feelings and experiences working in the aftermath of hurricanes katrina and rita. the sample consisted of female school nurses from across the state of louisiana who attended an annual school nurse conference held in march . nurse participants had an average age years. researchers reported that the participants were from all areas of louisiana, including areas that were not in the path of either hurricane. participants were asked one question: "please share your experiences and feelings about hurricanes katrina and/or rita". in addition to the qualitative question, demographic data were collected that included: (a) age, (b) years of experience as a school nurse, (c) gender, (d) support systems loss or damage to home and vehicle, (e) damage to school, and (f) change in work assignment as a result of the storm. data analysis was not described; however, findings were categorized into major themes: personal impact and professional impact. personal impact included subthemes: (a) uncertainty, (b) helplessness, and (c) thankfulness. professional impact included themes: practice challenges and practice rewards. the participants portrayed a wide array of emotions and feelings that were similar to previous studies. researchers recommended that all school nurses would benefit from having both formal and informal support systems and mental health services available to them in the aftermath of future hurricanes. identifying the philosophic disaster nursing underpinnings as well as the method for data analysis and rigor would have strengthened the validity of this study. although some nurses identified their experiences of working during and in the aftermath of hurricane katrina and other health emergencies as rewarding, they also identified planning and education as critical needs for providing care in future disasters. , [ ] [ ] [ ] hughes and colleagues report that nurses believe that they need to be involved at the onset of the emergency planning process. during emergencies, nurses stated that they used their most basic skills and teamwork when providing patient care, but recognized that further education is necessary to enhance their knowledge prior to future events. , , according to the international nursing coalition for mass casualty education (incmce), every nurse must have sufficient knowledge and skill to recognize the potential for a mass casualty incident. in addition, the incmce states that every nurse must be able to identify when a mass casualty event may have occurred, know how to protect oneself, know how to provide immediate care for those individuals involved, and be able to recognize their own role and limitations during such a disaster. the incmce also recommends that nurses know where to seek additional educational information and how to access resources. the position of the american nurses association (ana) related to practice during disaster is that all nurses are individually accountable for their actions and should practice according to their code of ethics. , despite that the ana acknowledges that working during disasters places nurses in unusual situations and conditions, the organization's code of ethics defines and directs the responsibilities of all practicing nurses regardless of the situation or setting. however, in the draft of the scope and standards of practice, the ana recognizes that these standards may change during times of disaster. the essentials of baccalaureate education for professional nursing practice was created by the american association of colleges of nursing (aacn). this document provides guidelines for baccalaureate-level nursing schools to prepare students for disaster response. the aacn mandates that the baccalaureate nursing education curriculum contain emergency-preparedness and disaster-response information. specifically, the guidelines state that baccalaureate nursing programs should prepare graduates to use clinical judgment appropriately and provide timely interventions when making decisions and performing nursing care during disasters, mass casualties, and other emergency situations. in addition, nursing students should understand their role and participation in emergency preparedness and disaster response with an awareness of environmental factors and the risks these factors pose to self and patients. it is not known whether the voices of nurses experienced in disaster have informed these essentials of education. educational competencies for associate degree nurses were created by the national league for nurses (nln) with support from the national organization of associate degree nursing. although the document provides core competencies that all associate degree nurses must meet, it does not specifically explicate the responsibilities of associate degree nurses during emergency situations. a particular skill indirectly related to disaster preparedness includes the ability to adapt patient care to changing health care environments. gebbie and qureshi, well-known nurse experts in disaster management, maintain that it is necessary for all nurses to be prepared during disasters. these experts define stangeland the difference between emergency and disaster, and state that disasters disrupt many services and cause unforeseen threats to public health. these researchers further describe disasters as requiring assistance from outside the affected community. gebbie and qureshi, at the request of the centers for disease control and prevention (cdc), developed core emergency preparedness competencies for nurses. although these competencies were developed by nurses; it is not known whether they have been incorporated or implemented in any educational program or facility where nurses work. research has shown that nursing schools may be lacking in the area of preparing students for disaster nursing. , jennings-saunders and colleagues completed a descriptive survey study that investigated nursing students' perceptions regarding disaster nursing. one purpose of the study was to propose recommendations to help advance the discipline of nursing and nurse clinicians. a convenience sample of senior nursing students participated. each participant completed the disaster nursing perception questionnaire and the demographic profile form. data were analyzed for meaning and relationships of words using the data analysis technique of morgan and baxter. this study revealed that nursing students do not comprehend what disaster nursing means and why it is important to know what community resources are available during times of disaster. furthermore, the study revealed that it is not known to what extent nursing faculties teach disaster preparedness in nursing programs, even though it is required. weiner and colleagues administered an on-line survey to united states nursing program deans and nursing program directors to assess the level of disaster preparedness curricula in united states nursing schools. only surveys ( %) were completed and returned. this low response rate was identified as a limitation of the study. baccalaureate and associate degree nursing programs made up more than % of the response rate. the study revealed that faculty was inadequately prepared to teach disaster preparedness and that most programs were overly saturated, leaving little room for disaster-preparedness education. a significant finding revealed that united states nursing school program curricula were limited in the area of disaster preparedness. this review of the literature revealed that nursing school governing bodies have developed competencies to be included in the nursing curriculum; however, nursing programs have been identified as still lacking in the area of disaster nursing curriculum. in addition, studies reveal that nursing faculty members are not prepared to teach disaster nursing. education of faculty in the area of disaster preparedness and response is an area that requires added consideration to adequately prepare students for disaster situations that may arise in the students' future careers. military nursing has played a critical role in the history if nursing. including data related to military nursing further enriches this review by addressing a significant area related to disaster and emergency preparation for nurses. nurses' involvement in war-zone care dates back to the crimean war in the s, when florence nightingale cared for injured soldiers and introduced modern nursing during times of war. researchers today posit that nursing during wartime has increased the profession's understanding of caring and responding during disasters. it is recognized today that military nursing is challenged by working in diverse situations. yet, according to recent studies, literature does not adequately describe military disaster nursing. on december , , the united states declared war on japan after the bombing of pearl harbor. trapped in the midst of this war were army and navy nurses who had no combat training. these nurses were caught in the middle of the battle on bataan, a province of the philippines. a few of the nurses escaped by boat but were captured by the japanese and held captive for years in the philippines. these nurses represent the first group of women in the military to be imprisoned by enemy forces. elizabeth norman had the privilege of interviewing of the female nurses and wrote a book titled we band of angels: the untold story of american nurses trapped on bataan by the japanese. norman began her study in and discovered that only of the nurses were still living. during this study, she also found that most of the nurses had joined the military seeking adventure and romance. the nurses interviewed by norman reported that the philippine islands were paradise until the war broke out and they were captured and held prisoner. norman realized and reported that the nurses always started the conversation with humor but the interview soon found the nurses talking about the painful memories, with a few interviews ending in tears. during the study it was reported that all the nurses had similar accounts of the ordeal of being held captive and that all of the nurses answered the interview questions using "we" instead of "i." these comments led norman to realize that the nurses viewed "unit cohesiveness" as their most important survival tool. baker and colleagues, using a self-report questionnaire, studied the stresses experienced by female nurses in vietnam. a sample of female army nurses was recruited to complete this study. findings revealed that % of the participating nurses reported they were poorly prepared by the military to serve in vietnam. also, registered nurses with less than years of clinical experience before going to vietnam were more likely to experience posttraumatic stress syndrome (ptsd) than nurses with more years of experience. the investigators identified the use of a self-report questionnaire as a study limitation, noting that the nurses had to recall events that occurred between to years prior to the study, adding to possible response bias. baker and colleagues concluded that more research in this area is necessary. ravella completed a descriptive study using a voluntary sample of air force nurses in san antonio, texas, who served in vietnam at various times during the vietnam war. this study used in-depth interviews to gain insight into individual nurse perceptions of their wartime experiences, coping skills, and significant events that they remembered. findings revealed that % of the participants described symptoms of ptsd. participants also reported crucial survival skills including strong social support, maturity, nursing experience, humor, religion, and relaxation. the most significant events remembered were directly related to patient care situations and threats to survival. these events were reported by % of the nurses interviewed. lastly, all of the nurses interviewed reported that their most rewarding professional experience was serving in the vietnam war. using a qualitative design, stanton and colleagues examined and compared experiences of nurses who served during world war ii, the korean war, the vietnam war, and operation desert storm. a sample of nurses who volunteered to participate in the study were interviewed and asked to describe their experiences of serving during wartime. these researchers revealed that military nursing is an experience that is very different from community nursing. the common themes that emerged from the study were: (a) reacting personally to the war experience, (b) living in the military, (c) the meaning of nursing in the military, (d) the social context of war, and (e) images and sensations of war. in a proposed model for military disaster nursing was developed. this model included actions deemed necessary during the phases of disaster: (a) preparedness, (b) response, and (c) recovery. military nurses possess a wide range of skills and are usually leaders in patient care. according to wynd, future disasters will encompass a wide range of disasters causing diverse mass casualties. wynd also emphasized that more research is necessary to determine whether this proposed model for military disaster nursing will be useful during military as well as civilian disasters. although both can be stressful and traumatic, the literature reviewed revealed that nursing in the military is different from community disaster nursing. because the literature reveals that working during disasters and traumatic situations causes increased stress for nurses, it is necessary to include information related to disorders that have been associated with experiencing traumatic situations. working during disasters can have an immense impact on responders. it has been recognized in the literature that ptsd can develop soon after experiencing a traumatic event. during times of disaster, caregivers and first responders react immediately to address physical injuries. however, these same caregivers have a tendency to react slowly or ignore injuries to themselves that are concealed deep within the consciousness. the national institute of mental health (nimh) defines ptsd as: an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. traumatic events that may trigger ptsd include violent personal assaults, natural or human-caused disasters, accidents, or military combat. according to the nimh, ptsd can start at any time after experiencing a traumatic event. symptoms of ptsd include bad dreams, flashbacks from the traumatic event, feeling like the traumatic incident is happening again, terrifying thoughts that one cannot control, staying away from places and things that are reminders of the event, feeling worried, guilty, or sad, feeling alone, problems sleeping, feeling on edge, angry outbursts, and thoughts of hurting oneself or others. , traumatic stress can change lives forever. researchers report that long-term dissociative and ptsd symptoms may occur after natural disasters. , in addition; survivors of disaster experience traumatic stress and the sights, sounds, and smells of the disaster are embedded in their minds forever. acute stress disorder (asd) is a condition that has a close relationship to ptsd. researchers have documented that women are at higher risk for developing asd and ptsd than men who have experienced traumatic events. , laposa and colleagues completed a secondary data analysis study addressing the correlation between sources of workplace stress and ptsd symptoms. the study sample included emergency department employees located in urban canada. seventythree percent of the participants were identified as nurses. ptsd was assessed using the posttraumatic stress diagnostic scale (pds). stress was measured using the health professionals' stress inventory-revised (hpsi-r). both scales were reported to have a cronbach alpha of . or higher, which is adequate for internal consistency. major findings included that % of the participants met all of the criteria for ptsd. eighty-two percent of the respondents confirmed they did not attend debriefing sessions provided by the hospital and % of the respondents reported they did not receive professional help for stress outside of the workplace. in addition, results revealed that % of the participants reported they had considered changing jobs disaster nursing after stressful incidents. researchers concluded that this study supports the need for employers to provide emotional support for workers who have experienced working during disaster or other traumatizing events that may lead to long-term emotional upset. hughes and colleagues completed a review of the literature to describe nursing's contribution to the psychosocial recovery of survivors of emergencies during all stages of disaster preparedness and recovery over a long-term period. the purpose of the integrative review was to provide guidance to nurses who are involved in emergency planning and response during the acute phase of an emergency. a second objective of the study was to inform nurses of the psychosocial effects that they may experience as health care providers working during disaster situations. these researchers revealed that nurses may experience stress-related psychosocial consequences that continue well past the disaster. relevant factors that must be taken into account are: (a) level of exposure to the disaster, (b) environmental or working conditions and management practices, (c) nurses' perceptions and individual coping and stress reduction practices, and (d) the amount and type of training and previous experience. hughes and colleagues state that nurses are the largest entity of the emergency response team and need to be included from the beginning of emergency planning. nurse responders must also undergo extensive education on the potential psychosocial symptoms that may be experienced as a result of working during a disaster. when entire communities are affected by disaster, it is not possible to maintain previously normal daily activities. conner and colleagues suggest that identifying persons at risk for ptsd may improve outcomes after exposure to disasters and trauma. in addition, it is recognized that many screening and assessment instruments exist that measure ptsd after disaster; however, the validity of these instruments is unclear and more research is needed to verify their appropriateness. brewin and colleagues state that in order for ptsd screening instruments to be useful, they must be brief, consist of the minimum number of items necessary for accurate identification, and be written in a language that is easy to read. furthermore, the symptoms of ptsd and asd that may be experienced by nurses responding specifically to a major hurricane disaster may be different. thus, one must first explore these perspectives by asking those who actually did respond and work in an affected facility. only then will researchers begin to understand why nurses may elect not to respond during future hurricanes. conflicting issues between family and self, safety, and work obligations often make it difficult for nurses and other hcps to decide to work during a disaster. , , ethical opinions vary widely regarding decisions to report to duty during times of disaster and other health emergencies. the duty to report to work in health emergencies remains an intense topic of discussion in the health care arena. as unparalleled demands are placed on nurses and other hcps who are called to work during disasters, some believe that the code of ethics for health care workers should specifically define the responsibilities of the hcp. while the american medical association (ama) and the canadian medical association (cma) have addressed the issue of responsibilities of physicians in their code of ethics, some researchers believe that it remains to be determined whether other health care professions will follow the same course of action in addressing the issue of providing care during health emergencies. the ana revised the code of ethics for nurses to include interpretive statements to accommodate nurses' comprehensive role in the health care environment. because nurses are continually confronted with many challenges including unpredictable and complex medical and emergent conditions that affect both individuals and communities, the revised code of ethics addresses some of the more complex ethical obligations of nurses. the ana code of ethics does not explicitly detail the obligation of nurses to report to duty during emergencies; however, it does address nurses' responsibilities to the public. one such responsibility outlined in the ana code of ethics is that nurses have an obligation to "participate in institutional and legislative efforts to promote health and meet national health objectives." in an effort to examine ethical issues that arise during a pandemic disaster, ehrenstein and colleagues completed a quantitative survey design study. surveys were sent to health care workers (hcws) at a university hospital in regensburg, germany. only surveys were returned and of the returned surveys, of these hcws were nurses. the purpose of the study was to solicit opinions of employees on professional ethics of proper response to pandemic influenza. researchers discovered that ( %) of the hcws surveyed believed that it was professionally acceptable to abandon the workplace to protect themselves and their family during a pandemic. in addition, % of the respondents disagreed that hcws should be permanently dismissed for not reporting to work during a pandemic, and % of the participants believed that hcws without children should care primarily for the influenza patients. the researchers concluded that hcws would benefit from further education regarding efficacy and availability of medications during a pandemic. it was also recognized that professional ethical guidelines are needed to help hcws fulfill their duties in cases of pandemics. although this study revealed interesting information regarding the hcw's willingness to report to work during a pandemic, the survey used to complete the study was a newly developed instrument, and reliability and validity have not been established. qureshi and colleagues completed a quantitative survey design study using a item questionnaire. the sample consisted of hcp in the new york area. the purpose of this study was to assess the ability and willingness of hcps in new york city to report to work during different types of catastrophic events. this study revealed that . % of the participants reported the most frequent reason for employees' unwillingness to report to duty during a disaster was a fear and concern for the safety of their family and themselves. in addition, . % of participants reported that they were most likely to report to duty in cases of mass casualty. however, % of the participants reported that they were not sure of their ability or willingness to report to duty during any catastrophic event. the researchers reported that a majority of the hcp participants in the new york area said they were least likely to report to duty in the case of severe acute respiratory syndrome ( . %), radiation ( . %), chemical terrorism ( . %), and smallpox ( . %). a reported limitation to this study is that it was conducted only in new york and cannot be generalized to other populations. using a survey design, balicer and colleagues explored public health workers' perceptions toward working during an influenza pandemic as well as factors that may influence intent to respond if such an event occurred. the survey was sent to employees of major health departments in maryland, with a return of surveys. clinical staff, nurses, physicians, and dentists accounted for of the respondents. data were analyzed using logistic regression to evaluate the association of demographic variables, and attitudes and beliefs with self-described likelihood of reporting to work during a pandemic disaster. the researchers studied the association between attitudes and beliefs related to pandemic preparedness and the self-reported likelihood of reporting to work. of the participants, only ( . %) stated that they would most likely report to work during a pandemic emergency. forty percent noted that they would be asked by their health department to respond during an influenza pandemic event. balicer and colleagues reported that % of all participants perceived themselves to be at risk when performing their duties during a pandemic event. it was concluded that to reduce the perceived personal threat during a pandemic and increase the likelihood of employees responding during influenza pandemics, hcps would benefit from continuing education regarding pandemics. these individuals must be assured that adequate protective equipment and psychological support would be made available to responders. researchers also concluded that if employees are unwilling to respond during an influenza pandemic emergency, this behavior may cause a considerable deficit in national emergency response plans. limitations to this study include the use of a subjective self-report survey and subject recruitment from clinics in maryland, therefore findings cannot be generalized to other populations. lastly, the power of the study was not reported. grimes and mendias completed a descriptive study that examined nurses' intentions to respond to an infectious disease emergency. this study was guided by icek ajzen's theory of planned behavior. a sample of licensed nurses in texas who completed a state board of nursing mandated -hour bioterrorism continuing education class were recruited to participate in this study. data were collected using researcher-developed questionnaires. the statistical package for the social sciences (spss) version was used to analyze data. according to the researchers, participants completed all questionnaires. the sample included both registered nurses ( %) and licensed vocational nurses ( %), with the majority being female ( %). only % of the nurses who reported that they had a professional duty to respond also had a high intent-to-respond score. this significant finding raises concerns about adequate staffing during times of bioterrorism disasters or infectious disease events. james and colleagues completed a quantitative cross-sectional study with a sample of nurses who worked during hurricane katrina in mississippi. the purpose of this study was to evaluate the impact of hurricane katrina with respect to age on mississippi nurses who worked during hurricane katrina. nurses' ages in this sample ranged from to years. the sample was divided into groups according to age: group was to years old and group was to years old. the researchers reported that there was a significant positive association between nurses aged to years and the development of poststorm depression, anxiety, ptsd, and lower health status when compared with nurses who were to years old. older nurses developed more symptoms of stress-related disorders than the younger nurses. it was concluded that taking into consideration the growing shortage of nurses in the united states, it is important to understand how working during stressful situations affects older nurses, as retention of older nurses is important as a short-term resolution to the nursing shortage. this study used self-report scales to gather data, which can be considered a limitation of the study. self-report questionnaires are an excellent method to gain knowledge about a participant's feelings or beliefs; however, data gathered through self-report relies on the accuracy of the participant's subjective account and may also reveal socially desirable responses. the findings of this study relied solely on self-reported data; hence, the results must be reviewed with caution. individuals as well as whole communities are greatly affected by any type of disaster emergency; whether it is natural or human-made. a study performed by brodie and colleagues reported that there were approximately , hurricane katrina evacuees from new orleans displaced to houston, texas. following hurricane katrina, the cdc and the louisiana department of health and hospitals reported that there were nonfatal injuries such as cuts, broken bones, and animal bites secondary to clean-up efforts after hurricane katrina between september and october , . these incidents make it clear that there is an unquestionable need for nurses to understand the importance of their response in times of disaster emergencies. conflicts of duty to family and work are further complicated by reports of nurses who have lost their jobs for not reporting to duty during times of emergency and impending disaster. , , in addition to conflicts of duty to family and work, there is growing concern among hcps that there is a lack of obligation in the duty of care during emergencies. natural disasters cannot be prevented; however, damage caused by the event may be reduced if advanced action is taken to curtail risk and vulnerability to potentially affected communities. government policies have attempted to address the issue of disaster relief and assistance to communities after large-scale disasters. to better understand disaster-related policy, it is important to review policies that directly impact society as a whole. disasters cause a disruption in government and community functions of affected areas. because of this disruption of functions, congress created and passed the robert t. stafford disaster relief and emergency relief act. this public law authorizes the president of the united states to declare that a state of emergency or a major disaster exists. a stipulation to the president's authority is that the governor of the state(s) affected must request a declaration of disaster to receive assistance. the robert t. stafford disaster relief and emergency assistance act, pl - was signed into law november , and remains in effect today. this law amended the disaster relief act of pl- - and constitutes the statutory authority for most federal disaster response activities, especially as they pertain to the federal emergency management agency (fema) and fema programs. although this law has been amended several times throughout the past few years, the primary purpose remains the same: to provide orderly and systematic assistance to local governments in areas of declared disaster so they can provide aid to citizens. during the bush administration, the directives that were used to disseminate presidential decisions on national security matters were designated as national security presidential directives. the united states department of homeland security requires states to assume an all-hazards approach to the development of competencies to prevent, prepare for, respond to, and recover from a broad array of disasters. these laws are designated as homeland security presidential directives, and stipulate continuity requirements for all executive departments and agencies. the laws provide guidance for state, local, territorial, and tribal governments, as well as private sector organizations, to ensure a comprehensive integrated national program that will enhance the credibility of the united states national security position and enable a rapid and effective response to and recovery from national emergencies. homeland security presidential directive establishes policies to strengthen the preparedness of the united states to prevent and respond to all disasters, and establishes mechanisms for improved delivery of preparedness assistance to federal, state, and local entities. nurses' input into these policies is unknown. although hospitals are but one component of health care during disasters, they are critical entities during disaster response. there is a paucity of research in the literature disaster nursing that directly relates to nursing and hospital policy. hospital policy is guided by standards set forth by the joint commission (tjc). the tjc is an independent, notfor-profit organization that completes reviews, and evaluates and accredits hospitals and other health care organizations, basing its decisions on national quality and safety standards. according to tjc, hospital emergency policies should include disaster incidents both human-made and natural that are specific to the organization. types of disasters that should be included in hospital policies are identified by probability and frequency of incidents for the area, and are based on definitions provided by the arc and the disaster relief act of . using an exploratory, descriptive design, french and colleagues investigated the needs and concerns of the nurses who responded during hurricane floyd. the purpose of the study was to determine whether the written plans of hospitals addressed the needs and concerns of the nurses who worked during this disaster. a sample of nurses who worked in the emergency department of the hospitals participated in focus groups to discuss their experiences. findings revealed that hospital policies were inadequate to deal with valid concerns of nurses. according to french and colleagues, nurses' concerns included personal safety, family safety, and provision of basic needs, wages, adequate leadership, and pet care. furthermore, the study reported that family commitment conflicted with professional obligations, resulting in nurses losing their jobs if they were unable to report to work. bartley and colleagues completed an anonymous pre-and postinterventional study to test the hypothesis that an audiovisual presentation of hospital disaster plans would improve the knowledge, confidence, and skill of hospital employees. the sample included a convenience sample of hospital employees that consisted of nurses, physicians, and administrators who would most likely be in a position of authority during a disaster. findings showed a significant increase in the test passrate results from preintervention ( %) to postintervention ( %). in addition, pretest mean scores were higher for emergency room staff ( . ) versus other staff ( . ) in various areas of the hospital. the researchers also reported that there were no significant results in the general perception of preparedness. bartley and colleagues reported that the participants described the exercise as beneficial to themselves and their departments. it was acknowledged that the convenience sampling technique used to complete this study may have added to bias of the study, and that the small sample size resulted in decreased power of the study. this study suggests that simulation exercises can enhance staff knowledge levels related to disaster planning. however, it is recognized by many that more research is needed in the area of hospital disaster preparedness plans and policies. a plethora of information exists in the literature regarding emergencies and disasters. nevertheless, significant gaps in the science related to nurses working during disasters are revealed. few studies have addressed the perspective of nurses and their intent to respond to future disasters. because nurses are invaluable to disaster response efforts, more research is essential to validate current findings and elucidate the needs of nurses who respond to disasters and other health emergencies. there is a paucity of research in the literature describing nurses' lived experiences of working during hurricanes. natural disasters inevitably inflict human suffering, and nurses are expected to respond and provide services during these catastrophic times. lost within this expectation are the experiences and concerns of the nurses who are stangeland called upon and intend to respond to the disaster, and yet are themselves affected by the disaster. understanding the experiences and needs of nurses who decide to respond to the call of duty and work during disasters remains unclear in the literature. research in the area of disaster response intentions by nurses becomes the initial step in understanding the phenomenon of working during a disaster and creating innovative approaches that address working during disasters. disaster policies have been developed and implemented at the international, national, state, local, and hospital level. nevertheless, disasters continue to adversely impact communities and hospitals at all levels causing injuries, death, and destruction of infrastructure. to reduce the impact of disasters, continued research is needed to inform and strengthen future disaster policies. knowledge gained from future research has great potential to inform nursing education, research, and 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homeland security presidential directive : management of domestic incidents what a disaster? assessing utility of simulated disaster exercise and associated educational process key: cord- - kudq h authors: hahn, austin m.; adams, zachary w.; chapman, jason; mccart, michael r.; sheidow, ashli j.; de arellano, michael a.; danielson, carla kmett title: risk reduction through family therapy (rrft): protocol of a randomized controlled efficacy trial of an integrative treatment for co-occurring substance use problems and posttraumatic stress disorder symptoms in adolescents who have experienced interpersonal violence and other traumatic events date: - - journal: contemp clin trials doi: . /j.cct. . sha: doc_id: cord_uid: kudq h decades of research demonstrate that childhood exposure to traumatic events, particularly interpersonal violence experiences (ipv; sexual abuse, physical abuse, witnessing violence), increases risk for negative behavioral and emotional outcomes, including substance use problems (sup) and posttraumatic stress disorder (ptsd). despite this well-established link—including empirical support for shared etiological and functional connections between sup and ptsd –the field has been void of a gold standard treatment for adolescent populations. to address this gap, our team recently completed a large randomized controlled trial to evaluate the efficacy of risk reduction through family therapy (rrft), an integrative and exposure-based risk-reduction and treatment approach for adolescents who have experienced ipv and other traumatic events. the purpose of this paper is to provide a detailed description of the design and methods of this rct designed to reduce sup, ptsd symptoms, and related risk behaviors, with outcomes measured from pre-treatment through months post-entry. specifically, the recruitment and sampling procedures, assessment measures and methods, description of the intervention, and planned statistical approaches to evaluating the full range of outcomes are detailed. clinical and research implications of this work are also discussed. interpersonal violence experiences (ipv; sexual abuse, physical abuse, witnessing violence) and other forms of traumatic events (e.g., traumatic grief, disasters, accidents involving injury) during childhood serve as strong and consistent predictors of substance use problems (sup) [ ] [ ] [ ] [ ] [ ] , posttraumatic stress disorder (ptsd) [ ] , depression [ ] , and risky sexual behaviors [ , ] during adolescence and adulthood [ , ] . evidence-based treatments have been developed and evaluated for treating pediatric ptsd and depression among adolescents who have experienced ipv and other traumatic events through individual, office-based approaches [ ] . trauma focused-cognitive behavioral therapy (tf-cbt) [ ] , an exposure-based treatment that teaches youth and caregivers skills for managing trauma-related behavioral and emotional problems, is the most widely-disseminated pediatric trauma-focused, evidence-based treatment, with an abundance of rcts to support its safety, efficacy, and effectiveness with trauma-related mental health concerns [ , ] . existing treatments for adolescent sup emphasize teaching youth new cognitive and behavioral skills for responding to internal and external substance use cues and often involve the caregiver in establishing contingencies for achieving and maintaining substance use reductions (e.g., cbt, motivational enhancement therapy with cbt, multisystemic therapy [mst], contingency management, etc.) [ ] . among youth who have experienced ipv and other traumatic events, substance use may result from feelings of distress in relation to trauma cues and expectancies that using substances will help the young person cope with such distress. long-standing, siloed approached to treatments for sup versus https://doi.org/ . /j.cct. . received february ; received in revised form april mental health problems has resulted in a fragmented set of treatment offerings wherein interventions for substance using populations rarely address common co-occurring mental health disorders, such as ptsd, despite the fact that they may be functionally related [ , ] . prior to the current trial, only two small pilot rcts (n's < ) had been published to evaluate integrated approaches to treatment of cooccurring sup and ptsd among adolescents [ , ] . although both pilot studies supported the feasibility of integrated approaches, only one found significant main effects for both sup and ptsd [ ] . neither study was adequately powered to establish efficacy, leaving the field without a gold standard treatment for this vulnerable population. risk reduction through family therapy (rrft) [ , ] is an integrative, exposure-based treatment approach for adolescents who have experienced ipv and other traumatic events. to address the need for an empirically-supported psychosocial therapy for adolescents with cooccurring sup and ptsd, our team recently completed the first large, sufficiently powered randomized controlled efficacy trial of rrft, focusing on the sup and ptsd outcomes [ ] . while a concise overview of the methods specific to those outcomes are included in the published paper, it does not provide a full description of the recruitment and sampling procedures, assessment measures and methods, description of the intervention, and planned statistical approaches to evaluating the full range of outcomes. thus, the current paper describes the full protocol of this nih-funded stage ii rct designed to evaluate the efficacy of rrft in comparison to treatment as usual in reducing sup, ptsd, hiv sexual risk behavior, and putative risk mechanisms (e.g., emotion regulation, parenting) among a sample of adolescents who had experienced ipv and other traumatic events who were treated in a "real world" setting. a stage ii rct was conducted to examine the efficacy of rrft in comparison to treatment as usual in reducing sup, ptsd, and related problems (e.g., hiv sexual risk behaviors) when delivered in a community-based mental health treatment setting under the supervision of the treatment developer. beyond serving as the first large rct to date to address the long-standing question of efficacy of an integrative treatment targeting co-occurring sup and ptsd for adolescents, the study aimed to improve clinical practice by offering: ) a more efficient alternative to the current compartmentalized approach to treatment of this population (which often involves referrals to multiple agencies) [ ] ; and ) a risk-reduction option for youth at elevated risk for developing substance abuse and related mental health problems in the future, but who may or may not meet diagnostic thresholds. a sample of adolescents with current sup and ptsd symptoms was recruited between december -january . each participant and a designated caregiver completed a structured clinical interview and standardized questionnaires at five timepoints: pre-treatment (baseline), three months post-baseline, six months post-baseline, months post-baseline, and months post-baseline. the first five cases enrolled into the study were assigned to the rrft clinicians as pilot cases to practice implementation of the treatment and were not entered into the rct. families entering the study after the pilot cases (n = ) were assigned to either an experimental condition or a control condition. one hundred twenty-four cases were urn randomized to condition (described below in detail) and of these cases were not randomized bur rather assigned to a specific condition either because they had a sibling already enrolled in the study (and a family could not receive both treatments due to contamination factors) (n = ) or because of case load issues (e.g., if therapists in the control condition were on a wait list and the rrft clinician had several open slots, it was preferable not to have the participant wait to receive treatment and thus were assigned to rrft or vice versa) (n = ). see consort diagram (insert figure here) . participants randomized to the experimental condition were assigned to a therapist who was trained and supervised in rrft. participants randomized to the control condition received treatment as usual (tau). these treatment conditions are described in greater detail below (see interventions). the final sample in the rct consisted of adolescents who met the following inclusion criteria: ) aged to years; ) reported at least one memorable experience of ipv (other traumatic events were permitted and included-but ipv was required); ) reported current non-tobacco substance use as defined by at least one substance using day in the past days; and ) reported five or more ptsd symptoms. youth were excluded from the current study if they: ) were previously identified as having a pervasive developmental disability or moderate to severe mental retardation; ) were actively suicidal or homicidal; or ) reported active psychotic disorder. statistical power was estimated for the difference between rrft and tau in change from baseline to each follow-up assessment. using g*power [ ] , the design effect formula was used to calculate the effective number of independent observations provided by each pair of measurements [ ] . results showed that at an alpha of . and with independent observations from participants, the study was adequately powered (i.e., power = . ) to detect a small-to-medium effect of f = . for the between-group differences in change. youth were primarily recruited through two local child advocacy centers (cacs). cacs provide victims of child maltreatment with a variety of services, including forensic interviewing, medical examination, advocacy, and outpatient mental health treatment. cacs are among the most common entry points to community services for abused children, and ipv victims make up~ % of the cases seen at cacs nationally (www.cac-sc.org). cacs are mandated by their accreditation standards to provide mental health treatment for abused children or have strong referral relationships with professionals and organizations that do. while use of community-based therapists required the investigative team to create more extensive training and supervision protocols than a trial conducted at the academic medical center, it provided a realistic evaluation and promoted future transportability and dissemination [ ] . as part of routine care, all adolescents who presented to the cacs for evaluation and/or treatment underwent a semi-structured intake assessment to determine traumatic event history, trauma-related symptoms, and appropriateness for outpatient care. findings were then used to determine study eligibility. eligible youths and their families were informed about the study and referred to research study staff for further screening and potential enrollment. research staff confirmed youth used non-tobacco substances (alcohol and/or drugs) at least once in the past days using the timeline followback (tlfb) [ ] and the presence of five or more ptsd symptoms using the global appraisal of individual needs (gain) [ ] . adolescents who met these criteria and their caregivers were then asked to provide written consent/assent for recruitment into the study, sign a release of information (allowing for chart reviews), and schedule the pre-treatment assessment. all consent procedures were approved by the medical university of south carolina institutional review board (irb). an adaptive randomization procedure, known as urn randomization, was used to balance potentially confounding variables among the participants randomized to each condition [ ] . this approach to randomization reduces pre-treatment variability between groups on these factors. the urn randomization procedure was implemented using an adaptation of the microsoft access application grand [ ] and was set up by the study statistician (jc). to keep assessors blind to condition, participants were urn randomized to the rrft or tau conditions by a trained cac staff member (not a study clinician) using this program immediately following completion the baseline assessment. specifically, once the research assistant screened and consented a new participant entering the study, she or he provided the necessary information to the cac staff member to enter into the urn to produce the condition assignment. specifically, condition assignment was balanced based on pre-treatment ptsds severity (score on ucla-ptsd-ri [ ] [ ] [ ] ≥ ), frequency of pretreatment substance use (≥ substance using days over past days); and the gender of the adolescent. once the condition was identified, the cac staff member informed the pi and the tau supervisor of the condition assignment. the pi (for rrft assignment) or the tau supervisor (for tau assignment) would then determine therapist assignment (based on case load and participant schedule match) and then inform the clinician about the new client. treatment for participants in both the rrft and tau conditions was provided by master's level clinicians ( clinicians in the rrft condition and clinicians in the tau condition) housed at the two cac settings. all of the clinicians were female and white. clinician effort dedicated to treating study participants across both conditions were covered by the grant. all cac clinicians had previous training in trauma-focused treatments, but no prior training in substance use treatment. rrft clinicians completed intensive formal training in rrft and received weekly supervision from the developer of rrft, while tau clinicians completed gold-standard training in tf-cbt and received weekly supervision from an experienced clinician with expertise in tf-cbt. each clinician was assigned to one treatment condition exclusively. for all cases in this study, effort for clinicians in both conditions was covered by the grant funding which supported the study, and treatment was provided at no cost participants and their families. rrft is an adaptation and integration of preexisting empiricallysupported, cognitive-behavioral interventions and principles designed to address the adolescent behavioral health problems targeted here including: tf-cbt [ ] , multisystemic therapy [ ] [ ] , and empirically-supported psychoeducation strategies for prevention of highrisk sexual behaviors [ ] and sexual revictimization [ ] . based on the integration of these models, the rrft manual outlines seven treatment components: ( ) psychoeducation and engagement, ( ) family communication, ( ) substance abuse, ( ) coping, ( ) ptsd, ( ) healthy dating and sexual decision making, and ( ) revictimization and risk reduction. several theoretical models underpin rrft intervention strategies. first, the rrft treatment model draws upon ecological theory [ ] by assessing and targeting the web of social influences (e.g., family, peer, community) that promote risk (e.g., substance using peers) [ ] and resiliency (e.g., family activities) [ ] for substance use and related risk behaviors at each level of an adolescent's ecology. for example, the youth and caregivers work with the therapist to determine what maintaining factors ("drivers") contribute to a given risk behavior at each level of their ecology (e.g., substance use as a coping strategy; low parental monitoring; substance-using peers) and how those drivers can be modified to reduce substance use and promote emotional resilience (e.g., teach positive coping skills, involve other family members or neighbors for monitoring, connect the youth with structured activities that provide a forum for meeting non-using peers). second, mowrer's two-factor theory [ ] is applied in rrft, as therapists aim to extinguish distress and fear that an adolescent who has experienced ipv and other traumatic events has paired with memories and cues of the trauma. according to this theory, fear is acquired through a classical conditioning process by which the individual pairs a neutral stimulus (e.g., the dark; a certain word/smell) with a stimulus that invokes a fear response (e.g., sexual assault) -such that the neutral stimulus elicits the fear/distress response in the absence of the feared stimulus. change occurs through exposure therapy, as individuals can reduce a fear response during exposure to the feared stimuli without the feared aversive consequences. based on its adaptation from tf-cbt, rrft includes gradual exposure therapy to address ptsd symptoms via the development of a detailed written or verbal account of the ipv experiences and other traumatic events. as part of this exposure-based trauma narrative work, cognitive-behavioral therapy also is involved, where the therapist helps adolescents identify and replace inaccurate and/or unhelpful beliefs that they have developed in relation to the traumatic events (e.g., "i am damaged goods"; "the abuse was my fault"; "i am unlovable"; "being high is the only way to deal with what happened.") skill-building in the area of coping (e.g., emotional reactivity) is an important preamble to the exposure work and is accomplished by teaching distress tolerance and relaxation skills. third, the connection between substance use and trauma-related symptoms can be conceptualized in the context of negative reinforcement theory [ ] , which posits that escape and avoidance of negative affect (in this case, trauma-related distress) is an important motive for substance use. sometimes referred to as the "self-medicating hypothesis," a decrease in trauma-related substance use is thought to occur with improvement of self-regulation deficits [ ] , such as emotional reactivity. the coping and ptsd components of rrft focus on improving such skills-with a particular focus on reducing emotional suppression and empowering the youth with safe, healthy, prosocial skills to withstand distress and negative affect. rrft is individualized in that the different needs, strengths, preferences, and developmental factors of each adolescent and family are incorporated into case conceptualization and tailored treatment planning. the rrft manual provides suggested language in introducing and teaching specific skills, session activities, and therapy homework ideas. the order in which the components (table ) are administered is determined by needs of the youth/family and is based on severity of the problems. the rrft protocol is typically administered through weekly, - min individual sessions. when feasible and applicable, brief joint family sessions are also conducted. therapists are encouraged to engage in brief phone or sms/text check-ins with families between sessions to promote treatment engagement, particularly when new skills have been taught or during times of family crisis. duration of treatment is not fixed in rrft; rather, treatment is ended when the youth and family's goals have been met. treatment progress is tracked systematically with standardized tools (questionnaires, urine drug screens) as well as ongoing updates to the functional assessment of risk and protective factors. although pharmacological interventions were not implemented as part of this trial, participants were not prohibited or discouraged from pursuing medication from outside providers. adolescents assigned to the tau condition received the standard treatment that a ipv victim would typically receive at the cac where the trial took place. at the study site, tau clinicians had completed gold-standard training in tf-cbt (i.e., -day in person clinical training workshop, approximately months of follow-up consultation calls delivered by experienced national tf-cbt trainers) and received on-going weekly supervision in tf-cbt. in addition to treatment that is typically offered at the cacs, tau included capacity to refer to other agencies in the community (e.g., group therapy for substance use problems), which was documented in their charts. tau has been utilized as a comparison condition for several behavioral treatment evaluations involving adolescent substance abuse [ ] or trauma [ ] . the primary reason tau was selected for the control condition was that no "standard of care" exists for co-occurring substance use problems and ptsd among adolescents. alternative comparison conditions were considered, including evidence-based substance use treatment only, evidence-based ptsd treatment only, and waitlist control. these approaches were deemed insufficient because they would effectively result in withholding treatment for known problems in participants. a pre-defined course of parallel or sequential treatments for each presenting problem (i.e., delivered as separate treatments, likely by separate providers and possibly in separate clinics) was also considered but deemed unnecessarily burdensome for participants. thus, given the ethical need to provide treatment to the control group (adolescents with current substance use and clinically significant ptsd symptoms) and a deficiency of information regarding how to address the heterogeneous clinical needs of this population, tau was selected as the most appropriate comparison condition for this study. the frequency and nature of services provided was closely monitored and recorded using several strategies. first, a comprehensive chart review was conducted of the therapy session notes across both conditions, where study staff recorded information regarding characteristics of each session (e.g., duration of session, who participated in the therapy session, focus of session, and contact in between sessions), as well as whether outside for referrals were made (for the tau condition). second, all therapy sessions across both conditions were audio-taped to measure therapist adherence to rrft and to characterize tau. the audio recordings of % of sessions across both conditions ( sessions total) were coded by raters trained to > % inter-rater reliability. tapes were coded using the family therapy scale from the therapy procedures checklist [ ] , which is an assessment of techniques used in session (e.g., improving family communication patterns), and an rrft therapist adherence measure (rrft-tam) [ ] . the rrft-tam was developed using guidelines from the standards for educational and psychological testing [ ] and accompanying rasch methods [ ] . because rrft represents an integration of tf-cbt for ptsd and mst for sup, the rrft-tam was designed to capture key features of those models. finally, caregivers also completed the services assessment for child and adolescent [ ] at the final assessment point to report on a wide range of services that had been accessed over the course of participation in the study. both the control and experimental groups were assessed at five timepoints: pre-treatment (t ), months post-baseline (t ); months post-baseline (t ); months post-baseline (t ); and months postbaseline (t ) by a highly trained research assistant who was blind to condition. assessment time points were anchored to study entry/baseline assessment rather than treatment completion due to variable duration of treatment. the full assessment battery lasted approximately h (see table for research instruments). several strategies were employed to maximize retention. first, to establish a long-term collaborative relationship with families, assessments were scheduled at the family's convenience, contacts were as friendly and personalized as possible, and families were reimbursed for their participation in each assessment session. second, at consent, we requested up to eight phone numbers of the caregivers' and adolescents' best friends, closest relatives, and places of employment to facilitate contact each time the family is assessed; we also asked if participants had plans to change their place of residence. third, we received consent to reach the adolescents (and caregivers as applicable) through text messaging and social media in addition to phone and mail. fourth, direct contact with the families helped to maintain the cohort, as all families were tracked monthly for therapist adherence and school placement reports. when possible, participants were followed by the research assistant responsible for the initial research interview, which promoted rapport and a sense of involvement. the research assistant administered the assessment battery in each family's home or at the cac, based on the participant's preference and availability. to compensate for their time, families were paid $ for completing the intake interview and $ for each subsequent assessment. data from all timepoints were collected on all families who were randomized into the study, even if they dropped out of treatment. the statistical analyses will follow intention-to-treat methods, with youth and caregivers included in the randomly assigned condition independently of their participation in the clinical intervention. the data are structured with five repeated measurements (level- ) nested within participants (level- ). to address this, the primary statistical models will be implemented as mixed-effects regression models [ ] , with continuous outcomes analyzed according to a normal sampling distribution and discrete outcomes analyzed using bernoulli (dichotomous), negative binomial (count), or ordinal (ordered categories) sampling distributions. primary outcomes focus on substance using days and ptsd symptom severity, with secondary outcomes targeting marijuana use and marijuana using days, alcohol use and alcohol using days, and polysubstance use (i.e., the use of at least two different substances). sexual risk behaviors, as measured by the sexual risk behavior scale [ ] , are secondary outcomes that will be evaluated as well. to model change over time, polynomials and/or time-related indicators will be entered at the level of repeated measurements. for instance, by including linear and quadratic polynomials, the model would estimate an instantaneous rate of change that, over time, can slow down or speed up. alternatively, more basic formulations, such as the use of dummy-coded indicators for the post-baseline assessments, could test for change between baseline and each subsequent assessment occasion. the effect of rrft will be tested using a dummy-coded indicator for intervention condition ( = tau, = rrft), which will be entered at participant-level along with cross-level interactions between condition and the level- time term(s). significance testing will be based on the wald test (i.e., β/se), and tests that are not directly provided by this formulation (e.g., the significance of within-group change for rrft) will be obtained using planned contrasts. a number of potential control variables will be considered. for instance, at level- , an indicator may be included for treatment status at each measurement occasion. this would test for an overall shift in the level of the outcome [ ] socioeconomic data, and family composition ac chart review of information from intake interview semi-structured interview to assess lifetime history of ipv and ipv incident characteristics [ ] a c substance use and abuse timeline followback (tlfb) [ ] type, quantity, and frequency of non-tobacco substance use over past days a urine drug screens [ ] the urine toxicology screen to validate tlfb self-report a diagnostic interview schedule for children (c-disc) [ ] diagnosis of axis i disorders ac substance use risk and protective factors family environment scale (fes) [ ] cohesion and conflict subscales; social and environmental characteristics of families ac bad friends subscale [ ] youth's peer relations ac alabama parenting questionnaire (apq) [ ] parenting practices across the following domains: corporal [ ] severity of depressive symptoms a sexual risk behavior scale [ ] severity of risky sexual behaviors (e.g., condom use) a other trauma-related treatment targets and mechanisms emotion regulation questionnaire (erq) [ ] tendency to regulate emotions in two ways: ( ) cognitive reappraisal and ( ) expressive suppression a upps-r-c child version [ ] impulsivity traits a hopelessness scale for children (hsc) [ ] current level of hopelessness a child attributional style questionnaire -revised (casq) [ ] causal explanations for positive and negative events. a treatment assessment rrft therapist adherence measure (rrft-tam) [ ] content & skills that were addressed (and not addressed) at each session n/a a therapy procedures checklist [ ] techniques used in each session based on those from the most commonly used youth interventions (e.g., cbt) n/a a services assessment for child and adolescent (saca) [ ] interview to assess any additional services (e.g., church counseling, inpatient hospitalizations) that had been accessed over the course of participation in the study c client satisfaction questionnaire- [ ] consumer satisfaction with treatment ac chart reviews see description above in control condition: treatment as usual. n/a note. a/c denotes person completing the assessment a = adolescent, c = caregiver. a n/a indicates measure was used for coding of therapy session tapes across both conditions, as described below. trajectory following the end of treatment. likewise, at level- , variables may be included to control for participant demographic variables (e.g., age, sex, race) and/or indicators of treatment intensity (e.g., duration, frequency). the models will be implemented using supermix [ ] or similar software for mixed-effects regression models. the objective of this paper was to describe the rationale and methods for a recently completed nida-funded stage ii rct to rigorously evaluate the efficacy of rrft, an integrative and exposure-based treatment approach for adolescents who had experienced ipv and other traumatic events, in comparison to treatment as usual. this study was conducted to address a significant gap in the field with regard to integrative treatment for co-occurring sup, ptsd, and related problems (e.g., hiv sexual risk behavior) among adolescents. that is, although significant progress has been made in treating trauma-related psychopathology among adolescents and in treating sup among adolescents independently, significantly less is known about treatment of sup and ptsd in an integrative fashion among adolescents who have experienced ipv and other traumatic events. research with trauma-exposed adults suggests that integrated approaches to the treatment of comorbid ptsd and sup are safe and efficacious [ , , ] . however, a review noted that few studies examining integrated approaches to sup and ptsd have included sufficient follow-up assessments [ ] . given that post-treatment substance use relapse rates are high, including among youth [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] , assessments that extend to the year following treatment are critical in determining whether gains are indeed maintained after treatment. a substantial strength of the stage ii trial was that it included -and month post baseline assessments to determine if indeed rrft was successful in targeting long-term improvements in sup and ptsd symptoms, as well as sexual risk behaviors. another strength of the stage ii trial is that it evaluated the safety and efficacy of an exposure-based, integrative approach to treatment of these co-occurring problems. exposure-based approaches (i.e., intentionally approaching and recalling specific thoughts, feelings, memories, and cues of traumatic event experiences) have strong empirical support for the treatment of ptsd among adults [ ] and youth [ , ] . integrated intervention approaches for ptsd and sup that do not incorporate exposure have had less robust findings [ , ] . the stage ii builds upon the prior research completed with rrft. prior to the stage ii study, a stage ia feasibility trial [ ] and a stage ib pilot rct [ ] evaluating rrft have been completed. the stage i work resulted in a treatment manual, a clinician training protocol, and a quality assurance system. the results from these prior studies were promising, indicating that rrft can be readily learned and implemented with fidelity, and that it can lead to improvements in drug use, drug use-related risk and protective factors, ptsd symptoms, and hiv sexual risk behaviors. the first outcome paper for the current trial indicates that the results hold true for sup and ptsd symptoms. numerous other strengths of the stage ii rct design are noteworthy. first, this study focuses on a 'real world' population of adolescents-where the focus was on heterogeneous symptoms (e.g., current substance use, ptsd symptoms), rather than requiring meeting full diagnostic criteria (e.g., severe substance use disorder + ptsd diagnosis). this ensures the study results will generalize to a broader population of youth who are highly vulnerable for the wide range of negative sequelae that can follow ipv and other traumatic event experiences. the multi-faceted clinical needs of this population call for an innovative solution to bridge the gap between early intervention and treatment, resulting in an inclusive risk-reduction approach with the potential for a wider-spread impact. second, establishing an integrative treatment option for this population directly addresses issues related to client burden (having to navigate separate, parallel or sequential treatments for sup and ptsd delivered by different therapists in different settings) and clinician preferences [ ] to have tools to address the multi-faceted problems most representative of their clients. third, the stage ii trial affords a unique opportunity to pursue mechanisms of action research, which can direct improvements to treatment models and inform important next steps in this line of research. as noted in the methods, we assessed several empirically-informed skills specifically targeted in rrft (e.g., emotional regulation; parenting) that may lead to improvements in sup and ptsd. next steps with the study 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from posttraumatic stress disorder (ptsd) symptoms may be particularly vulnerable when facing the covid- pandemic. yet trauma exposure may also lead to salutogenic outcomes, known as posttraumatic growth (ptg). nevertheless, the implications of ptg attributed to prior trauma, for trauma survivors’ adjustment when facing additional stressors, are unclear. addressing this gap, israeli trauma survivors were assessed for ptg and ptsd symptoms attributed to prior trauma, as well as peritraumatic stress symptoms related to the pandemic, as part of an online survey. analyses revealed that being younger, female, quarantined, negatively self-rating one’s health status, and suffering from ptsd symptoms were associated with elevated peritraumatic stress symptoms. furthermore, ptg attributed to prior trauma made a significant contribution in explaining elevated intrusion, avoidance, and hyperarousal symptoms. the present results point to the need for clinicians to take into account reports of ptg attributed to prior trauma when treating trauma survivors during the current pandemic. the covid- pandemic might be traumatogenic, leading to the development of peritraumatic stress symptoms. individuals who have a history of trauma exposure and, as a result, suffer from posttraumatic stress disorder (ptsd) symptoms might be particularly vulnerable. at the same time, prior exposure to trauma has also been claimed to have salutogenic effects, known as posttraumatic growth (ptg). nevertheless, the implications of ptg attributed to prior trauma for trauma survivors' adjustment when they face an additional stressor, such as , has yet to be investigated. the rationale of the present study was to shed light on the unique contribution of ptg attributed to prior trauma in explaining peritraumatic stress symptoms related to covid- among trauma survivors. the novel coronavirus and the disease it causes, covid- , first appeared in wuhan, china, presenting a global health threat (world health organization). symptoms of infection consist of fever, chills, cough, coryza, sore throat, breathing difficulty, myalgia, nausea, vomiting, and diarrhea , and severe cases can result in cardiac damage, respiratory failure, acute respiratory distress syndrome, and death (holshue et al., ) . since late december , when the outbreak was first revealed, the number of cases of this highly contagious virus (ryu et al., ) has escalated exponentially, spreading to many parts of the world (world health organization). according to the world health organization ( ), the virus was identified for the first time in israel at the end of february . since then, there have been , confirmed cases of covid- , and deaths, with the highest infection rate being documented at the end of march and early april (world health organization). the government of israel, in an attempt to prevent the spread of the disease, took a variety of stringent measures: issuing shelter-in-place orders (individuals were not to go further than meters from their j o u r n a l p r e -p r o o f homes, and only for essential goods); closing schools, synagogues, and other places where people might gather; quarantining anyone who might have come into contact with an infected individual, etc. the manifold stressors entailed by the covid- pandemic could very well have substantial implications for individuals' mental health. being diagnosed with the virus, belonging to a risk group for covid- complications, and appraising one's health negatively, may intensify fears of falling sick, feelings of helplessness, and stigma (shi et al., ; wang et al., a) . worries about close others who are ill or who belong to a covid- risk group might add to the emotional burden, exacerbating one's psychological distress (wang et al., a) . social distancing, closures of schools and businesses, and being under quarantine, might fuel negative emotions, which could eventuate in psychopathology (s. k. van bortel et al., ) . lastly, the economic crisis related to the shutdown of businesses and workplaces may result in mental health difficulties (bareket-bojmel et al., ; reger et al., ) . as such, and as suggested above, the covid- pandemic could very well take a toll on individuals' mental health, leading to the development or exacerbation of psychopathology lai et al., ; qiu et al., ; shigemura, ursano, morganstein, kurosawa, & benedek, ) . furthermore, for some individuals in particular, this pandemic could be highly traumatic, and could lead to trauma-related symptoms (horesh and brown, ) . peritraumatic stress symptoms -the focus of the present investigationare responses that occur during and immediately following a traumatic event. these symptoms constitute four clusters: intrusion, avoidance, changes in mood and cognition, and hyperarousal. intrusion symptoms reflect a reexperiencing of the traumatic event (e.g., intrusive memories, flashbacks, nightmares). avoidance symptoms are manifested in evading stimuli associated with the event (e.g., avoidance of trauma-related thoughts or feelings and j o u r n a l p r e -p r o o f reminders). changes in mood and cognition consist of pessimistic beliefs (e.g., overly negative thoughts and assumptions about oneself or the world) and negative mood states (e.g., fear, sadness, anger, guilt, shame). lastly, hyperarousal symptoms reflect increased reactivity to stimuli (e.g., irritability and aggression, difficulty sleeping; american psychiatric association, ). studies exploring the implications of covid- for individuals' mental health have documented various types of psychiatric symptoms as well as traumarelated symptoms (jiang et al., ; lahav, under review; wang et al., b) . specifically, increases in psychiatric symptomatology, such as anxiety and depression (gao et al., ; qiu et al., ) , have been detected. findings of a longitudinal study conducted among the general population in china during the pandemic indicated clinically significant peritraumatic stress symptoms, which did not change significantly from the time of the initial outbreak to four weeks later (wang et al., b) . additionally, a study among , chinese individuals uncovered three profiles consisting of mild ( . %), moderate ( . %), and high levels of peritraumatic stress symptoms ( . %; jiang, nan, lv, & yang, ) . according to scholars, prior trauma exposure and subsequent ptsd symptoms might intensify one's vulnerability when facing additional stressors. trauma-exposure and ptsd symptoms might drain one's resources (hobfoll, (hobfoll, , , as well as one's coping capacity, and might heighten one's sensitivity to stress (resnick et al., ; yehuda et al., ) . empirical evidence has supported this claim, indicating that a history of trauma exposure and resultant ptsd were associated with an elevated risk for ptsd following a later trauma (breslau et al., ; cougle et al., ; green et al., ; kessler et al., ; ozer et al., ) . furthermore, a recent study that explored psychological distress related to covid- indicated that prior trauma exposure and j o u r n a l p r e -p r o o f subsequent ptsd symptoms were associated with elevated levels of psychiatric symptomatology and peritraumatic stress symptoms during the pandemic (lahav, under review) . alongside the negative ramifications of prior trauma exposure, such exposure may also have salutogenic effects, with posttraumatic growth (ptg) being one of the most prevalent terms used to describe it. posttraumatic growth denotes the tendency to report a positive transformation in the aftermath of trauma exposure (tedeschi et al., ; calhoun, , ) . this transformation is assumed to reflect changes which go beyond pre-trauma adjustment and which are manifested in an enhanced appreciation for life, changes in priorities, more meaningful relationships with others, a sense of increased personal strength, new possibilities for the future, and existential/ spiritual thriving (e.g., tedeschi et al., ) . reports of ptg have been documented among survivors of various types of traumatic events. these include combat or other military-related traumatic events (mark et al., ; stein et al., ; zerach, ) , natural and manmade disasters (s. palgi et al., ) , accidents, life-threatening physical illnesses (hefferon et al., ) , bereavement (waugh et al., ) , and childhood abuse (kaye-tzadok and davidson-arad, ; lev-wiesel et al., ; shakespeare-finch and de dassel, ). nevertheless, scrutinizing the clinical and empirical literature suggests that the phenomenon of ptg is yet to be fully understood. in fact, both the essence and implications of ptg for adjustment have been the focus of a great deal of controversy. whereas some view ptg as reflecting authentic positive changes that result from struggling with the trauma calhoun, , ) , others claim that ptg might consist of illusory or avoidant elements, which may be maladaptive, at least to some degree (davis and j o u r n a l p r e -p r o o f mckearney, ; maercker and zoellner, ; mcfarland and alvaro, ) . a recent theoretical model further elaborated on this latter line of thought, and suggested that ptg should be understood in terms of dissociation, which denotes a disruption in the integration of mental processes (lahav et al., a (lahav et al., , b . according to this perspective, whereas some reports of ptg may in fact reflect a deep, genuine, positive transformation that either has no effect or a beneficial effect on adjustment over time, other reports of ptg may be rooted in dissociative mechanisms and might be maladaptive . research on the implications of ptg for adjustment has further deepened questions regarding the nature of ptg, as it has provided mix findings. for example, previous studies exploring the associations between ptg and psychological distress in regard to a wide range of traumatic events revealed positive, negative, and no relations between the two (helgeson et al., ; linley and joseph, ; a.-n. liu et al., ; shakespeare-finch and lurie-beck, ; zoellner and maercker, ) . the theoretical debate and the inconsistent findings regarding the nature and consequences of ptg point to the need to further illuminate the association between ptg, adjustment, and distress. furthermore, to the best of our knowledge, no research to date has explored the relations between ptg attributed to prior trauma and adjustment in the face of additional trauma exposure. given the high prevalence of trauma exposure worldwide, and the fact that trauma survivors are argued to suffer from heightened vulnerability in the face of new stressors, investigating this subject matter is imperative. the current study, conducted among trauma survivors in the midst of the covid- pandemic in israel, was designed to fill this lacuna. specifically, it explored the unique contribution of ptg attributed to prior trauma in explaining peritraumatic stress symptoms j o u r n a l p r e -p r o o f related to the pandemic, above and beyond background characteristics, covid- -related stressors, and ptsd symptoms resulting from past trauma. in this way, the current study aimed to reveal whether ptg resulting from prior trauma was related to low distress in the face of an additional traumatic event (in this case, or, alternatively, was either unrelated to distress or related to higher levels of distress due to an additional stressor (again, in this case, the pandemic). being the first, presumably, to address this subject matter, the current study consisted of three main objectives: . to describe peritraumatic stress symptoms related to covid- , and their relation with background characteristics and covid- -related stressors, among trauma survivors. . to explore the relation between ptg and ptsd symptoms attributed to prior exposure, on the one hand, and peritraumatic stress symptoms related to covid- , on the other hand. . to assess the unique contribution of ptg attributed to prior trauma exposure in explaining peritraumatic stress symptoms related to covid- , above and beyond background characteristics, covid- -related stressors, and ptsd symptoms related to prior trauma exposure. participants and procedure. an online survey was conducted among a convenience sample of israeli adults. the survey was accessible through qualtrics, a secure web-based survey data collection system. the survey took an average of minutes to complete and was open from april , to april , . it was anonymous, and no data were collected that linked participants to recruitment sources. the [masked for review] institutional review board (irb) approved all procedures and instruments. clicking on the link to the survey guided potential respondents to a page that provided information about the purpose of the study, the j o u r n a l p r e -p r o o f nature of the questions, and a consent form (i.e., the survey was voluntary; respondents could quit at any time; responses would be anonymous). the first page also offered researcher contact information. each participant was given the opportunity to take part in a lottery that included four $ gift vouchers. a total of , people answered some of the questionnaires. based on the trauma history screen (ths; carlson et al., ) , participants were classified as having been exposed to traumatic events. of them, only participants ( . %) who had data regarding all of the study's variables were included in the present analyses. no differences were found between participants who were included in the study and those who were not in terms of gender, χ ( ) = . , p = . ; relationship status, χ ( ) =. , p = . ; education, χ ( ) =. , p = . ; or income, χ ( ) =. , p = . . however, there was a significant difference between the groups in terms of age, t( . )= . , p < . , so that the average age among the group of participants who were not included in the study was higher (m = . , sd = . ) than among the study sample (m = . , sd = . ). participants' ages ranged from to (m = . , sd = . ), with the majority of the sample being below the age of ( . %). most of the participants were jewish ( . %) women ( . %); were secular ( . %); had a high school education or below ( . %); were in a relationship ( . %); and had an average or below-average income ( . %). traumatic events consisted of exposure to rocket attacks (n = , . %), accidents (n = . %), a physical or sexual assault during childhood (n = . . %), a natural disaster (n = , . %), a physical or sexual assault in adulthood (n = , . %), being attacked with a gun, knife, or other weapon (n = , . %), the sudden death of a family member or close friend (n = , . %), seeing someone die or get badly hurt or killed (n = , . %), and seeing something traumatizing during military service (n = , . %). the vast majority of participants reported two traumatic events or more ( . %). measures background variables. participants completed a brief demographic questionnaire that assessed age, gender, education, relational status, religiosity, and income. covid- -related stressors. participants were asked to generally indicate which of the potential implications of the pandemic were the most concerning to them and to state whether they experienced specific stressors related to the covid- pandemic. these were measured via nine items designed by the research team. participants were asked ) how they perceived their own physical health, ) whether they were diagnosed with the disease, ) whether they were quarantined, ) whether they were living alone during the outbreak, ) whether they belonged to a high-risk group for covid- , ) whether they had close others who belonged to a high-risk group, ) whether they had close others who had been diagnosed with the disease, ) whether they had close others who had been hospitalized due to the disease, and ) whether they had experienced the loss of close others as a result of the disease. given that only four participants reported being diagnosed with the disease, this specific stressor was not included in the present analyses. in addition, in order to assess a pandemic-related economic stressor, participants were asked whether they had become unemployed or furloughed since the outbreak of the pandemic. all stressors apart from perceived health were coded as dummy variables, with " " reflecting the absence of stressor and " " reflecting the presence of stressor. perceived health ranged from " " reflecting poor health to " " reflecting excellent health. peritraumatic stress symptoms related to covid- . peritraumatic stress symptoms in response to covid- were measured via a modified version of the ptsd checklist (pcl- ) (weathers et al., ). this -item self-report measure asks participants to indicate the extent to which they experienced each ptsd symptom, on a -point likert scale ranging from (not at all) to (extremely). items correspond to the newly approved ptsd symptom criteria in the diagnostic and statistical manual of mental disorders ( th ed., dsm- ; american psychiatric association, ). the original version was adapted so that the timeframe for experiencing each symptom was changed from "in the past month" to "since the outbreak of the covid- pandemic and subsequent to the pandemic," and the index event was the covid- pandemic. a total score of peritraumatic stress symptoms was calculated by summing all items. although not a definitive diagnostic measure, preliminary research suggests that a cutoff score of is a useful threshold to indicate symptomatology which may be at clinical levels (bovin et al., ) . the pcl- demonstrates high internal consistency and test-retest reliability (bovin et al., ) . internal consistency reliability in this study for intrusion, avoidance, negative alterations in mood and cognition, and hyperarousal clusters, as well as the pcl- total score, ranged from good to excellent (α = . , . , . , . , . , respectively). ptsd symptoms as a result of prior trauma exposure. ptsd symptoms were measured via the pcl- (weathers et al., ) . participants were asked to anchor responses to "stressful/traumatic life experiences" other than the pandemic, which they had experienced in the past and reported via the ths (carlson et al., ), on a scale ranging from (not at all) to (extremely). a total score is also calculated to assess the overall ptsd severity. internal consistency reliability in this study for the pcl- total score subscales was excellent (α = . ). ptg attributed to prior trauma exposure. ptg attributed to prior trauma exposure was assessed via the post traumatic growth inventory (ptgi; tedeschi & calhoun, ) . for each of the statements in the questionnaire, participants were asked to rate the extent to which the indicated change occurred in their lives as a result of their stressful/traumatic life experiences" other than the pandemic, which they had experienced in the past and reported via the ths (carlson et al., ) . each item was scored on a -point scale ranging from (i didn't experience this change at all) to (i experienced this change to a very great degree). the total score was computed according to five subscales: relating to others (i.e., "i learned a great deal about how wonderful people are"), new possibilities (i.e., "i established a new path for my life"), personal strength (i.e., "i discovered that i'm stronger than i thought i was"), spiritual change (i.e., "a better understanding of spiritual matters"), and appreciation of life (i.e., "appreciating each day"). the ptgi has shown good internal consistency, construct, convergent and discriminant validities (tedeschi & calhoun, ) . internal consistency reliabilities were good (α = . , . , . , . , . , . , for relating to others, new possibilities, personal strength, spiritual change, appreciation of life, and total score, respectively). the current analyses were conducted using spss . to assess associations between background characteristics and covid- -related stressors, on the one hand, and peritraumatic stress symptoms related to covid- , on the other, four linear regressions were conducted for each of the clusters of peritraumatic stress symptoms. to assess the associations between ptsd symptoms and ptg as a result of prior trauma exposure, on the one hand, and peritraumatic stress symptoms related to covid- , on the other, pearson correlation analyses were conducted. lastly, to explore the unique contribution of ptg attributed to prior trauma exposure in explaining peritraumatic stress symptoms related to the pandemic, above and beyond background characteristics, covid- -related stressors, and ptsd symptoms resulting from prior trauma, four hierarchical regressions were conducted for each cluster of peritraumatic stress symptoms. to determine whether including the independent and control variables in the regression analyses was adequate, we assessed for multicollinearity and examined the variance inflation factors (vifs) for the study's variables. findings indicated that all were j o u r n a l p r e -p r o o f within the acceptable range (all vifs were smaller than ), indicating that multicollinearity was not a problem in our analyses. the analyses included four blocks. the first block consisted of background characteristics. the second block consisted of covid- -related stressors. the third block consisted of ptsd symptoms related to prior trauma exposure. the fourth block consisted of the ptg total score attributed to prior trauma exposure. respondents reported experiencing several covid- -related stressors. these consisted of being quarantined (n = , . %), living alone during the outbreak (n = , . %), belonging to a high-risk group for covid- (n = , . %), perceiving one's physical health in a negative fashion (n = , . %), having a close other who was diagnosed with covid- (n = , . %), having a close other who belonged to a high-risk group (n = , . %), having a close other hospitalized due to the disease (n = , . %), experiencing the loss of close others as a result of the disease (n = , . %), and becoming unemployed or furloughed since the outbreak of the pandemic (n = , . %). these covid- -related stressors seemed to capture respondents' main areas of concern regarding the pandemic, which consisted of potential threats to their own health or their close others' health (n= , . %), negative economic consequences (n= , . %), social distancing and loneliness (n= , . %), and other (n= , . %). of the total sample, . % (n = ) reported at least one intrusion symptom, . % (n = ) reported at least one avoidance symptom, . % (n = ) reported at least one symptom reflecting negative alterations in mood and cognition, and . % (n = ) reported at least one hyperarousal symptom. furthermore, . % (n = ) of the participants had a peritraumatic stress symptom total score of or above, indicating that their symptoms were clinically significant. table as can be seen in the table, age, gender, and education were related to peritraumatic stress symptoms. being younger was associated with higher levels in all clusters of peritraumatic stress symptoms. being female and having a high school education or below were also associated with higher intrusion, hyperarousal, and negative alterations in mood and cognition symptoms. covid- -related stressors were associated with peritraumatic stress symptoms as well. negative perceived health was related to higher levels in all clusters of peritraumatic stress symptoms. living alone during the outbreak was related to higher levels of hyperarousal and negative alterations in mood and cognition symptoms, and being quarantined was related to higher levels of negative alterations in mood and cognition symptoms. all other covid- -related stressors had a nonsignificant effect in explaining peritraumatic stress symptoms. pearson correlations between ptsd symptoms resulting from prior trauma exposure, ptg attributed to prior trauma exposure, and peritraumatic stress symptoms related to are presented in table . as can be seen in the table, ptsd symptoms subsequent to prior trauma exposure were significantly associated with peritraumatic symptoms related to covid- . the higher the ptsd symptoms subsequent to prior trauma exposure, the higher the levels of all peritraumatic symptom clusters. posttraumatic stress disorder symptoms were significantly associated with ptg attributed to prior exposure. the higher the ptsd symptoms, the higher the ptg scores. furthermore, results indicated significant associations between ptg attributed to prior trauma exposure and peritraumatic symptoms related to covid- . the higher the ptg scores subsequent to prior trauma exposure, the higher the scores in all peritraumatic symptom clusters. to explore the unique contribution of ptg in explaining peritraumatic stress symptoms, above and beyond background characteristics, covid- -related stressors, and ptsd symptoms, four hierarchical regressions were conducted. the first block consisted of the background characteristics of age, gender, and education -all three of which variables had the largest contribution in explaining peritraumatic stress symptoms compared to the other background variables. the second block consisted of the covid- -related stressors of perceived health, living alone during the outbreak, and being quarantined -all three of which variables had the largest contribution in explaining peritraumatic stress symptoms compared to the other covid- -related stressors. the third block consisted of ptsd symptoms resulting from prior trauma exposure. the fourth block consisted of the ptg total score attributed to prior trauma exposure. results of the analyses are presented in table . as can be seen in table , ptg attributed to prior trauma exposure had a unique effect in explaining intrusion, avoidance, and hyperarousal peritraumatic stress symptoms. higher scores of the ptg total score were associated with higher intrusion, avoidance, and hyperarousal symptoms related to covid- . these effects were found above and beyond background characteristics, covid- -related stressors, and ptsd symptoms. the only exception was found in regard to the "alteration in cognition and mood symptoms" cluster, where ptg had a non-significant effect. this study described the unique contribution of ptg attributed to prior trauma in explaining trauma-related symptoms during the covid- pandemic, among trauma survivors. findings indicated that more than a quarter of the sample reported having at least one peritraumatic stress symptom related to the pandemic, and . % of the participants had a peritraumatic stress symptom total score of or above, indicating that their symptoms were clinically significant. these findings provide further support for the notion that the covid- pandemic has the potential to be traumatogenic (horesh and brown, ) , and are in line with findings of recent studies that documented peritraumatic stress symptoms as a result of covid- (jiang et al., ; qiu et al., ; wang et al., b) . our results revealed that several background characteristics and covid- -related stressors were associated with peritraumatic stress symptoms during the pandemic, even after taking into account ptsd symptoms and ptg attributed to prior trauma. consistent with recent studies that explored the effects of the covid- pandemic (jiang et al., ; wang et al., b) , we found that young age and being female were associated with elevated peritraumatic stress symptoms. the increased vulnerability of the female population when facing trauma has been consistently documented in trauma research (e.g., haskell et al., ; j o u r n a l p r e -p r o o f sareen, ) and might be the result of sex differences in psychophysiology, threat appraisal, and coping style (irish et al., ; olff et al., ) . in regard to the age factor, the relation between younger age and elevated peritraumatic reactions found in our study might reflect the negative effects of exposure to information about the pandemic via social media (roberts et al., ) -exposure which is presumed to be higher among younger than older individuals. in addition, and in line with previous findings (e.g., fiorillo & gorwood, ; wang, pan, wan, tan, xu, ho, et al., ) , we found that being in quarantine and negatively self-rating one's health status explained elevated levels of peritraumatic stress reactions. being quarantined might impair feelings of belongingness, as well as limit social support; the latter (limited social support) has been found to have buffering effects when one faces psychological trauma (kaniasty and norris, ) . appraising one's health negatively may produce fears of becoming ill (wang et al., a) and may lead to evaluating the pandemic as particularly threatening and traumatic. conversely, becoming unemployed or furloughed since the outbreak of the pandemic was unrelated to peritraumatic stress symptoms. these findings are surprising and inconsistent with former findings that indicated the negative implications of the pandemic-related economic crisis for individuals' mental health (bareket-bojmel et al., ; reger et al., ) . it might be that the negative effects of economic difficulties are not manifested in trauma-related symptoms, but in other types of psychopathology such as depression or anxiety, which were not assessed in the current study. alternatively, it might be that the economic stressor that was assessed in this study was only one of potentially many such stressors and did not capture the full economic implications of the pandemic. our results revealed that ptsd symptoms resulting from prior trauma were associated with trauma-related symptoms during the covid- pandemic, with effect sizes ranging from medium to large. these findings are in line with theory, as well as with empirical j o u r n a l p r e -p r o o f evidence (breslau et al., ; kessler et al., ) , suggesting that ptsd might heighten trauma survivors' vulnerability when facing additional traumas. a number of processes might be at the basis of this susceptibility. these include physiological alterations related to ptsd, such as greater brainstem and hippocampal activity in response to threat stimuli (felmingham et al., ; nutt and malizia, ) , which might intensify arousal and distress; negative appraisals of new stressors (lee et al., ) , which might further fuel distress; as well as a tendency to adopt avoidant coping strategies that are known to impede adjustment to trauma (badour et al., ; foa and kozak, ) . although the present findings regarding the adverse implications of ptsd symptoms may be somewhat predictable, our investigation of the contribution of ptg yielded innovative findings. the current results indicated that ptg attributed to prior trauma was associated with elevated peritraumatic stress symptoms related to covid- ; specifically, the higher the level of ptg, the higher the scores on the peritraumatic stress symptoms. furthermore, we found that ptg made a unique contribution in explaining elevated peritraumatic stress symptoms, above and beyond background characteristics, covid- related stressors, and ptsd symptoms resulting from prior trauma. this trend was found in regard to all of the clusters of peritraumatic stress symptoms, apart from the cluster of negative alterations in cognition and mood. in view of the heightened vulnerability of traumatized individuals when facing new stressors (e.g., kessler et al., ; ozer et al., ) , and given the high prevalence of reports of ptg among this population (tedeschi et al., ) , the questions concerning the quality and implications of ptg raised by the present findings are weighty. several explanatory routes can be proposed in regard to these results. first, the present findings may reflect a greater willingness on the part of trauma survivors who experienced ptg to acknowledge their distress. according to calhoun & tedeschi ( ) , a positive transformation resulting from trauma stems from schema j o u r n a l p r e -p r o o f reconstruction. trauma survivors who report ptg seem to experience, as a result of their trauma, the rebuilding of their schemas, which eventually leads to wider, more complex, and integrated views, consisting of both negative and positive cognitions (calhoun and tedeschi, ) . as part of this new belief system, trauma survivors might view themselves as "vulnerable yet stronger" (calhoun & tedeschi, , p. ) ; that is, they may experience themselves as less immune or impervious to life's adversities, but at the same time, as having the strength to cope with and survive it. thus, it might be that the current study participants who experienced positive changes as a result of their prior trauma were more inclined to recognize and report their distress when facing covid- . at the same time, it could be that the reports of ptg in the present study were shaped by participants' current distress and reflected their efforts to rely on positive retrospective appraisals of prior trauma as a way to cope with the threat of the pandemic. trauma survivors who participated in the present study and suffered from elevated peritraumatic stress symptoms during the pandemic might have painted their prior trauma in bright, positive colors, attributing to it beneficial effects, as a way to find comfort and better cope with their current plight. previous research has provided some support for this explanation, indicating that perceptions of personal improvement might reflect strongly-held illusions that are aimed at helping the individual cope with threatening life events (mcfarland and alvaro, ) . finally, the results of this study could also reflect illusory-defensive aspects of reports of ptg, which might be maladaptive, at least to some degree (e.g., maercker & zoellner, ) . this illusory-defensive facet of ptg may be rooted in an over-reliance on dissociative mechanisms which -although potentially providing emotional relief in the short term -may hamper an individual's ability to reprocess and overcome the trauma in the long term (lahav et al., a) . thus, it may be that whereas trauma survivors are generally more vulnerable to distress when exposed to additional stressors, those who report ptg may end j o u r n a l p r e -p r o o f up being even more susceptible to the various negative effects of such future traumas, such as those posed by today's global pandemic. specifically, these individuals might suffer from elevated levels of intrusion, avoidance, and hyperarousal peritraumatic stress symptoms. previous findings which have indicated associations between ptg and various negative outcomes (dekel et al., ; lahav et al., a lahav et al., , b a.-n. liu et al., ; shakespeare-finch and de dassel, ) provide some support for this explanation. the idea that reports of ptg are reflective of dissociative beliefs might also explain the lack of ptg's contribution in regard to the negative alterations in cognition and mood cluster, found in the present study. these dissociative beliefs are argued to reflect the formation of a fragmented and disintegrated belief system that includes, in a disconnected manner, cognitions regarding a positive transformation attributed to prior trauma, on the one hand, and negative cognitions that echo the pain and suffering caused by the trauma, on the other (lahav et al., , a . hence, although these beliefs might be associated with individuals' distress when facing an additional trauma, such as the covid- pandemic, they may be unrelated to the co-existing split-off negative cognitions, which remain separated and detached. empirical evidence that has revealed associations between reports of ptg and dissociation (greene, ; lahav et al., lahav et al., , a suggest such a prospect. nevertheless, as the present investigation did not explore the mechanisms underlying the relations between ptg and peritraumatic stress symptoms, all three explanations offered herein are speculative. the present findings must be considered in light of several limitations. first, a major limitation of the present study is its cross-sectional design. although participants in the present study were specifically asked to report peritraumatic stress symptoms subsequent to the covid- pandemic, the present data does not allow identifying the time of the symptoms' onset. additionally, based on the current data the direction of association between ptg and peritraumatic stress symptoms cannot be inferred. second, the present study relied on convenience sampling. the majority of participants in the sample were below the age of , and there was an overrepresentation of the female gender. these trends, which have been found in other surveys on the covid- pandemic (lai et al., ; mazza et al., ; wang et al., b) , should be acknowledged prior to generalizing from the results to the population at large. third, although many covid- -related stressors were explored in this study, there was only one pandemic-related economic crisis stressor explored (i.e., becoming unemployed or furloughed since the outbreak of the pandemic). thus, other effects of the economic crisis on trauma-related symptoms during the pandemic might not have been identified. fourth, the current study relied on self-report measures, which may be subject to response biases and shared method variance. additionally, the validity of the posttraumatic growth inventory (tedeschi and calhoun, ) , one of the most commonly used measurements of ptg, was, in an earlier study, called into question (frazier et al., ) . future studies should therefore include additional methods of data collection such as clinical interviews and other types of self-report measures tapping ptg. fifth, the present study did not include data regarding the time that had passed since the prior trauma, a factor that might affect the process of schema reconstruction that lies at the basis of ptg. furthermore, we did not include data regarding potential mechanisms that might underlie the link between ptg and peritraumatic distress, such as avoidance coping strategies. finally, our analyses focused on israeli trauma survivors, and thus the study's generalizability might be limited. future prospective studies should explore the relation between ptg attributed to prior trauma and adjustment in the face of additional traumas over time, among survivors of various traumatic events with diverse cultural backgrounds. bearing in mind these limitations, this study represents a step toward understanding the potential implications of trauma survivors' ptg under conditions of additional trauma exposure. though the processes at its basis are yet to be investigated, the current findings j o u r n a l p r e -p r o o f reveal associations between ptg attributed to prior trauma, on the one hand, and peritraumatic stress symptoms in the face of additional trauma, on the other. in light of a possible second wave of covid- , and the expected long-term repercussions of this pandemic, the results indicate the need to provide therapy to trauma survivors and particularly to those who suffer from ptsd symptoms. adapting evidence-based treatments for trauma, such as prolonged exposure therapy (foa, hembree, & rothbaum, ) or eye movement desensitization and reprocessing therapy (emdr; shapiro, ) to the current conditions, and providing them online (wind et al., ) , might allow traumatized individuals to reprocess their prior traumatic event as well as their current peritraumatic reactions during the pandemic, and thus alleviate their distress. furthermore, the current results suggest that clinicians should not only assess ptsd symptoms attributed to prior trauma but ptg as well, and should take a cautious approach when treating trauma survivors who report ptg, given that the essence of ptg is still unclear. reports of ptg might reflect a positive transformation subsequent to prior trauma, or alternatively may mirror efforts to cope with current distress or maladaptive dissociative beliefs. exploring patients' reports of ptg while taking into account their current distress as well as their tendency to rely on dissociative mechanisms may help clinicians to treat these patients more effectively. nevertheless, future longitudinal studies exploring the implications of ptg for individuals' mental health in the face of additional stressors, while assessing potential mechanisms underlying these effects, are needed in order to promote the development of clinical practice guidelines. j o u r n a l p r e -p r o o f j o u r n a l p r e -p r o o f note: gender values: = male, = female; education values: = high school education or below, = higher level education. all stressors apart from perceived health were coded as dummy variables, with " " reflecting the absence of stressor and " " reflecting presence of the stressor. lower scores on perceived health reflect negative perceptions of one's health. *p < . , **p < . , ***p < . j o u r n a l p r e -p r o o f table . inter-correlations between ptsd symptoms and ptg attributed to former trauma exposure, and peritraumatic stress symptoms related to ** p < . . *** p < . step age -. . ** -. . * -. *** . *** -. *** . *** gender . ** . . * . * education -. ** -. * -. ** -. step age -. * . *** -. ** . *** -. *** . *** -. *** . *** gender . ** . . . * education -. * -. -. * -. perceived health -. *** -. *** -. *** -. *** in quarantine . . . * . live alone during outbreak -. -. * -. ** -. * step j o u r n a l p r e -p r o o f age -. . *** -. . *** -. *** . *** -. *** . *** j o u r n a l p r e -p r o o f note: gender values: = male, = female; education values: = high school education or below, = higher level education. all stressors apart from perceived health were coded as dummy variables, with " " reflecting the absence of stressor and " " reflecting presence of the stressor. lower scores on perceived health reflect negative perceptions of one's health. *p < . , **p < . , ***p < . ptg 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of cumulative lifetime trauma and recent stress on current posttraumatic stress disorder symptoms in holocaust survivors posttraumatic growth among combat veterans and their siblings: a dyadic approach posttraumatic growth in clinical psychology-a critical review and introduction of a two component model key: cord- -xihpfidg authors: ford, julian d.; grasso, damion j.; elhai, jon d.; courtois, christine a. title: social, cultural, and other diversity issues in the traumatic stress field date: - - journal: posttraumatic stress disorder doi: . /b - - - - . -x sha: doc_id: cord_uid: xihpfidg this chapter describes how the impact of psychological trauma and posttraumatic stress disorder (ptsd) differ, depending on individual differences and the social and cultural context and culture-specific teachings and resources available to individuals, families, and communities. a social-ecological framework is used to differentiate the impact of exposure to traumatic stressors and the development of (or resistance to) ptsd, based on the individual’s or group’s (i) personal, unique physical characteristics, including skin color, racial background, gender, and sexual orientation; and (ii) family, ethnocultural, and community membership, including majority or minority group status, religious beliefs and practices, socioeconomic resources, and political and civic affiliations. while personal, familial, social, and cultural factors can be a positive resource contributing to safety and well-being, they also can be a basis for placing the person, group, or entire community or population in harm’s way or at heightened risk of developing ptsd. this is an adaptive response in one sense, providing an awareness and readiness to respond should the genocide or any associated forms of stigma, discrimination, or violence ever recur with impunity. however, it can also become a form of persistent hypervigilance similar to that seen in ptsd, placing a strain upon the individual's or group's daily life that may compromise their well-being. our discussion of the impact of exposure to traumatic stressors and ptsd on ethnoracial groups and individuals whose forebears have experienced historical trauma will bear this fact in mind. in addition, gender-based biases and beliefs, many of which are based on longstanding religious and cultural traditions, have caused women to be systematically discriminated against and subject to routine physical and sexual assault. genderbased discrimination and violence against females (whether intra-or extrafamilial) have been so widespread as to be implicated in what kristof and wudunn ( ) term "gendercide." in their recent book, they cite examples of selective abortions based on a fetus's gender and differential nutrition and care beginning in infancy also based on gender preference. they are then often followed by lifelong major disparities in education and restricted role and career opportunities for females as compared to males. unfortunately, even today, with all the advances that have occurred predominantly in western societies, these same issues remain in place around the world. the increased recognition of the underclass status of the majority of women and girls and the discrimination they face, along with the violence perpetrated against them (often seemingly with impunity), in countries around the world (whether industrialized and "advanced," or relatively primitive) has led to the recent development of major initiatives against global violence and discrimination against women. malala yousafzai, who was shot by the taliban for her espousal of universal education for girls, was awarded the nobel peace prize, the youngest recipient to date. the brutality of the attack against her was shocking, yet it served to highlight the traumatic threat to which many girls and women across the world are exposed when targeted for hateful acts by those who believe this is necessary to maintain the status quo and the subservience of females. discrimination and violence based on sexual orientation and transgender/intergender status are yet other sources of traumatic victimization that must be well recognized. sexual orientation is both a personal and social characteristic that is more complex than the gender that a person inherits based on inborn sexual characteristics. when socially ascribed gender and culturally promulgated expectations for gender-based activities, such as mating, are a mismatch to an individual's sense of his or her own true sexual preferences and identity, the conflict can be psychologically devastating. global initiatives therefore are underway to prevent or ameliorate the adverse impact of discrimination, stigma, and violence based on sexual orientation and identity providing an essential foundation for the basic liberties, freedom from assault, and the right to marry to gay, lesbian, bisexual, and transgendered (glbt) individuals. it should also be noted that boys and men are also subject to abuse and assault at rates that are not yet adequately researched. males may be more subject to violence when they are in a position of vulnerability of some sort due to being a member of a group that is targeted and/or of lesser status/lesser strength. depending on social, cultural, and other diversity issues in the traumatic stress field their cultural background and its traditions and beliefs, individuals may also have "multiple vulnerability status"-that is, to be members of more than one group or to have characteristic that cause them to be even more susceptible to discrimination or victimization (i.e., adolescent black male in the united states; a baby born with physical or developmental disabilities in a culture that endorses selective resources to the ablebodied; a gay man or lesbian woman of color in a highly homophobic and racist society). age is yet another vulnerability factor dimension that has not received adequate recognition, with individuals at either end of the life span as most vulnerable. research has substantiated that children and adolescents are the most at-risk segment of the population globally (finkelhor, ) . victimization of the elderly and the lessabled/disabled members of the population is now documented as widespread in many societies and is increasingly under investigation. like other forms of abuse, victimization of the elderly and less-abled is often based on the victim's relative degree of dependence and his powerlessness to defend himself. the extent and impact of exposure to traumatic stressors experienced by each of these vulnerable populations is discussed in this chapter, as are the efforts of international non-governmental organizations (ngos) to provide them with resources to reduce their exposure to traumatic stressors or to mitigate the adverse effects of traumatic exposure and ptsd (box . ). box . key points . culture, ethnicity, gender, sexual orientation, and disability are potential sources of resilience, but they also may lead to chronic stressors such as social stigma, discrimination, and oppression, which can increase psychological trauma and ptsd. . cumulative adversities are faced by many persons, communities, ethnocultural minority groups, and societies that may lead to-as well as worsen the impact of-ptsd: • persons of ethnoracial minority backgrounds; • persons discriminated against due to gender or sexual orientation; • persons with developmental or physical disabilities; • economically impoverished persons and groups, including the homeless; • victims of political repression, genocide, "ethnic cleansing," or torture; • persons chronically or permanently displaced from their homes and communities due to catastrophic armed conflicts or disasters. . members of ethnoracial minority groups have been found to be more likely in some cases to develop ptsd than other persons, but in other cases they are less likely to develop ptsd (e.g., persons of asian or african descent). . members of ethnoracial minority groups often encounter disparities in access to social, educational, economic, and health care resources; it is these disparities that are the most likely source of the increased vulnerability of these persons to psychological trauma and ptsd. (continued ) to psychological trauma in the immediate or most distant past, or both. psychological trauma and ptsd occur across the full spectrum of gender, racial, ethnic, and cultural groups in the united states (pole, gone, & kulkarni, ) . psychological trauma and ptsd are epidemic internationally as well, particularly for ethnoracial minority groups (which include a much broader range of ethnicities and cultures and manifestations of ptsd than typically recognized in studies of ptsd in the united states; de jong, komproe, spinazzola, van der kolk, & van ommeren, ; de jong, komproe, & van ommeren, ) . the scientific and clinical study of ptsd and its treatment among gender and ethnoracial majority and minority groups is of great importance, especially given the disparities, adversities, and traumas to which they have been subjected historically (miranda, mcguire, williams, & wang, )-and to which they are still exposed in health and health care, education and income, and adult criminal and juvenile justice (ford, ) . although latinos (and possibly african americans) persons are at greater risk than european americans for ptsd based on available research findings (pole, gone, & kulkarni, ) , it is possible that the elevated prevalence may be due to differences in the extent or types of exposure to psychological trauma (including prior traumas that often are not assessed in ptsd clinical or epidemiological studies; eisenman, gelberg, liu, & shapiro, ) or to differences in exposure to other risk or protective factors such as poverty, education, or gender-based violence (turner & lloyd, , . in addition, there is sufficient diversity (in norms, beliefs, values, roles, practices, language, and history) within categorical ethnocultural groups such as african americans or latinos to call into question any sweeping generalizations about their exposure and vulnerability or resilience to psychological trauma (pole et al., ) . race, ethnicity, gender and sexual identity, and culture tend to be described with shorthand labels that appear to distinguish homogeneous subgroups but that actually obscure the true heterogeneity within as well as between different groups (marsella, friedman, gerrity, & scurfield, ) . one partial antidote for this problem is for clinicians and researchers to be curious about these issues and to ask study participants or clinical patients to self-identify their own racial, ethnic, and cultural background and to essentially educate them about their unique characteristics and associated belief systems and traditions (brown, ; brown, hitlin, & elder, ) . it also is important to carefully assess factors that are associated with differential exposure to adverse experiences (such as racial-ethnic discrimination) or differential access to protective resources (such as income, health care, education, police protection), rather than assuming that each member of an ethnocultural group is identical on these crucial dimensions. however, when systematic disparities in exposure to stressors or deprivation of resources are identified for specific groups, such as persons from indigenous culturesthe original inhabitants of a geographic area who have been displaced or marginalized by colonizing national/cultural groups-are found to have a generally increased risk of discrimination, poverty, addiction, family violence, and poor health (harris et al., ; liberato, pomeroy, & fennell, ) , it is crucial not to mistakenly conclude that those persons are less resilient than others when they are confronted with traumatic stressors. commonly, the very opposite is true: persons and groups who are subjected to chronic stressors or deprivations tend to be more resilient than others, but they also are more exposed to and less protected from traumatic stressors (pole et al., ) . racism and associated discrimination and mistreatment are particularly chronic stressors faced by many members of ethnoracial and other minority groups. racism may constitute a form of psychological trauma in and of itself, increasing the risk of exposure to psychological trauma, and exacerbating its impact by increasing the risk of ptsd (ford, ) . as of yet, few systematic studies have directly examined racism as a risk factor for exposure to psychological trauma, although the connection is increasingly recognized (carter & forsyth, ; hunter & schmidt, ; miller, ) . perhaps, the holocaust and other forms of genocide have been the most investigated to date. studies of survivors of the holocaust and other types of ethnic annihilation provide particularly graphic and tragic evidence of the infliction of psychological trauma en masse in the name of racism (staub, ; yule, ) . studies are needed that systematically compare persons and groups who are exposed to different types and degrees of racism in order to test whether (and under what conditions) racism is a form of, or leads to exposure to other types of, traumatic stressors (ford, ) . when racism leads to the profiling and targeting of ethnoracial minority groups for violence, dispossession, dislocation, or annihilation, the risk of ptsd increases in proportion to type and degree of the traumatization involved (pole et al., ) . for example, studies based in the united states (pole et al., ) and internationally (macdonald, chamberlain, & long, ) suggest that racial discrimination may have played a role in placing military personnel from ethnoracial minority groups at risk for more extensive and severe combat trauma exposure. one study found that self-reported experiences of racial discrimination increased the risk of ptsd among latino and african american police officers (pole, best, metzler, & marmar, ) . another study with asian american military veterans from the vietnam war era showed that exposure to multiple race-related stressors that met ptsd criteria for psychological trauma was associated with more severe ptsd than when only one or no such race-related traumas were reported (loo, fairbank, & chemtob, ) . this study more precisely operationalized racism than any prior study, utilizing two psychometrically validated measures of race-related stressors and ptsd. however, as in the pole et al. ( ) study, the stressors/traumas and ptsd symptoms were assessed by contemporaneous self-report, so the actual extent of racism experienced by the participants cannot be definitely determined. the loo et al. ( ) study also did not control for traumatic stressor exposure other than that which was related to racism. in order to extend the valuable work these studies have begun, it will be important to utilize measures based on operationally specific criteria for categorizing and quantifying exposure to discrimination (e.g., wiking, johansson, & sundquist, ) as a distinct class of stressors that can be assessed separately as well as concurrently with exposure to psychological trauma. research also is needed to determine to what extent the adverse outcomes of racial disparities are the direct result of racism as a stressor (e.g., racially motivated stigmatization, mistreatment, subjugation, and deprivation resulting in personal and community depression and destabilization), as opposed to the indirect effects of racism (such as microaggressions that accrue over time). racism can also indirectly reduce access to protective factors (adequate nutrition and other socioeconomic and community resources) that protect against the adverse effects of stressors (such as poverty, pollution, disaster) and traumatic stressors (such as accidents, crime, or violence). hurricane katrina and its aftermath provided just such an example. it is important to determine whether ptsd is the product of either the direct or indirect effects of racism, or both, particularly given its demonstrated association with other psychiatric conditions (such as depression, anxiety, and addiction) and with increased risk of physical illness (such as cancer and cardiovascular disease) in ethnoracial minorities (e.g., among american indians; sawchuk et al., ) . education is a particularly relevant example of a socioeconomic resource to which ethnoracial minorities often have restricted access as that as a protective factor mitigating against the risk of ptsd (dirkzwager, bramsen, & van der ploeg, ) and overall health status (wiking et al., ) . racial disparities in access to education are due both to direct influences (such as lower funding for inner-city schools that disproportionately serve minority students) and indirect associations with other racial disparities (such as disproportionate juvenile and criminal justice confinement of ethnoracial minority persons). racial disparities in education are both the product of and a contributor to reduced access by minorities to other socioeconomic and health resources (such as income, health insurance, adequate nutrition) (harris et al., ) . when investigating risk and protective factors for ptsd, it is essential therefore to consider race and ethnicity in the context not only of ethnocultural identity and group membership but also of racism and other sources of racial disparities in access to socioeconomic resources. although all ethnoracial minority groups tend to be disproportionately disadvantaged with regard to the more privileged majority population, particularly severe disparities in access to vital resources often are complicated by exposure to pervasive (both intrafamilial and community) violence and by the loss of ties to family, home, and community. when family and community relationships are severed-as occurs with massive political upheaval, war, genocide, slavery, colonization, or catastrophic disasters-racial and ethnocultural groups may find themselves scattered and subject to further victimization and exploitation. for example, there continue to be massively displaced populations in central and south america, the balkans, central asia, and africa. when primary social ties are cut or diminished as a result of disaster, violence, or political repression, the challenge expands beyond survival of traumatic life-threatening danger to preserving a viable life, community, and culture in the face of lifealtering losses and suppression of those very factors needed to maintain (garbarino & kostelny, ; rabalais, ruggiero, & scotti, ) . ethnoracial groups that have been able to preserve or regenerate core elements of their original cultural norms, practices, and relationships within intact or reconstituted families may actually be particularly resilient to traumatic stressors and protected against the development of ptsd. for example, persons of asian or african descent have been found to be less likely than those of other ethnocultural backgrounds to develop ptsd. whether this is due to factors other than ethnicity per se, such as having cultural practices and beliefs that sustain family integrity and social ties, is a question that has not been scientifically studied and should be a focus for research (pole et al., ) . a recurring theme is that the psychological trauma inflicted in service of racial discrimination may lead not only to ptsd but also to a range of insidious psychosocial problems that result from adverse effects upon the psychobiological development of the affected persons. when families and entire communities are destroyed or displaced, the impact on the psychobiological development of children and young adults may lead to complex forms of ptsd that involve not only persistent fear and anxiety but also core problems with relatedness and self-regulation of emotion, consciousness, and bodily health that are described as "complex ptsd" (herman, ) or "disorders of extreme stress" (de jong et al., ) . a critical question not yet answered by studies of ptsd and racial discrimination (pole et al., ) and race-related stress (loo et al., ) , as well as by the robust literature that shows evidence of intergenerational transmission of risk for ptsd (kellerman, ) , is whether racism constitutes a "hidden" (crenshaw & hardy, ) or "invisible" (franklin, boyd-franklin, & kelly, ) form of traumatization that may be transmitted across generations. recent research findings demonstrating highly adverse effects of emotional abuse in childhood (teicher, samson, polcari, & mcgreenery, ) are consistent with a view that chronic denigration, shaming, demoralization, and coercion may constitute a risk factor for severe ptsd and associated psychobiological problems. research is needed to better describe how emotional violence or abuse related to racism may (along with physical violence) constitute a form of traumatic stress and how this may adversely affect not only current but also future generations. a fully articulated conceptual model for the scientific study and social/clinical prevention and treatment of the adverse impact of psychological trauma and ptsd requires principles and practices informed by this diversity of factors, rather than a "black and white" view of race, ethnicity, or culture that misrepresents the individual's and group's heritage, nature, and needs. treatment preferences, in terms of characteristics of the therapist as well as the therapy model, differ substantially not only across but also within ethnoracial groups (pole et al., ) . as a result, it is not possible as yet-and may never be possible-to precisely prescribe how best to select or train therapists and design or adapt therapies to fit different ethnocultural groups and the individuals within them. a culturally competent (brown, (brown, , a (brown, , b approach to treating ptsd (ford, ) begins with a collaborative discussion in which the therapist adopts the stance of a respectful visitor to the client's outer and inner world-clarifying the client's expectations and preferences, and the meaning of sensitive interpersonal communication modalities (such as spatial proximity, gaze, choice of names, private versus public topics, synchronizing of talk and listening, use of colloquialisms, providing advice or education). ptsd therapists thus must avoid stereotypic assumptions and become both a host and guest in the client's psychic world in order to ensure that assessment and treatment are genuinely collaborative and sensitive to each client's ethnocultural traditions, expectations, goals, and preferences (parson, ; stuart, ) . at times, it is helpful to involve other members of the family or culture in assisting with the treatment. religious beliefs and spirituality are other dimensions of culture that have not yet been given sufficient focus in most psychotherapy but must also be assessed and understood by the therapist (walker, courtois, & aten, ) . cultural competence means many things to many people, and unfortunately, it is often mistakenly equated with being of the same racial, ethnic, cultural, religious, or national background as the persons involved in a study or receiving services, or knowing in advance exactly what each person believes and expects, how they communicate with and are most receptive to learning from others, and what their experience has been in relation to sensitive matters such as psychological trauma or ptsd. this is likely to be a serious mistake for several reasons. sharing some general racial, ethnic, cultural, or national features (or an apparently identical language or religion) is not synonymous with shared identity, knowledge, or history. even persons from as virtually identical backgrounds as monozygotic twins raised in the same family have substantial differences in physical and temperamental characteristics as well as often quite distinct social learning histories, and thus rarely if ever can reliably read one another's minds or exactly know one another's vulnerabilities and strengths. therefore, cultural competence should not be defined in terms of stereotypic assumptions about identity or prescience but instead based upon a respectful interest in learning from each person and community what they have experienced and how they understand and are affected by psychological trauma and ptsd. we should also note that the idioms of distress can differ by culture and tradition. professionals from industrialized nations and anglo cultures must be cautious and respectful in working with individuals and communities from other cultures that are challenged by ptsd in the aftermath of exposure to violence or disasters. before offering or providing education or therapeutic assistance, it is essential to become aware of how the potential recipients understand and prefer to communicate about traumatic stress and the process of healing from traumatization. the implication for psychometric assessment of psychological trauma and ptsd with clients of ethnocultural minority groups (hall, ; marsella et al., ) is that it is essential to carefully select protocols that do not confront individuals with questions that are inadvertently disrespectful of their values or practices (e.g., including peyote as an example of an illicit drugs in a native american tribe that uses it for religious rituals), irrelevant (e.g., distinguishing blood family from close friends in a group that considers all community members as family), or incomplete (e.g., limiting health care to western medical or therapeutic services, to the exclusion of traditional forms of healing). a systematic assessment of trauma history and ptsd thus should include not only a recitation of events in a person's life and symptomatic or resilient responses in the aftermath but how the person interpreted these events and reactions based on their cultural framework, beliefs, and values (manson, ) . interventions for prevention or treatment of ptsd typically have been developed within the context of the western medical model (parson, ; but see andres-hyman, ortiz, anez, paris, & davidson, ; hinton et al., ; hwang, , for examples of culturally sensitive adaptations). evidence-based ptsd treatment models are not necessarily incompatible with culturally specific healing practices and have in common the goal of fostering not just symptom reduction but a bolstering of resilience and mastery (see chapters and ). the integration of culturally specific methods and rituals in prevention or treatment interventions for ptsd, however, requires careful ethnographic study (i.e., observing and learning about the values, norms, beliefs, and practices endorsed and enforced by different cultural subgroups and their particular idioms (ways of describing and explaining) traumatic stress and ptsd) so the ptsd clinician and researcher can truly work collaboratively withrather than imposing external assumptions and standards upon-the members of the wide range of ethnic and cultural communities. in most cultures, girls and women are subject to discrimination in the form of limitations on their access to crucial socioeconomic resources. women earn - % lower wages or salaries than men in most job classes in the united states (http://www.payequity.org/info.html) and europe (http://www.eurofound.europa.eu/ewco/ / / es i.htm). although girls and women are approaching parity with boys and men in access to education in most areas of the world (and exceed the enrollment of boys or men in secondary and college/university education), in sub-saharan africa and asia, women and girls are as much as % less likely to be able to enroll in education and to have achieved literacy as adults (http://www.uis.unesco.org/template/ pdf/educgeneral/uisfactsheet_ _no% _en.pdf). girls and women also may be systematically subjected to extreme forms of psychological and physical trauma as a result of their gender being equated with second-class citizenship and social norms that permit or even encourage exploitation. sexual exploitation of women and girls is an international epidemic, including abuse and molestation, harassment, rape and punishment of rape victims, forced marriage, genital mutilation, and sex trafficking or slavery (box . ). physical abuse or assault of women and girls is tolerated-and in some cases actually prescribed as a form of social control-in both mainstream cultures and subcultures that span the globe and include most religions and developed as well as developing or preindustrial societies. similar potentially traumatic forms of violence are directed at many glbt persons as a result of both formal and informal forms of social stigma and discrimination. epidemiological studies have been conducted with samples of glbt youth (d'augelli, grossman, & starks, ) and adults (herek, ) in the united states, suggesting that they are often subjected to potentially traumatic violence as a result of their nontraditional sexual orientation and behavior. instances of violence specifically related to sexual orientation include: • - % of gay men and % of lesbians who were physically assaulted in the past year; • - % of glb adults who were subjected to actual or threatened violence toward their person or a property crime at some point in their lives; • - % of glb adolescents reported past incidents of physical or sexual violence. in contrast to the general pattern of stigma-related violence being directed toward girls and women, gay and bisexual boys (d'augelli et al., ) and men (herek, ) were more likely to report violent victimization or threats than lesbian or bisexual women or girls. the findings from the survey of glb adolescents suggest that stigma and victimization begin early in life, with physical and sexual attacks occurring as early as ages - years old. one in eleven glb adolescents met criteria for ptsd, box . "making the harm visible": sexual exploitation of women and girls women from every world region report that the sexual exploitation of women and girls is increasing. all over the world, brothels and prostitution rings exist underground on a small scale, and on an increasingly larger scale, entire sections of cities are informally zoned into brothels, bars, and clubs that house, and often enslave, women for the purposes of prostitution. the magnitude and violence of these practices of sexual exploitation constitute an international human rights crisis of contemporary slavery. in prostitution: a form of modern slavery, dorchen leidholdt, the coexecutive director of the coalition against trafficking in women, examines the definitions of slavery and shows how prostitution, and related forms of sexual exploitation, fit into defined forms of slavery. in some parts of the world, such as the philippines, prostitution is illegal but well entrenched from providing "recreational services" to military personnel. in "blazing trails, confronting challenges: the sexual exploitation of women and girls in the philippines," aida f. santos describes the harmful conditions for women and girls in prostitution in the philippines, with problems related to health, violence, the legal system, and services. in other regions, such as northern norway, organized prostitution is a more recent problem, stemming from the economic crisis in russia. in "russian women in norway," asta beate håland describes how an entire community is being transformed by the trafficking of women for prostitution from russia to campgrounds and villages across the border in norway. political changes combined with economic crises have devastated entire world regions, increasing the supply of vulnerable women willing to risk their lives to earn money for themselves and their families. aurora javate de dios, president of the coalition against trafficking in women, discusses the impact of the southeast asian economic crisis on women's lives in "confronting trafficking, prostitution and sexual exploitation: the struggle for survival and dignity." economic globalization controlled by a handful of multinational corporations located in a few industrialized countries continues to shift wealth from poorer to richer countries. in her paper "globalization, human rights and sexual exploitation," aida f. santos shows us the connection between global economics and the commodification and sexual exploitation of women and girls, especially in the philippines. structural adjustment programs implemented by international financial institutions impose loan repayment plans on poor countries, which sacrifice social and educational programs in order to service their debt to rich nations and banks. fatoumata sire diakite points to structural adjustment programs as one of the factors contributing to poverty and sexual exploitation in her paper "prostitution in mali." zoraida ramirez rodriguez writes in "report on latin america" that the foreign debt and policies of the international monetary fund are primary factors in creating poverty for women and children. these forces leave women with few options, increasing the supply of women vulnerable to recruitment into bride trafficking and the prostitution industry. (continued ) social problems such as sexual and physical abuse within families force girls and women to leave in search of safety and a better life, but often they find more exploitation and violence. physical and sexual abuse of girls and women in their families and by intimate partners destroys girls' and women's sense of self and resiliency, making them easy targets for pimps and traffickers who prey on those who have few options left to them. these factors are evident in many of the papers from all world regions in this volume, such as jill leighton and katherine depasquale's, "a commitment to living," and martha daguno's, "support groups for survivors of the prostitution industry in manila." government policies and practices also fuel the demand for prostitution, as they legalize prostitution or refuse to enforce laws against pimps, traffickers, and male buyers. in making the harm visible, we see how countries with governmental structures and ideological foundations as different as the netherlands and iran, both promote and legalize sexual violence and exploitation of girls and women. in "legalizing pimping, dutch style," marie-victoire louis exposes the liberal laws and policies that legalize prostitution and tolerate brothels in the netherlands. at the other extreme, religious fundamentalists in iran have legalized the sexual exploitation of girls and women in child and temporary marriages and the sexual torture of women in prison. sarvnaz chitsaz and soona samsami document this harm and violation of human rights in "iranian women and girls: victims of exploitation and violence." global media and communication tools, such as the internet, make access to pornography, catalogs of mail-order brides, advertisements for prostitution tours, and information on where and how to buy women and girls in prostitution widely available. this open advertisement normalizes and increases the demand by men for women and girls to use in these different forms of exploitation. donna m. hughes describes her findings on how the internet is being used to promote the sexual exploitation of women and children in "the internet and the global prostitution industry." in this milieu, women and girls become commoditiesbought and sold locally and trafficked from one part of the world to another. how do we make the harm of sexual exploitation visible? in a world where sexual exploitation is increasingly normalized and industrialized, what is needed to make people see the harm and act to stop it? the women in making the harm visible recommend four ways to make the harm of sexual exploitation visible: listen to the experiences of survivors, expose the ideological constructions that hide the harm, expose the agents that profit from the sexual exploitation of women and children, and document harm and conduct research that reveals the harm and offers findings that can be used for policy initiatives. reprinted with permission from the introduction to making the harm visible, edited by d. hughes - times the prevalence of children (copeland, keeler, angold, & costello, ) and adolescents (kilpatrick et al., ) in national samples in the united states. although gender and sexual orientation may seem intuitively to be simpler phenomena than race or ethnicity, in reality they are quite complex in terms of referring to not just biological characteristics but many aspects of psychological identity and social affiliations. being a female or a male, let alone gay, lesbian, bisexual, or transgendered/ intergendered, means many different things to different people. although more stable than changeable, sexual orientation and even gender may be changed for the same person over time. it is inaccurate to assume that all or even most people of a given gender or sexual orientation are identical or even similar without careful and objective assessment of how they view themselves and how they actually act, think, and feel. in relationship to psychological trauma and ptsd, therefore, the broad generalizations that have been suggested by research concerning gender and sexual orientation relate more to the way in which people of a gender or sexual orientation are generally viewed and treated (which varies, depending on the society and culture) than to inherent qualities of a given gender or sexual orientation (which is highly individual across all societies and cultures). the finding that girls and women are more often subjected to sexual and intrafamilial traumatic stressors, while boys and men more often experience physical, accidental, combat, and assaultive traumatic stressors is consistent with stereotypic sex roles that are found in many (but not all) cultures that assign females to the role of subservient helper and caregiver, while males are assigned to the role of leader and warrior. there are biological foundations for these differences-such as due to distinct levels of the sex-linked hormones estrogen and testosterone, and brain chemicals that differentially affect females and males (oxytocin and vasopressin; see chapter ). however, biology need not dictate a person's or a group's destiny, so it is inaccurate to assume that males or females must always fill these sex role stereotypes, particularly when there are severe adverse consequences, such as the epidemics of abuse of girls and women and of boys and men killed as violent combatants or as the "spoils of war." stereotypes can be even more insidious and damaging in relation to sexual orientation. only in the past decades has homosexuality been rescued from the status of a psychiatric disorder (as it was in the first three editions of the diagnostic and statistical manual). stigma and harassment evidently are still experienced, potentially with traumatic results when violent acts are tolerated or even encouraged, by glbt adults and youth. it is not surprising that the prevalence of ptsd is greater among persons with other than heterosexual sexual identities, and the extent to which this is the result of the pernicious stigma directed at such individuals in most cultures or of outright traumatic violence, or both, remains to be tested. persons with physical or developmental disabilities are another group of persons who unfortunately may be subjected to stigma and discrimination. physical disabilities are more common in developing countries than in more industrialized and affluent nations in which medical technology and accident and illness prevention have reduced the risk of severe injury or genetically based physical disabilities (mueser, hiday, goodman, & valentini-hein, ) . persons with physical disabilities may be at risk for exposure to traumatic accidents or maltreatment as children and as adults due to limitations in their abilities to care for themselves and live independently, particularly if they have cognitive impairment due to conditions such as mental retardation or serious mental illness. only one study that examined the prevalence of exposure to potentially traumatic events among physically disabled persons could be located. that was a national survey of women with physical disabilities by the center for research on women with disabilities (nosek, howland, & young, ) . on the one hand, the study found that disabled women were no more likely to report exposure to physical or sexual abuse than women without physical disabilities. however, in more detailed interviews with a subsample, more than % reported instances of abuse, on average two incidents per woman (each often lasting for a lengthy time period). for example, the report provides verbatim quotations: more than half of all respondents ( % with disabilities, % with no disability) reported a history of either physical or sexual abuse, or both, which is a substantially higher prevalence than that reported in epidemiological surveys of nationally representative samples of women. notably, women with disabilities were more likely than women without disability to report emotional abuse from a caregiver or family member and to have experienced all forms of abuse for a longer time period than women without disability. although ptsd was not assessed, women younger than years old with spina bifida ( %), amputation, traumatic brain injury (tbi), or multiple sclerosis (> %) were highly likely to be diagnosed with depression than women with no disability. in light of the extensive histories of potentially traumatic abuse and of depression, it appears that women with physical disabilities-particularly those in early to midlife adulthood with disabilities that involve progressive deterioration or mental or psychological disfiguration-may be at risk for having experienced traumatic interpersonal violence and other forms of abuse and suffering from undetected ptsd. tbi is a special case of physical disability because it involves physical injury that specifically compromises mental functioning. tbi ranges from mild (no more than minutes of unconsciousness and hours of amnesia) to severe (coma of at least hours or amnesia for more than hours). studies with adults and children of both genders who have sustained tbi demonstrate that they are as likely to develop ptsd as persons in equally severe accidents or assaults who have not (mcmillan, williams, & bryant, ) . fewer studies have been conducted with persons with severe than mild tbi, but they have not been found to be less likely to develop ptsd, as was originally hypothesized-due to not being able to experience or later recall the psychologically traumatic aspects of the injury as vividly as a person who does not lose consciousness or have amnesia. a subsequent study confirmed that adults with tbi were less likely to report acute traumatic stress symptoms immediately after the injury and to recall having felt helpless when interviewed several weeks later but that months after the accident, they were equally likely to report ptsd symptoms as injury survivors with no tbi (jones, harvey, & brewin, ) . tbi definitely exacerbates, and indeed may cause, ptsd, as tragically is illustrated by the extremely high estimates of prevalence of ptsd among military veterans of the iraq and afghanistan wars with tbi. thus, ptsd warrants careful assessment when tbi has occurred. concerning developmental disabilities, similarly, only one published study of ptsd could be located (ryan, ) . in that study, adults receiving services for learning disability were more likely than other adults (kessler, sonnega, bromet, & hughes, ) to report exposure to traumatic stressors ( % prevalence, on average two past traumatic events). however, they had no greater risk than adults in the general population when exposed to traumatic stressors. the most frequently reported types of traumatic exposures were multiple experiences of sexual abuse by multiple perpetrators (commonly starting in childhood), physical abuse, or life-threatening neglect. traumatic losses involving a caregiver or close relative or friend (including witnessing the death in several instances (such as witnessing a sibling dying in a fire, a close friend die during a seizure or an accident, or a parent commit suicide by shooting himself in the head with a gun)) were also reported by at least % of the participants. most of the learning-disabled adults who met criteria for ptsd had been referred for treatment for violent or disruptive behavior, typically with no psychiatric diagnosis or a diagnosis of schizophrenia, autism, or intermittent explosive disorder. when ptsd was diagnosed, major depression was a frequent comorbid disorder; yet, neither ptsd nor depression typically had been identified prior to the clinical assessment study. the findings of this study suggest that adults with developmental disorders often have been targets for abuse or neglect in childhood or have sustained severe traumatic losses and that their ptsd and depression tend to go undiagnosed as clinicians make their behavioral difficulties the focus of treatment services (box . ). poverty is an adverse result of having low "social status." this does not mean that a person or group is objectively deficient but rather that he or she is identified socially and politically as either not deserving or not possessing the social mandate to have access to resources such as money, safety, housing, transportation, health care and nutrition, education, and gainful employment. kubiak's ( ) social location theory states that each individual possesses identities within their society that are defined ( ) show the adverse impact of undetected ptsd: "a -year-old girl with a learning disability has suffered early abuse of a physical and sexual nature, including neglect. she presented [for medical evaluation] in early childhood with behavioral problems of aggression. she settled in a residential school from age to before an act of arson. she later revealed that she had experienced inappropriate sexual behaviors with peers at school. she complained of intrusive thoughts and images, along with depressive symptoms. at times she shows sexually inappropriate behavior and self-harm." "a -year-old man with a moderate learning disability who had been sexually assaulted by a care[giver] presented [for medical evaluation] in [an] acute state with disturbance of appetite, sleep, loss of skills, and emotional numbness, but the abuse was revealed only months later. on being exposed to the perpetrator at a later date, he showed a deterioration in mental state with acute symptoms of anxiety, and later developed a depressive disorder requiring medication. his level of functioning never returned to that prior to the traumatic event." a third case illustrates the therapeutic gains that a ptsd perspective can provide: a -year-old woman with learning disabilities and pervasive developmental disorder had been diagnosed at age with schizophrenia and subsequently had been diagnosed with schizoaffective disorder, bipolar disorder, and borderline personality disorder. for years after the first psychiatric diagnosis and hospitalization, she had been psychiatrically hospitalized more than times due to episodes of acute suicidality complicated by auditory command hallucinations (i.e., she believed she was hearing voices telling her to kill herself) and compulsive self-harm behavior (she used sharp objects to cut virtually every area on both arms and legs). treatment included high doses of antipsychotic, antiseizure, antidepressant, and antianxiety medications and two courses of electroconvulsive therapy, with periods of relative stabilization sufficient for her to live in an assisted living residential home and on two occasions to live in an independent apartment with in-home daily case management and nursing care. each period of improvement was relatively brief, lasting no longer than - months, at which time she experienced severe worsening in the apparently psychotic, depressive, and anxiety symptoms, requiring multiple rehospitalizations and progressive loss of social and cognitive abilities. for several years, family therapy was conducted, and the patient's history of traumatic stressors was assessed gradually in order not to lead to further destabilization. in addition to potential episodes of sexual assault as an adolescent and young adult, her mother disclosed that her biological father had been severely domestically violent during the patient's first years of life, until the mother ended that relationship. when ptsd was confirmed and accepted by the treatment team and the patient and her family as the primary diagnosis, the patient felt that she finally understood why she was experiencing the cyclic surges in distress and was able to utilize affect by factors such as their race, socioeconomic class, gender, age, residential status, and legal status. the greater the number of oppressed identities that one possesses, the more likely one will be "poor," including not only low income but also living in neighborhoods plagued with high crime, gang violence, abandoned buildings, drugs, teen pregnancy, high unemployment rate, underfunded schools, housing shortage, food of limited nutritional value, and unresponsive police. thus, poverty fundamentally is a breakdown of the social order as well as a resultant deprivation of resources for some people. the relationship between low income and exposure to psychological trauma and ptsd has been studied primarily in relationship to women and families, including those who currently have stable housing and those who do not. morrell-bellai, goering, and boydell ( ) identify poverty as a core risk factor for homelessness, because the socioeconomic benefits provided by a diminishing societal safety net and the typically insufficient employment wages provided by marginal jobs force people to rely on an increasingly limited pool of subsidized housing or to become homeless. associated risk factors include a lack of education, lack of work skill, physical or mental disability, substance abuse problem, minority status, sole support parent status, or the absence of an economically viable support system (fischer & breakey, ; morrell-bellai et al., ) . snow and anderson ( ) found that the most common reasons for homelessness reported in a survey of men and women living "on the street" were family-related problems such as marital breakup; family caregivers becoming unwilling or unable to care for a mentally ill or substance-abusing family member; escape from a dysfunctional and/or abusive family; or not having a family to turn to for support. poverty and homelessness involve a vicious cycle in which socioeconomic adversities are compounded by the experience of homelessness, leading to psychological disaffiliation, hopelessness, and loss of self-efficacy, and often substance dependence (bentley, ; hopper & baumohl, ; morrell-bellai et al., ) -which thus tends to perpetuate poverty and homelessness. a recent study by frisman, ford, lin, mallon, and chang ( ) reported that % of a sample of very low-income homeless women caring for children had experienced at least one type (and on average, five different types) of psychologically traumatic events, usually repeatedly and over long periods of time, with one in three having experienced full or partial ptsd at regulation skills (taught using dialectic behavior therapy and trauma affect regulation: guide for education and therapy; see chapter ). over the next year, her medications were carefully reduced to the lower therapeutic range for attentional problems and anxiety, with a sustained improvement in mood and social and cognitive functioning such that she was able to successfully work as a skilled volunteer in an assisted living center for older adults. some time in their lives. in addition, ford and frisman ( ) found that one in three of these homeless women with children had experienced a complex variant of ptsd involving problems with dysregulated affect or impulses, dissociation, somatization, and alterations in fundamental beliefs about self, relationships, and the future (i.e., "complex ptsd" or "disorders of extreme stress"; ford, ) . more than half of the sample had a history of either or both ptsd and its complex variant. exposure to violence and other forms of victimization begins in childhood for many homeless individuals, in part due to their exposure and the vulnerability of their living conditions (north, smith, & spitznagel, ) . rates of childhood physical abuse as high as % among homeless adolescents have been reported (maclean, paradise, & cauce, ) , and this figure may be on the low end. extremely poor women, whether homeless or not, have elevated rates of lifetime ptsd or other mental illness, and a history of such disorders is associated with having grown up in family and community environments with violence, threat, and anger (bassuk, dawson, perloff, & weinrub, ; davies-netzley, hurlburt, & hough, ) . however, homelessness per se may confer additional risk: homeless mothers and their children have higher lifetime rates of violent abuse and assault than equally impoverished housed mothers (bassuk et al., ) . thus, poverty puts people at risk for traumatic violence, but not having a stable residence compounds this risk and the likelihood of developing ptsd. victims of political repression, genocide ("ethnic cleansing"), and torture when political power is used to repress free speech and citizens' self-determination, there is an increase in the risk to members of that nation or community and its neighbors and associates of psychological trauma. domestic violence (see box . ) is a microcosm that shares much in common with large-scale political repression, because physical, psychological, and economic power is used to entrap, systematically break down, and coercively control the thoughts as well as the actions and relationships of the victim. on a larger scale, political repression involves similar psychological (and often physical as well) assaults by the people and institutions in power on the people, families, communities, and organizations that are deprived of access to political power and socioeconomic resources-and therefore also on their fundamental freedoms and values. without access to self-determination and the resources necessary to sustain independence, people are vulnerable to not just traumatic exploitation and violence but also to the traumatic loss of their intimate relationships, their families, their way of life, and their values (box . ). genocide (also described as "ethnic cleansing") involves the planned and systematic elimination of an entire collectivity of people, based on discrimination against them. historically, genocide has occurred often when conquering nations not only dominated and subjugated other nations but sought to eradicate their core culture and its leaders and teachers and to kill off or enslave the entire population. examples in the twentieth century include the armenian genocide in turkey, the holocaust box . the lost boys of sudan: complex ptsd in the wake of societal breakdown in the book what is the what?, by dave eggers ( ), valentino achak deng (a fictional character based upon a real person) provides an autobiography that includes his trials and tribulations in his current home in atlanta, georgia, after a traumatic journey of many years as a "lost boy" fleeing from his family's home in a rural village in southern sudan to refugee camps in ethiopia and kenya. valentino graphically describes a relentless series of traumatic experiences that include his village becoming a war zone, the deaths of family and friends, starvation and continual threats of being killed while traveling by foot with thousands of other "lost" children to escape sudan, witnessing brutal acts of violence by children as well as adults (e.g., a boy beating another boy to death in a fight over food rations), and being robbed and beaten unconscious in his own home in atlanta by a predatory african american couple. valentino is a good example of a person who suffers from chronic and complex ptsd, yet is extremely articulate, intelligent, and resourceful. valentino struggles with both unwanted memories and the need to keep his memories so that he ultimately can make sense of what has happened to him: what is the what? by writing his autobiography, he did what the therapy for children or adults with ptsd is intended to do: making sense of, rather than attempting to avoid, memories and reminders of traumatic experiences as a part-albeit horrible or tragic-of one's complete life story (see chapters and ). for example, in trauma-focused cognitive behavior therapy, the therapist helps the child to write (or in other creative ways to depict, such as by drawing pictures; using puppets, dolls, or action figures; or using collage or music) a "story" of what happened to them before, during, and after traumatic experience(s) and to share this "story" with a parent who can help the child with feelings of guilt and fear so that the traumatic memory can be "over" in the child's mind. because valentino was not able to get that kind of help, his autobiography as an adult (the book) is a kind of second attempt to achieve a sense of resolution by telling his story. but we see how this is very difficult to do when current life involves new problems and dangers that interfere with achieving a sense of safety. whether valentino succeeds in achieving some degree of emotional resolution about what he and his loved ones have suffered is an open question. what is clear is that he never stops trying to do so. it also is apparent that valentino's ethnic identification and heritage as an african man from the dinka tribe is very important as a protective factor enabling him to retain a small but significant fragment of his sense of personal identity and his intimate ties to his family and community. he experiences an odyssey as a victim fleeing the scene of horrific trauma, an initially reluctant but eventually drug-induced savage combatant, and a refugee "stranger in a strange land" when he is able to escape to what seems like an entirely different planet in the cosmopolitan urban setting of atlanta and the southern united states. it is the psychological trauma that he experiences on this odyssey, and the chronic stressors and societal breakdown and oppression that led him-and millions of others of all ages and a multiplicity of ethnocultural groups-on this journey of crisis and survival, and not his ethnicity or cultural background that is responsible for the profound symptoms of ptsd that he develops. inflicted on jewish people in europe by the nazis, the "ethnic cleansing" in bosnia and serbo-croatia in the s, and the massacres and mass starvation and epidemics perpetrated in rwanda in , in sudan beginning in , and in somalia, kenya, and zimbabwe most recently. genocide was first used as a term in by raphael lemkin, combining the words genos, from the greek for "race" or "kind," and cidere, which is latin and can be translated as "kill" (brom & kleber, ) . in , the term was adopted by the united nations general assembly and defined by the united nations convention on the prevention and punishment of the crime of genocide (cppcg) as follows: gregory stanton, the president of genocide watch, described " stages of genocide"; http://www.genocidewatch.org/aboutgenocide/ stagesofgenocide.htm. accessed / / : . classification-earliest stage, dividing people into "us" and "them" (the victim group). . symbolization-assigning particular symbols to designate the victim group members. . dehumanization-equating certain people with subhuman animals, vermin, or insects. . organization-militias or special units created for the purpose of genocide. . polarization-broadcasting of propaganda aimed at marginalizing the out-group. . preparation-out-group members are physically separated or confined in a "ghetto." . extermination-murder, starvation, infection, or other forms of inflicting pain and death. . denial-refusal to accept responsibility or admit wrongdoing, maintaining the self-righteous position that the victim group deserved annihilation and were subhuman. these stages are approximate and vary in each separate incident, but they demonstrate how genocide differs from other forms of even very horrific violence (such as war) because the aim is not simply to subdue, harm, or exploit but to dehumanize, exterminate, and annihilate. genocide thus involves several traumatic features, including loss of self-worth and allegiance to core values and institutions; prolonged pain and suffering; bereavement; terror and horror of annihilation; injury; helplessness while witnessing demeaning, cruel, and violent events; and confinement. survival responses to genocide are described by brom and kleber ( ) as: … a narrowing of functioning and awareness in order to maximize the chances of survival [often involving] psychic closing off (also called robotization-that is, acting and feeling emotionally and mentally empty or on "automatic pilot" like a "robot"), [and] regression-that is, feeling, thinking, and acting like a child (or in the case of children, like a much younger age than actual chronological age). often victims also experience a strong dependence on perpetrators who decide on life and death. the "muselman effect" … manifested by complete physical decrepitude, apathy, slowing of movement, and gradual disintegration of personality (including loss of the capacity for rational reasoning) may result when individuals have been exposed to long-term and extreme circumstances. an additional phenomenon that is well documented is the so-called "death imprint" resulting when substantial witnessing of death continues to haunt the survivor. these reactions closely parallel the symptoms of both asd (such as dissociation and regression) and ptsd (such as intrusive reexperiencing and emotional numbing). the adverse long-term effects of experiencing genocide are severe and pervasive. more than one in three survivors become clinically depressed and develop ptsd. the social support of caring family members (and for children, parents, or other caregivers) and relationships and activities that individuals to retain their spiritual or religious beliefs and their sense of self-respect are crucial protective factors against ptsd and depression. however, even the most resilient and socially supported person is likely to experience distressing memories and survivor guilt years or even decades later. studies with elderly holocaust survivors who are physically and emotionally very hardy (often well into their s and s) have documented significant persisting emotional distress and ptsd symptoms or more years later (brom & kleber, ) . moreover, the offspring of holocaust survivors with ptsd are more likely than offspring whose parents do not have ptsd to themselves experience ptsd as adults (yehuda et al., (yehuda et al., , . genocide often involves physical hardships that compromise physical health and may lead to long-term illnesses and depletion of the body's immune system. for example, the physical exertion and pain involved in torture, untreated physical illnesses, insufficient sleep, starvation, exposure to extreme temperatures, and forced labor may accelerate the aging process (brom & kleber, ) . genocide also often includes separating individuals from their families and community groups. this not only deprives the survivor of crucial social support but engenders a sense of isolation, distrust, and shame and of being permanently psychologically damaged (herman, ) . survivors also are faced with a choice of holding to their allegiance to their family, nation, culture, and racial identity, despite the punishment inflicted by the perpetrators, or abandoning these basic commitments and rejecting themselves and people like them. faced with this impossible choice (as epitomized in william styron's classic novel, sophie's choice), survivors often believe that they failed utterly and let down not only themselves but their family and culture no matter how resiliently they coped and the integrity of their efforts. survivor guilt is an expression of a sense of grief, powerlessness, and failure, including questioning why they survived and others did not. torture. torture is a terrible special case of political repression that involves "malicious intent and a total disregard for the recipient's dignity and humanity. thus, torture is among the most egregious violations of a person's fundamental right to personal integrity and a pathological form of human interaction" (quiroga & jaranson, ) . the united nations (un) office of high commissioner for human rights established a "convention against torture and other cruel, inhuman or degrading treatment or punishment (cat)," which has been endorsed by nations and defines torture as follows: for the purpose of this convention, the term "torture" means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purpose as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed, or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by, or at the instigation of, or with the consent or acquiescence of, a public official or other person acting in an official capacity. it does not include pain or suffering arising only from, inherent in, or incidental to lawful sanctions. (http://www.unhchr.ch/html/menu /b/h_cat .htm accessed / / ) an amnesty international worldwide survey found that % of countries practice torture systematically, despite the absolute prohibition of torture and cruel and inhuman treatment under international law. torture may be euphemistically referred to as "enhanced interrogation techniques" and condoned in order to obtain "intelligence" from designated enemies of the nation, although this is completely prohibited by the un resolution (quiroga & jaranson, ) . widespread controversy has attended the use of such techniques by the us central intelligence agency in response to the september , , terrorism incidents, controversy that peaked in with the presidential decision to close the guantanamo bay military prison, and the release of the us senate report revealing and questioning the legality and morality of torture tactics used in interrogation and incarceration. basoglu, livanou, and crnobaric ( ) , in a sample from the balkan war ( - ) studied from to , showed that the torture need not inflict physical pain in order to produce ptsd. psychological assessment of torture survivors was systematized by the istanbul protocol, a manual on the effective investigation and documentation of torture and other cruel, inhumane, or degrading treatment or punishment that includes modules for medical, psychological, and legal professionals united nations resolution / on december , (quiroga & jaranson, ) . the psychological problems most often reported by torture survivors are emotional symptoms (anxiety, depression, irritability/aggressiveness, emotional liability, self-isolation, alienation from others, withdrawal); cognitive symptoms (confusion/disorientation, memory and concentration impairments); and neuro-vegetative symptoms (lack of energy and stamina, insomnia, nightmares, sexual dysfunction) (quiroga & jaranson, ) . the most frequent psychiatric diagnoses are ptsd and major depression, other anxiety disorders such as panic disorder and generalized anxiety disorder, and substance use disorders. longer-term effects include changes in personality or worldview, consistent with complex ptsd (quiroga & jaranson, ) . the greater the degree of distress and loss of sense of control during torture, the greater the likelihood of ptsd and depression. resilience, through being able maintain a sense of personal control, efficacy, and hope while enduring torture, is associated with less distress during torture and lower risk of ptsd (quiroga & jaranson, ) . social, cultural, and other diversity issues in the traumatic stress field however, quiroga and jaranson ( ) cited a study by olsen showing that years after torture, physical pain was still prevalent even if torture was primarily psychological in nature. based on this finding and related studies, they conclude the following (p. ): the most important physical consequence of torture is chronic, long-lasting pain experienced in multiple areas of the body. all [physical] torture victims show some acute injuries, sometimes temporary, such as bruises, hematomas, lacerations, cuts, burns, and fractures of teeth or bones, if examined soon after the torture episode. permanent lesions, such as skin scars on different parts of the body, have been found in % to % of torture victims. … falanga, beating the sole of the feet with a wooden or metallic baton, has been studied extensively. survivors complain of chronic pain, a burning sensation. … acute renal failure secondary to rhabdomyolysis, or destruction of skeletal muscle, is a possible consequence of severe beating involving damage to muscle tissue. this condition can be fatal without hemodialysis. … a severe traumatic brain injury that is caused by a blow or jolt to the head or a penetrating head injury may disrupt the function of the brain by causing a fracture of the skull, brain hemorrhage, brain edema, seizures, and dementia. the effects of less severe brain injury have not been well studied. treatment for torture survivors must be multidisciplinary and involves a long-term approach. several treatment modalities have been developed, but little consensus exists concerning the standard of practice, and treatment effectiveness has not been scientifically validated by treatment outcome studies (quiroga & jaranson, ) . a key element that is widely agreed upon is to pay careful attention to not inadvertently replicating in benign ways aspects of torture in the treatment (such as by pressing a survivor to recount traumatic memories without the survivor's informed and voluntary consent; by encouraging or discouraging political, family, and social activities except as initiated by the survivor; or by behaving in authoritarian ways rather than seeking to be collaborative with the survivor). it also is best to use medical, psychiatric medication, and psychotherapy modalities to address the ptsd symptoms of impaired sleep, nightmares, hyperarousal, startle reactions, and irritability. quiroga and jaranson ( ) also recommend using groups for socializing and supportive activities to reestablish a sense of family and cultural values, and supporting the traditional religious and cultural beliefs of the survivor. currently, nearly torture survivor treatment centers exist worldwide, of them accredited by the international rehabilitation council of torture victims (quiroga & jaranson, ) . most of these centers also involve the survivors' families and communities in developing shared approaches to recovery and reparation of the harm done to all. the controversy concerning the use of torture on detainees in the so-called "war on terror" has led to deep concern on the part of not only the public at large but specifically by mental health professionals. the issue is that psychiatry and psychology professionals who are in the military or consult to the military have been involved in the detention and interrogation of suspected terrorists at high-security facilities such as the military base at guantanamo bay and the military prison in iraq, abu ghraib. as a result, guidelines for mental health professionals working in these or similar facilities in which prolonged detention and interrogation may involve practices that constitute torture have been developed by a special committee of the american psychological association's division ( ) on trauma psychology (box . ). the apa council of representatives … included in its "unequivocal condemnation" all techniques considered torture or cruel, inhuman or degrading treatment or punishment under the united nations convention against torture and other cruel, inhuman, or degrading treatment or punishment; the geneva conventions; the principles of medical ethics relevant to the role of health personnel, particularly physicians, in the protection of prisoners and detainees against torture and other cruel, inhuman, or degrading treatment or punishment; the basic principles for the treatment of prisoners, the mccain amendment, the united nations principles on the effective investigation and documentation of torture and other cruel, inhuman, or degrading treatment or punishment an "absolute prohibition against mock executions; waterboarding or any other form of simulated drowning or suffocation; sexual humiliation; rape; cultural or religious humiliation; exploitation of fears, phobias, or psychopathology; induced hypothermia; the use of psychotropic drugs or mind-altering substances; hooding; forced nakedness; stress positions; the use of dogs to threaten or intimidate; physical assault, including slapping or shaking; exposure to extreme heat or cold; threats of harm or death; isolation; sensory deprivation and overstimulation; sleep deprivation; or the threat [of these] to an individual or to members of an individual's family. psychologists are absolutely prohibited from knowingly planning, designing, participating in, or assisting in the use of all condemned techniques at any time and may not enlist others to employ these techniques. we have come to the conclusion that the united states' harsh interrogationdetention program is potentially trauma-inducing both in general (e.g., indefinite detention, little contact with lawyers, no contact with relatives or significant others, prolonged absence of due process, awareness that other prisoners have been tortured, lack of predictability or control regarding potential threats to survival or bodily integrity) and in terms of some of its specific components (e.g., prolonged isolation, waterboarding, humiliation, painful stress positions). in other words, these potentials for trauma extend beyond the narrow procedures that meet international definitions of torture. the evidence for risk of psychological trauma to detained enemy combatants is particularly compelling and well grounded in formal research, but there is also suggestive anecdotal and theoretical evidence of trauma induction in interrogators and the broader society. we were particularly struck by the fact that the potentially traumatic elements include not only activities designed to extract information from prisoners but also much of the detention process as it is currently conceived, beyond much oversight, or compliance with international law. given the pervasiveness of these traumatogenic elements, it is questionable whether psychologists can function in these settings without participating in, or being adversely affected by, heightened risk for trauma. nonetheless, as a group of psychologists with expertise in preventing traumatic stress and ameliorating debilitating posttraumatic sequelae, we believe that certain steps could … minimize the risk of psychological trauma. they are as follows: . we believe that the risk of traumatic stress and negative posttraumatic sequelae will be reduced if psychologists adhere to both the apa ethical standards and subsequent refinements of apa policies pertaining to interrogation, detention, and torture. such adherence would be more likely if the apa ethics code were revised to incorporate, as enforceable standards, the specific interrogation and torture-related policy refinements that have occurred since . psychologists should promote situations that maintain the risk of traumatic stress at acceptably low levels and avoid situations that heighten the risk for traumatic stress occurring. among other things, this means that psychologists should not provide professional services in secret prisons that appear to be beyond the reach of normal standards of international law or in settings in which torture and other human rights abuses have been credibly documented to be permitted on the basis of local laws. it also suggests that psychologists should not support or participate in any detention or interrogation procedure that constitutes cruel or inhumane treatment or that otherwise has been shown to elevate risk of traumatic stress (e.g., prolonged isolation). . if psychologists work in settings in which detention and interrogations are conducted, then they should conduct or seek an assessment of the potential traumatic features of the treatment of detainees before, during, and after interrogation. this assessment can be informal or formal, depending on whether other systems of oversight are in place. this assessment should include an examination of the social psychological factors that could elevate risk of trauma. because not all psychologists have expertise in assessing traumatic stress risk and/or social psychological (continued ) factors, the assessment should be conducted by psychologists who have this specific expertise. such assessments could inform decisions not only by psychologists but also by others working in facilities in which detention and interrogation occur. it is recommended therefore that apa advocate for appropriate governmental authorities to appoint an independent oversight committee for each facility of this type and that the oversight committees include psychologists identified by apa as having relevant expertise. . if psychologists work in settings in which risk of traumatic stress is found to be elevated then they should (i) formally recommend alterations that could reduce the traumatogenic potential of the detention and interrogation process (n.b. some recommendations may be aimed at policy makers rather than local authorities); (ii) conduct or seek an assessment of posttraumatic stress symptoms and associated features (e.g., depression, dissociation) in detainees, interrogators, and other directly or indirectly involved staff; (iii) recommend appropriate psychological interventions for any detainees or personnel found to be suffering from clinically significant psychological difficulties; and (iv) refuse to participate in any activities that significantly increase risk of traumatic stress. if a psychologist working in such settings does not have specific expertise required to meet some of the above recommendations, then she or he should consult with psychologist(s) who have this expertise to make the appropriate determination. . because some detainee abuses have been credibly linked to an absence of appropriate training and/or expertise, psychologists should advocate for, participate in designing, and/or assist with providing appropriate and comprehensive training to all personnel involved in interacting with detainees. this training should include (i) clear ethical guidelines emphasizing the prohibition of causing harm and the importance of protecting detainee rights, (ii) a research-based overview of the nature and consequences of traumatic stress and posttraumatic impairment as they relate to the interrogation and confinement process and all parties involved in layperson terms with practical implications, and (iii) detailed review of research on false confessions, in layperson terms, with practical implications for enhancing the validity and utility of information gathered in the course of interrogation and detention. because not all psychologists have expertise in these specific matters, apa should develop standardized training materials that cover the current state of psychological knowledge and practices on these important topics, and ensure that these materials are regularly updated by qualified psychologists in consultation with experts from other fields such as law enforcement, the military, and human rights. . because protecting human rights reduces the risk for traumatic stress and posttraumatic impairment, psychologists should collaborate with legal, military, and other colleagues to advocate for due process for all detainees, including providing clear guidelines about finite lengths of detention prior to formal hearing or trial and enforcing the recent supreme court decision to reinstate habeas corpus and other international standards of human rights. psychologists' support for these actions should not come from a blanket support for adherence to law but rather from an informed judgment that these … laws reduce the risk for harm. psychologists should be prepared to disagree with any future international laws or us supreme court decisions that heighten risk for traumatic stress. box . continued . psychologists should support increased transparency during the detention and interrogation process. such increased transparency could reduce the likelihood of traumatizing practices, increase the likelihood that traumatizing practices will be identified and stopped as early as possible, and protect ethical psychologists and other workers within the system from being falsely accused of acting unethically. we recognize that this recommendation raises an apparent conflict with the goal of secrecy commonly endorsed by national security organizations. we concur that full transparency is unreasonable and counterproductive. yet, we do believe that increased transparency is a safeguard against traumatizing practices. though the details of resolving this conflict are beyond the scope of this task force's expertise, we believe that reasonable, knowledgeable intelligence experts, in consultation with psychologists, can construct a system of oversight that will both retain credible independence from the military chain of command and guard classified information. one suggestion may be to establish a greater presence of psychological expertise within a framework of oversight protection. . if psychologists are going to continue to be involved in interrogations, then it will be important to continue to segregate the function of interrogation consultant from that of mental health provider to reduce risk of perceived or actual betrayal by the detainee. it is unknown whether betrayal of trust due to dual roles can constitute a direct form of traumatization under these circumstances, but it is likely that betrayal in this context could exacerbate traumatic stress that occurs of other aspects of detention and interrogation (especially in light of the ways that such detention appears to disrupt attachment as outlined in the body of our report). maintaining separate roles also may enable the psychologist to more effectively assist detainees with traumatic stress reactions by fostering a trusting therapeutic relationship. . psychologists should advocate for extra protections for detainees who are from vulnerable populations such as minors, ethnic minorities, or other groups that have limited access to socioeconomic or political resources or are potentially subject to societal discrimination or prejudice because such groups may be more likely to receive coercive interrogations and/or excessive force and less likely to be sympathetically viewed by the general public. for this purpose, psychologists may work within sponsor/authorizing organizations to institute developmental, gender, and culture sensitivity trainings for interrogators and should review evidence concerning the impact of different forms of traumatic stressors and differential sensitivity to the interrogation/detention setting/process on different (and particularly vulnerable) ages, genders, and cultural backgrounds. such psychologists should, to whatever extent possible, guard against such information being used to exploit vulnerable populations and instead emphasize ways to enhance safety and psychological wellbeing in the interrogation process. if psychologists lack relevant expertise to meet the recommendations, … they should seek or advocate for outside expert consultation. . psychologists should collaborate with colleagues from a variety of professions and organizations, including the military and intelligence organizations, to conduct ethical research on several aspects of the detention and interrogation process, especially its potential for inducing trauma. recent reviews suggest that most of the interrogation procedures used today have not received recent rigorous study (intelligence science board, ) . furthermore, very little of the recent study has been directed toward understanding the psychological effects of interrogation on not only the detainees but also the people working within and outside the interrogation and detention system. political violence not only leads to traumatic harm to people while they are living in their communities but also often when victims are forced to flee their homes either to another country or while remaining within their country. refugees are defined by the united nations high commissioner for refugees (unhcr) as persons who have left their nation of origin to escape violence. article one of the united nations convention relating to the status of refugees defines a refugee as someone who "owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it" (unhcr, p. ; http:// www.unhcr.org/home/publ/ b e ea .pdf; accessed . . ). therefore, refugees are distinct from both legal and illegal immigrants, economic migrants, environmental migrants, and labor migrants (weine, ) . refugees must involuntarily leave home, community, and family and friends, often with limited resources or preparation and usually without knowing whom they can trust and where they can find safe passage and a safe haven. thus, both prior to and during the displacement, refugees often suffer psychologically traumatic experiences, including having their community or homes attacked or destroyed due to war; racially, genderbased, or ethnically targeted genocide or terrorism; institutionally orchestrated deprivation and violence; along with torture, atrocities, rape, witnessing violence, fear for their lives, hunger, lack of adequate shelter, separation from loved ones, and destruction and loss of property (weine, ) . estimating the number of refugees is very difficult. a minimum estimate that is probably much lower than the actual number is calculated by the united nations based on the number of persons in resettlement camps or individually recognized by a host country. based on this definition, there were million refugees worldwide in (www.unhcr.org) (figure . ). in côte d'ivoire, and was quickly followed by others in libya, somalia, sudan, and elsewhere. in all, . million people were newly displaced, with a full , of these fleeing their countries and becoming refugees. " saw suffering on an epic scale. for so many lives to have been thrown into turmoil over so short a space of time means enormous personal cost for all who were affected," said the unhcr antónio guterres. "we can be grateful only that the international system for protecting such people held firm for the most part and that borders stayed open. these are testing times." worldwide, . million people ended either as refugees ( . million), internally displaced ( . million), or in the process of seeking asylum ( , ). despite the high number of new refugees, the overall figure was lower than the total of . million people, due mainly to the offsetting effect of large numbers of idps returning home: . million, the highest rate of returns of idps in more than a decade. among refugees, and notwithstanding an increase in voluntary repatriation over levels, was the third lowest year for returns ( , ) in a decade. viewed on a -year basis, the report shows several worrying trends. one is that forced displacement is affecting larger numbers of people globally, with the annual level exceeding million people for each of the last years. another is that a person who becomes a refugee is likely to remain one for many years-often stuck in a camp or living precariously in an urban location. of the . million refugees under unhcr's mandate, almost three-quarters ( . million) have been in exile for at least years awaiting a solution. overall, afghanistan remains the biggest producer of refugees ( . million), followed by iraq ( . million), somalia ( . million), sudan ( , ), and the democratic republic of the congo ( , ) . around four-fifths of the world's refugees flee to their neighboring countries, reflected in the large refugee populations seen, for example, in pakistan ( . million people), iran ( , ) , kenya ( , ), and chad ( , many people displaced from their communities by violence remain in their home country. they are not considered refugees, but "idps": "people or groups … who have been forced to leave their homes" due to "armed conflict, situations of generalized violence, violations of human rights, or natural-or human-made disasters, and who have not crossed an international border" (www.unhcr.org). as of , there were more than three times as many idps as refugees, an estimated million worldwide, million social, cultural, and other diversity issues in the traumatic stress field due to armed conflict and million due to mass natural disasters (www.unhcr.org). between one and more than million idps were known to be in several countries in , including colombia, congo, iraq, somalia, sudan, and uganda. azerbaijan, cote due n'orde, and sri lanka had more than , known idps each. at least another million persons are considered "stateless"-that is, to not be citizens of any nation, in . nepal and bangladesh have the majority of the stateless persons in the world, although nearly million persons in those two countries were made citizens in . palestine and iraq are the other countries with large numbers of stateless persons. there may be millions more stateless individuals, because only countries assisted the united nations in its census of stateless persons in (www.unhcr.org). the impact of forced displacement often is not just extremely stressful but traumatic. refugees, idps, and stateless persons have few protections and often must live in confined camps or crowded public shelters, where they are vulnerable to assaults (including rape), robbery, and illness. many have witnessed horrific violence associated with wars, genocide, or other forms of mass armed conflict that caused them to flee. loss of family and friends due to violence or illness is common, as well as due to being separated with no way to communicate. studies have documented high prevalence levels of ptsd and depression among refugees or idps from armed conflicts in central america, southeast asia, the middle east, and the balkans (fazel, wheeler, & danesh, ; marshall, schell, elliott, berthold, & chun, ) at least times higher than the - % prevalence estimates from epidemiological surveys (see chapter ). ptsd prevalence estimates that are more than three times higher than these very high levels, as high as - %, have been reported among disabled central american refugees (rivera, mari, andreoli, quintana, & ferraz, ) and among afghan mothers (seino, takano, mashal, hemat, & nakamura, ) . other studies have more specifically investigated physical displacement in the traumatic stress experienced by refugees. displacement may involve many stressors, and a research review found that "living in institutional accommodation, experiencing restricted economic opportunity, [being] displaced internally within their own country [or] repatriated to a country they had previously fled or whose initiating conflict was unresolved" were particularly problematic. this review of reports involving , participants ( , refugees and , persons who were not displaced) showed that displacement alone was associated with more severe mental health problems, including ptsd (porter & haslam, ) . in contrast to most research findings on the etiology (see chapter ) and epidemiology (see chapter ) of ptsd, "refugees who were older, more educated, and female and who had higher predisplacement socioeconomic status and rural residence also had worse outcomes" (porter & haslam, , p. ) . people become "internally displaced" as often due to mass natural disasters as to armed violence. in the united states, several hundred thousand people had to leave the new orleans area following hurricane katrina in august . almost , received medical care at american red cross shelters within the next month (mills, edmondson, & park, ) . many displaced persons already were severely disadvantaged due to living in poverty (roughly % of the population of new orleans), having limited access to quality health care, and exposure to community violence (mills et al., ) . in a study of adult evacuees from new orleans and surrounding parishes ( % men, average age years old, % black, % low income (annual income less than $ , ), % reporting a prehurricane psychiatric disorder ( % depression, % anxiety disorder, % bipolar disorder)), most ( %) waited several days to be evacuated, and a majority reported sustaining minor to severe injuries ( %) and mild to severe illness ( %) in the hurricane or evacuation process. one in seven lost a loved one due to death in the hurricane or its aftermath, and most ( %) were separated from a family member for a day or more. many ( %) lost their home, two-thirds of whom were without property insurance. almost two in three ( %), particularly women, people with a prior psychiatric disorder, and those who recalled feeling their lives were in danger during the hurricane or its aftermath, were injured physically, or felt they had limited control over their current life circumstances, reported symptoms sufficient to qualify for a diagnosis of asd. natural disasters of several magnitudes greater have occurred in less developed and affluent areas of the world. for example, the tsunami that struck on december , , in the wake of the sumatra-andaman earthquake killed an estimated , people along the coastlines of the indian ocean, including , indonesians. another half a million indonesians were displaced from their communities. studies of survivors of this tsunami from indonesian areas such as aceh and north sumatra (frankenberg et al., ) , as well as from thailand (van griensven et al., ) and sri lanka (hollifield et al., ) , have demonstrated that posttraumatic stress, anxiety, and depression are suffered by hundreds of thousands, and perhaps millions, of people who experienced psychological trauma due to the tsunami (box . ). box . refugee posttraumatic stress in the wake of mass natural disaster frankenberg et al. ( ) reported a unique study of the impact of a massive natural disaster: the indian ocean tsunami that struck the day after christmas . unlike most research on mental health after disasters, this study began with a survey of a representative sample of persons in the host country (indonesia) almost years before the disaster. this "national socioeconomic survey (susenas)" provided a registry of respondents and predisaster data on health and socioeconomic characteristics of people throughout indonesia. the "study of the tsunami aftermath and recovery (star)" attempted to recontact , persons interviewed in communities by the susenas. the study also was able to determine the extent of damage caused to each community by the tsunami. the researchers got data from the national aeronautics and space administration's moderate resolution imaging spectroradiometer sensor collected year prior to the tsunami, and again immediately after the tsunami, to assess the degree to which the pretsunami ground cover visible in the first image had been replaced by bare earth in the second image. communities with at least % loss of ground cover were classified as heavily damaged ( % of the surveyed communities). those with some loss of ground cover were categorized as moderately damaged ( % of all locales), and % with no loss of ground cover were classified as undamaged by the tsunami. community leaders' and field observers' estimates of damage strongly correlated (r= . and . ) with these satellite-based estimates. one in three of the survey respondents (average age years old) heard the tsunami wave or people screaming. fewer sustained injuries ( %), lost a spouse ( %), lost a parent or child ( %), or witnessed family or friends "struggle or disappear" ( %), but % lost a family member or friend, % lost their home, and % lost their farming land, livestock, or equipment. posttraumatic stress was assessed by asking every respondent years or older to answer seven of the items from the ptsd checklist (see chapter ), as follows: since the tsunami, have you ever experienced (never, rarely, sometimes, or exposure to probable traumatic stress due to hearing the wave or screams, being injured, or seeing friends or family members "struggle or disappear," doubled the severity of pcl-c scores. consistent with this finding, compared to the sleep difficulties reported before the tsunami, after the tsunami, there was a large increase in the likelihood of sleep difficulties only in the most heavily damaged areas. pcl-c scores increased the most in the worst damaged locales, followed by the moderately damaged ones, with little change in the nondamaged communities. pcl-c scores averaged . , . , and . for the heavily, moderately, and undamaged areas, respectively, at the time of the interview and had been % higher at their peak after the tsunami (based on respondents' recollections). this is consistent with other studies that have reported persistent ptsd symptoms among the worst exposed persons but a substantial decline in ptsd symptom severity over time even among heavily exposed persons (see chapter ). women reported higher pcl-c scores than men, but primarily only in the heavily damaged areas. age was a factor in all communities: persons younger than years reporting an increase after the tsunami and persons years and older reporting lower pcl-c scores after the tsunami. interestingly, respondents who had a parent alive before the tsunami had lower pcl-c scores after the tsunami, but marital status, education, and income were not related to posttsunami pcl-c scores. property damage also correlated with posttsunami pcl-c scores. (continued ) as frankenberg et al. ( ) noted, these findings probably understate the severity and widespread nature of the harm, including posttraumatic stress, caused by a massive disaster such as this tsunami. however, the study provides the strongest evidence to date that a disaster that is not only life threatening for many but that displaces tens or hundreds of thousands of persons from their homes, families, neighbors, and way of life has the strongest adverse impact on communities that are most directly affected. another study (van griensven et al., ) conducted weeks after the tsunami in six southwestern provinces of thailand (where more than persons died or were unaccounted for and another were injured) included random samples of displaced persons and nondisplaced persons from the most heavily hit area and persons from less damaged areas. even though the extent of death and destruction was less in the worst-hit areas of thailand than in indonesia, symptoms of ptsd were reported by % of displaced and % of nondisplaced persons in the most damaged area of thailand (and by % in the less damaged areas). anxiety or depression symptoms were reported by three times as many persons, with similar proportions depending on displacement and the severity of damage to the community. thus, this study adds to the findings of the study from indonesia by demonstrating that displacement from home and community was a factor in ptsd and related symptoms soon after a mass natural disaster. the thailand study also resurveyed participants from the worst-damaged area months later ( months after the tsunami) and confirmed that displaced persons continued to be more likely than nondisplaced persons to suffer from ptsd, anxiety, and depression symptoms. consistent with other studies (ford, adams, & dailey, ) of postdisaster recovery (including the indonesia study), as the first anniversary of the disaster approached, about % of each group had recovered sufficiently to no longer report severe symptoms. whereas the indonesia study examined the extent of damage to participants' homes and (for most) the source of their incomes (farmland, animals, and equipment), the thailand study inquired directly as to whether respondents had lost their source of income and found that loss of livelihood was the strongest correlate of ptsd, anxiety, and depression symptoms. thus, the thailand study showed that losing not only home or community but also one's ability to generate an independent income through gainful work may contribute to the development and persistence of ptsd and related anxiety and depression symptoms. the defining characteristics of becoming a refugee in the wake of disaster therefore include (i) exposure to life-threatening catastrophe; (ii) loss of or separation from family and friends, (iii) loss of home and community; and (iv) loss of one's personal or family livelihood. each of these factors may result in acute posttraumatic distress, and the combination of several places people at risk for persistent ptsd. as weine ( ) describes, resettlement of refugees is a substantial challenge not only for displaced persons themselves but also for the host country. relatively stable and affluent countries in asia (such as pakistan, due to afghan refugees), the middle east (such as lebanon and syria, due to palestinian refugees), and africa (such as kenya and south africa), as well as most european and british commonwealth nations and the united states, have had a large influx of refugees. the half of all refugees who are resettled in cities experience economic pressures due to poverty and low-wage work and must live in communities that are crowded, segregated economically and culturally, and often adversely affected by crime, gangs, drugs, aids, and troubled schools (weine, ) . another half of all refugees are resettled in suburban and rural areas, which are more isolated (www.unhcr.org). in either case, refugees often face prolonged separations from family, friends, and loved ones, as well as the burden of having to find a way to subsist while saving money to bring others to their new home and to provide support to those back home who have stayed behind. refugee children have additional needs and challenges, including having to survive life-threatening experiences without adult help or guidance and then, if they are fortunate enough to be permanently resettled, having to return to being a "child" with a new family, community, and culture (henderson, ) . refugee children often display not only the symptoms of ptsd but also behavior problems (such as control, aggression, or defiance of authority), profound bereavement, and developmental, learning, or educational delays or deficits that are understandable in light of their often chronic deprivations before and during displacement. however, children also can be particularly resilient in the face of the psychological losses and traumas of being a refugee, and often they are a key source of hope for their families in the resettlement process (weine, ) . many refugees have opportunities to receive mental health services, either in the context of a refugee camp or after resettlement, but many do not seek or utilize these services. survival; getting stable and predictable access to food, money, housing, transportation, and safety; renewing communication with friends and family; and sustaining or regaining connection to cultural and religious traditions, values, and practices may take precedence over mental health treatment (and may in fact be the best form of therapy for many, under the circumstances). in resettlement settings, clinical treatment for refugee trauma is typically organized through refugee mental health clinics or specialized torture victim treatment centers, with services including crisis intervention, psychopharmacology, individual psychotherapy, group psychotherapy, and self-help groups and activities (weine, ) . to deliver culturally appropriate services, many programs involve traditional healers, socialization or mutual support groups, multifamily groups, and culturally based activities (weine, ) . services also tend to be provided by staff who themselves are members of the refugees' ethnic community, in collaboration with traumatic stress specialists and mental health professionals. the traditional model of western professional "expert" doctor or consultant who unilaterally tells local staff or clients how best to do assessment, diagnosis, or treatment has been justly criticized as culturally insensitive and potentially harmful rather than helpful (weine, ) . instead, the joint experience and expertise of the refugee client, local professional and paraprofessional alike, traditional healers, and traumatic stress professionals are taken together in a team approach that validates the client's and local helpers' cultures and traditions. this approach enhances the providers' ability to make a true cross-cultural assessment of symptoms and diagnoses, to adapt interventions to reflect different cultural beliefs and practices, and to engage not just individual clients but families and communities in recovery from ptsd. such an approach is consistent with new theoretical views of refugee traumatic stress, which include "the concepts of cultural bereavement, cultural trauma, family consequences of refugee trauma, community trauma, and social suffering" (weine, ) . this more culturally grounded view of refugees' experiences of traumatic stress and recovery from ptsd has led to the development of innovative therapy approaches (such as incorporating personal testimony and reconciliation into treatment) that address refugees' psychological vulnerabilities but strongly acknowledge their (and their families' and communities') hopes and strengths (weine, ) . when mass catastrophes, whether human-made or "acts of god" in origin, including natural disasters such as tsunamis, tornadoes, hurricanes, floods, or earthquakes, or public health emergencies, such as aids, severe acute respiratory syndrome (sars), pandemic influenza, ebola, or human-made disasters such as terrorist attacks, airline crashes, ferry capsizes, and train derailments, cause tens or hundreds of thousands or even millions of people and families to experience psychological trauma, the resultant suffering and needs are generally beyond the capacities of traditional mental health services and other forms of government-sponsored services. ngos play a critical role supporting and assisting persons and communities affected by catastrophic disaster or violence, including providing psychological support through clinical and nonclinical behavioral health services (hamilton & dodgen, ) . ngo responses to the mental health needs of mass-disaster survivors are based on the core belief that "all disasters are local" (hamilton & dodgen, ) . this means that local responders such as law enforcement, police, emergency medical teams, and professionals from the health care facilities, schools, and government are invariably first on the scene and frequently remain involved for months or years afterward. when insufficient resources are available, a local community may request help from the country, state, or provincial governments, which in turn may request regional or national assistance from both government and private sectors. for that reason, ngos that provide assistance following disasters, such as the american red cross, the national voluntary organizations active in disaster (nvoad), the united way, and the salvation army do so through their local chapters, which organize the initial relief efforts to provide shelter, food, legal aid, health and mental health care, and humanitarian assistance. organized in , nvoad is the umbrella organization coordinating all disaster relief services provided by volunteer organizations such as the american red cross throughout the united states. ngos also work closely with faith-based organizations (fbos) in the united states (such as catholic charities united states, church world service, lutheran disaster response, national association of jewish chaplains) within the national response framework of the federal emergency management agency (fema), which guides the nation's "all-hazards incident response" (hamilton & dodgen, ) . for example, american red cross disaster mental health (dmh) volunteers provide mental health services to people in shelters, while the church of the brethren provides crisis intervention to young children through their disaster child care program (hamilton & dodgen, ) . the american red cross is the most widely recognized ngo providing dmh services in the united states. in , congress chartered the american red cross to "carry on a system of national and international relief in time of peace" to reduce and prevent the suffering caused by national calamities program (hamilton & dodgen, ) . in , the american red cross established a formal dmh services program and began training licensed and certified mental health professionals to volunteer and assist other red cross workers to cope with and recover from the traumatic stress (or "vicarious trauma") of their disaster relief work. initially only licensed psychologists and social workers were permitted to become red cross dmh volunteers, but recently professionals from other disciplines, such as psychiatry and masters-level marriage and family therapy or counseling professions, also have become eligible. the american red cross has set up formal agreements with the american psychiatric association, the american psychological association, the national association of social workers, the american counseling association, and the american association of marriage and family therapy. the agreements provide that in the event of a mass disaster, the red cross will notify each professional associations to put out a call to their memberships for professionals who have completed red cross preparatory training and who can take time out from their ordinary work to serve as dmh volunteers for weeks or more at red cross disaster services sites. the american red cross sets up and oversees family assistance centers for disaster-affected communities, provides crisis and grief counseling through its dmh volunteers, and coordinates with federal agencies such as fema and the national transportation safety board (for airline or mass transportation disasters) to provide child care services and interfaith memorial services. the red cross also works closely with disaster-focused ngos such as the national organization for victim assistance, disaster psychiatry outreach, and the international critical incident stress foundation, inc. (icisf). founded in , the icisf trains mental health professionals, emergency responders, clergy, and chaplains to conduct critical incident stress management (see chapter ) teams to support disaster services personnel. in , the american red cross broadened the scope of dmh services to include assisting disaster-affected persons who are seeking red cross assistance, as well as red cross volunteers. all dmh volunteers now are trained in psychological first aid (see chapter ) so that they will provide mental health services to disaster victims in an appropriately circumscribed manner that is therapeutic without attempting to conduct psychotherapy at a disaster relief site. two other freestanding programs participating in a dmh response are the green cross assistance program, which provides trained traumatology specialists and the association of traumatic stress specialists, an association of mental health professionals and paraprofessionals who assist survivors of psychological trauma (hamilton & dodgen, ) . a number of us ngos also work internationally to provide psychosocial support and traumatic stress counseling to survivors of disasters and mass conflicts. these include the international services of the american red cross, the united methodist committee on relief, church world services, green cross, action aid-the united states, the american refugee committee, the center for victims of torture, and doctors without borders (hamilton & dodgen, ) . the international federation of red cross and red crescent societies also assist many nations' red cross organizations in serving their own and neighboring countries. a analysis by the united states homeland security institute found that fbos and ngos had a significant beneficial impact during and after hurricanes katrina and rita, with mental health and spiritual support among types of services (hamilton & dodgen, ) . the study reported that while fbos and ngos faced significant limitations and challenges in providing services, mental health and spiritual support was one of the three best-applied special practices, particularly services designed to preserve family unity within disaster relief shelters. hamilton and dodgen ( , p. ) describe how ngos can work together to meet critical needs in times of mass crisis, using the september , , terrorist attacks in new york, washington, and pennsylvania, as a case in point: local mental health providers working in mental health settings mobilized quickly, but needs were expected to surpass local capability. the american red cross dispatched dmh providers from local and adjacent communities to provide mental health support and stress reduction assistance. national volunteers recruited from across the country arrived within a few days to augment that mission. concurrently, icisf-trained volunteers, some of whom were already part of military mental health systems, also arrived to provide assistance. other agencies, such as fbos, also organized support for victims. in washington, the military was the gatekeeper for volunteers and worked closely with the american red cross to coordinate mental health support. in new york, civilian authorities collaborated with the american red cross. as family assistance centers were set up to aid grieving families, national dmh volunteers continued providing mental health support. because the terrorist attacks created a crime scene, access was controlled and ngos needed official standing to provide assistance. incorporating lessons learned from / , a similar event today would be different in several ways: all ngos and government agencies would organize their response under the national incident management system (nims) and the nrf, thus creating a more centralized, coordinated response and reducing overlapping or competing activities on the part of nvoads. because of ongoing coordination and outreach efforts since / , a greater array of disciplines and specific types of expertise would be available through ngos. the benefits of these efforts were seen during the responses to hurricanes katrina and rita in . personal and community characteristics that reflect ethnocultural, national, gender, age, and disability factors are crucial in defining the identity of every human being. when traumatic stress occurs in a person's or community's life, its impact is influenced by these identity factors. when identity is used as a basis for stigma, discrimination, or socioeconomic disadvantage, those stressors compound the effect of traumatic stressors and can be traumatic in and of themselves. by addressing the vulnerability that this combination in a scientifically and clinically responsible manner (alcantara, casement, & lewis-fernandez, ; c'de baca, castillo, & qualls, ; ghafoori, barragan, tohidian, & palinkas, ) to assist rather than stigmatize persons and communities (ruglass et al., ) , the traumatic stress professional can play a crucial role in our society's quest for social justice. 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data was collected using a web‐based survey. a total of jordanian nurses ( % females) completed and returned the study questionnaire. results: the majority of nurses ( %) are experiencing asd due to the covid‐ pandemic and thus are at risk for ptsd predisposition. more than one third of nurses ( %) are also suffering significant psychological distress. among our sample, age, asd, and coping self‐efficacy significantly predicted psychological distress. more specifically, younger nurses are more prone to experience psychological distress than older ones. while higher scores on asd showed more resultant psychological distress, coping self‐efficacy was a protective factor. conclusion: given that individuals who suffer from asd are predisposed to ptsd, follow‐up with nurses to screen for ptsd and referral to appropriate psychological services is pivotal. coping self‐efficacy is found to ameliorate the effect of psychological distress on nurses' traumatic experience. such findings warrant intensive efforts from healthcare institutions to provide psychosocial support services for nurses and ongoing efforts to screen them for traumatic and psychological distress symptoms. implications for nursing management: nursing leaders and managers are in the forefront of responding to the unique needs of their workforces during the covid‐ crisis. they need to implement stress‐reduction strategies for nurses through providing consecutive rest days, rotating allocations of complex patients, arranging support services, and being accessible to staff. they also need to ensure nurses’ personal safety through securing and providing personal safety measures and undertake briefings to ensure their staff's physical and mental well‐being, as well as providing referrals to appropriate psychological services. this article is protected by copyright. all rights reserved healthcare workers are limited. one study investigated asd symptoms among emergency medical technicians (emts) and paramedics during combat and found that paramedics had higher asd symptoms than emts, with a prevalence of . % and . %, respectively (lubin et al., ) . asd has been found to result in subsequent psychological distress exemplified in depression, anxiety, and somatization among individuals who are exposed to a traumatic event (e.g., benight & harper, ) . it has been manifested in various trauma-exposed individuals including orthopedic patients (vincent et al., ) ; immigrants (li & anderson, ) ; and war survivors (qouta; punamäki; & sarraj, ) . it has been estimated that approximately one-third of individuals with major trauma suffer persisting significant psychological impact (shih, schell, hambarsoomian, belzberg, &marshall, ) . another factor that was found to play a significant role in psychological distress is the individual's coping self-efficacy (cse) (benight & harper, ) . cse refers to the individual's capability or confidence to cope effectively with stressful or traumatic event (chesney et al., ) . according to bandura's ( ) theory of self-efficacy, self-efficacy is considered a prerequisite for effective coping. it is a self-evaluative process in which individuals appraise their own capability to manage a threatening situation (bandura, ) . cse was found to play an important role in psychological recovery after trauma (bosmans & van der velden, ) . in a meta-analysis conducted on cross-sectional and longitudinal studies, higher levels of cse were associated with lower levels of distress and ptsd symptoms (luszczynska, benight, & cieslak, ) . it was also found that cse reduces immediate and long-term distress levels in various types of trauma including disasters (e.g., benight, cieslak, molton, & johnson, ; bosmans, benight, van der knaap, winkel, & van der velden, ) .coping self-efficacy reduces the individual's stress reaction through positive appraisal of one's capability in coping with the traumatic event and its aftermath (bosmans & van der velden, ) . psychological distress is also affected by the individual's sociodemographic and clinical background; gender, age, income, and the existence of a mental disorder. extensive research in trauma and non-trauma related psychological distress has shown that women report higher psychological distress than men (e.g., hansen & ghafoori, ; jayawardene, agha, lajoie, & torabi, ; matud, bethencourt, & ibanez, ) . both types of research explain that women tend to use ineffective coping strategies and have less social support than men, lending to their experiencing higher psychological distress (matud et al., ; watson & sinha, ) . furthermore, higher stress in women has been linked to women's tendency this article is protected by copyright. all rights reserved to carry out more household responsibilities (e.g., harryson, strandh, & hammarstrom, ) . however, in a study of childhood victimization among college men and women, elliott et al ( ) , did not find statistical gender differences in psychological distress as evaluated by the symptom checklist- -revised (scl- -r). research supports that, compared to younger populations, older individuals employ more adaptive and directive approaches to managing distress, thus contributing to younger people experiencing higher stress (hansen & ghafoori, ; krause, shaw, & cairney, ) . while existing mental disorders intensify psychological distress among traumaexposed individuals (e.g., lewis et al., ) , income has been shown to be a potential variant. although the majority of studied found that high income has a protective effect against psychological distress (e.g., fullerton et al., ; lewis et al., ), sun et al ( reported that perceived income inadequacy, rather than actual income level, significantly predicted psychological distress. healthcare professionals, particularly nurses, are considered a vulnerable group to experience (asd) amid the covid- pandemic. they are on the frontline of dealing with this aggressive and rapid-spreading virus; detecting and treating infected patients and thereby making themselves vulnerable to contracting the infection at any time, and possibly making them unable to care for future cases. concerns have been raised regarding the possible insufficiency of hospital beds and medical equipment to care for future patients given the exponential increase in covid- infections (world health organization [who], ), which also serves to add more pressure on healthcare professionals. recent studies on the psychological impact and trauma-related responses of covid- among healthcare workers are scarce and focused on symptoms of ptsd rather than asd. in a multinational, multicenter study on the association of psychological outcomes and physical symptoms among healthcare workers in which nurses constituted . % of the sample, . % of the study cohort screened positive for ptsd and . % reported moderate to severe levels of psychological distress (chewa et al., ) . in another study investigating mental health status among medical staff of which . % were nurses, . % of the study sample reported covid- related symptoms of ptsd (xing, sun, xu, geng, & li, ) .the importance of asd diagnosis is based on its capacity to predict individuals who will develop ptsd. bryant and harvey ( ) found that % of patients who had been diagnosed with asd developed ptsd symptoms six months later. edmondson, mills, and park ( ) reported that asd has a % predictive validity for ptsd. research indicates that early treatment of acute stress disorder can effectively prevent development of ptsd (bryant, harvey, dang, this article is protected by copyright. all rights reserved sackville, & bbasten, ) , particularly given that ptsd may develop months or years after the traumatic event takes place (bryant & harvey, ) . therefore, this study represents the first to focus on asd prevalence and predictors of trauma-related psychological distress among nurses. more specifically, this study aims to establish the prevalence of asd and predictors of psychological distress among jordanian nurses. a quantitative, cross-sectional, descriptive and comparative design was used in this study to (a) explore the prevalence of asd and (b) investigate the predictors of psychological distress among jordanian nurses amid covid- . a convenient sample of jordanian nurses working in jordanian hospitals was recruited electronically. we used qualtrics, which is an electronic survey, or more specifically a web-based survey to distribute the study questionnaire. according to stanton ( ), a web-based survey is a survey instrument that physically resides on a network server and which can be accessed only through a web browser. we used daniel's ( ) formula to calculate the sample size needed for the prevalence estimate using the following parameters: (a) a precision rate of % (appropriate if the prevalence is going to be between % and %, (b) an average prevalence of % based on (lubin et al., ) study of asd among healthcare workers, and (c) a % confidence interval (ci). the yielded sample size was participants. a total of jordanian nurses returned the online survey. of them, responses were incomplete with more than % of the data missing. therefore, these responses were not included in the analysis. the final sample included nurses. among this sample, the frequencies of missing values across all items were less than %. a multivariate diagnostic test (little, ) was used to explore the degree of randomness in the identified missing data. the analysis revealed that the missing pattern was completely at random (p > . ). the mean/median of the non-missing items was imputed for the missing scores and all analyses were run with and without imputed data yielding no significant differences. this article is protected by copyright. all rights reserved the survey link was distributed to nurses through hospitals' websites along with an online invitation letter explaining all aspects of the study including: its purpose, voluntary participation, confidentiality, length of survey and potential benefits and risks. furthermore, an online consent form was developed and participants were instructed to read the informed consent carefully, and click on the agreement button at the end of the consent form if they were willing to take part in the study. the anonymity option of the participants was guaranteed by not including the participants' identifying information in the study questionnaire. nor were they identified by the e-survey software once the survey was completed. since the study instruments may include some items that have the potential of eliciting negative feelings, participants were informed that they could refrain from answering any particular questions that may elicit distress. completed questionnaires were automatically saved on qualtrics software which is password protected and can only be accessed by the study authors. the study was approved by the institutional review board (irb) of xxxx. . sociodemographic data sheet. participants were asked to complete a sociodemographic data sheet containing participant' age, gender, income, years of work experience, hospital ward where they are working, and past or current diagnosis of mental disorder. et al., ) . this instrument consists of -item relevant to the diagnosis of asd. it presents items representing three subscales including: dissociation ( items in total), reexperiencing of trauma ( items), avoidance ( items), anxiety and hyperarousal ( items). it also has two additional items regarding impairment in functioning. sasrq is scored on a -point likert scale ranging from (not experienced) to (very often experienced). the scale has been shown to present adequate psychometric properties (e.g., cardena et al., ; benight & harper, ) . . trauma coping self-efficacy scale. this measure is an adaptation of the hurricane coping self-efficacy scale (benight, ironson, & durham, l ) which assesses an individual's confidence in his/her ability to cope effectively with a trauma. the words "caused by the hurricane" at the end of each item of the original measure were changed to "caused by covid- ". the measure consists of items scored on a -point likert scale ranging from "not at all capable" to "totally capable". the items measure the individual's capability to maintain personal, financial, housing, and food security, in addition to their this article is protected by copyright. all rights reserved capability to deal with the emotions and personal losses they have experienced from the trauma. examples of scale items were: ' maintaining personal security-protecting yourself and your property' , and 'maintaining housing and food-negotiating and dealing with contractors, landlords, obtaining and keeping food fresh ' (benight et al., l ) . the psychometric properties of the scale were found adequate (e.g., benight et al., ) . the statistical package for social sciences version was used for data entry and analyses. descriptive statistics of frequencies, means, range, and standard deviations were calculated to describe participants' demographics and the prevalence of asd and psychological distress. simultaneous multiple regression was used to estimate predictors of this article is protected by copyright. all rights reserved nurses' psychological distress. the psychological distress total score was entered as an outcome variable, whereas nurses' gender, age, income, history of mental disorders, asd total score, and cse total score were entered as potential predictors. a total of jordanian nurses ( % females) completed and returned the online survey. the mean age was . years (sd= ) across a field ranging from - . the majority were married ( %, n= ), full time workers ( %, n= ), and had a bsn degree ( %, n= ). the mean monthly income was jd (usd ). on average, participants had years (sd= ) of work experience as nurses, with the total ranging from to years. thirteen nurses ( %) reported they either previously had or currently have a mental disorder (primarily, anxiety and depression) (see table ). the mean asd score among the nurses was (sd= ), with scores ranging from - . according to cardena et al ( ), a cutoff score of or greater signifies clinical asd and predicts ptsd predisposition. in this study, % of nurses had scores at or above the cutoff point of on the sasrq. results for sasrq eight subscales are described in table ii . on the trauma coping self-efficacy scale, the mean score was (sd= ), with scores ranging from - . on the brief symptom inventory, the mean psychological distress scale was (sd= ), with scores ranging from - . approximately % of nurses had a gsi tscore of and greater, indicating significant psychological distress. results related to psychological distress subscales of somatization, depression and anxiety are described in table ii . the results revealed that overall, the model was able to predict a significant proportion of nurses' psychological distress (f ( , ) = . , p < . , r = . ). almost % of the variability in nurses' psychological distress was accounted for by their gender, age, income, history of mental disorders, acute stress, and coping self-efficacy. however, it should be noted that only age, asd, and coping self-efficacy were significant predictors of psychological distress. more specifically, younger nurses ( = -. , t ( ) = - . , p = . ), and those this article is protected by copyright. all rights reserved with higher asd ( = . , t ( ) = . , p < . ), and lower coping self-efficacy ( = -. , t ( ) = - . , p = . ) reported higher psychological distress than their counterparts. table iii shows the model fit. our findings show that the majority of nurses are experiencing asd due to the covid- pandemic, and thus are at risk for ptsd predisposition. more than one-third of nurses are also suffering significant psychological distress. among our sample, age, asd, and coping self-efficacy significantly predicted psychological distress. more specifically, younger nurses are more prone to experience psychological distress than older ones. while higher scores on asd resulted in more psychological distress, coping self-efficacy was a protective factor. although available literature shows that asd predicts ptsd among trauma-exposed individuals (e.g., bremner et al., ; weiss, marmar, metzler, & ronfeldt, ) , the majority of available studies focused on the latter one. the very few studies that investigated asd among healthcare workers reported lower rates compared to our sample of nurses. the prevalence of asd among disaster workers including healthcare professionals ranged between . % (biggs et al., ) to . % (fullerton et al., ) . in the study of lubin et al ( ), rates of asd among physicians and paramedics during combat were . % and . %, respectively. prevalence of asd during infectious diseases pandemic was reported in the study of bai et al ( ) . this study found that only % of healthcare professionals met criteria for asd during the sars outbreak (bai et al., ) . some researchers argued that the prevalence of ptsd is not stable and that it depends on the population that has been investigated ( sadock & sadock, ) . a higher prevalence is found among women and those who are at high risk (e.g., sadock & sadock, ) . the majority of our sample was female nurses ( %) who are at high risk for contracting covid- infection due to their being on the frontline for screening and treating patients at risk. the aggressiveness and rapid spread of covid- may also explain the high rate of asd observed within our sample. another reason can be related to the rising number of covid- cases, both suspected and infected, in jordan at the time of the study, and the inadequate preparedness of hospitals to provide the necessary care. the first case of covid- in jordan was identified on march nd (alarabiya, ) , and two weeks after, the country was in a strict lockdown as the this article is protected by copyright. all rights reserved number of infected was rising rapidly. as of april th , the starting date of our study, officials announced that the number of infected cases had reached (world meters, ) significant psychological distress among trauma-exposed individuals is widely reported in the literature. clinically significant psychological symptoms were reported among urban trauma-exposed adults (hansen & ghafoori, ) ; college students with childhood victimization (elliott et al., ) ; and physically injured adults (munter et al., ) among others. nurses in the present study however, had a higher rate of psychological distress ( %) than those reported in the literature. for example, rates of psychological distress exemplified in depression and anxiety among patients with traumatic facial injury ranged from . % to % (islam, ahmed, walton, dinan, & hoffman, ) and from % to % among physically injured adults (munter et al., ) . a recent study of the impact of covid- outbreak on healthcare professionals' psychological health reported that among healthcare workers in singapore, % suffered from anxiety and % from depression. a study by suleiman et al ( ) that was conducted between march and march , which was around the time of our data collection, reported that only . % of frontline physicians in jordan had all protective measures (ppes) available at hand and the most shortage was for facemasks ( . %). doctors without full ppes reported significantly higher fear and anxiety than those with full ppes. we would expect that nurses were also experiencing similar shortages in ppes equipment for personal safety, which may explain the high rate of reported psychological distress. this warrants nurse mangers in other countries where ppes resources are inadequate to proactively test their healthcare workers for psychological distress. munter et al ( ) found that rates of psychological distress due to anxiety and depression were higher one week after trauma and decreased thereafter. therefore, this necessitates the provision of early psychological interventions for nurses with continued screening and referral for such services. o'donnell et al ( ) explains that early interventions in trauma high-risk individuals are associated with better outcomes. our findings on the inverse relationship between age and psychological distress are consistent with available literature. in a study of a community sample during sars outbreak; younger individuals were found to suffer greater psychological comorbidity (sim, chan, chong , chua , & soon, ) . younger people were more likely to utilize ineffective coping strategies during the outbreak (sim et al., ) . other studies reported that psychological distress, especially depression and anxiety, decline with increasing age (e.g., christensen et this article is protected by copyright. all rights reserved al. ; jorm et al., ) . one possibility is that the aging of the brain affects emotional responsiveness. older adults are found to be less likely to attend to and remember negative emotional experiences than positive ones (mather et al. ) . future research needs to investigate the role of aging on psychological distress and the specific risk factors interplay between both variables. the findings on the association between psychological distress and sociodemographic and clinical variables of gender, income, and existing mental disorders are inconsistent with the majority of literature. a plethora of trauma-related articles on psychological distress have reported women having higher psychological distress than men (e.g., hansen & ghafoori, ; jayawardene et al., ) . however, our finding of the non-existent relationship between gender and psychological distress is consistent with the study of elliott et al ( ) , in which no significant gender differences were found. some researchers (e.g., emslie et al., ) explain that context and socio-cultural factors should be taken into account in explaining psychological distress. our sample of nurses is mainly female ( %) and the higher female representation in the current study may relate to nursing being a female- regarding the non-existent relationship between income and psychological distress in our data, one possibility is offered by sun et al. ( ) who reported that it is the perception of income inadequacy, rather than actual income, which affects psychological distress. a more reasonable explanation is that all of the nurses in our study are employed and thus their income is secured, rendering income as a non-significant predictor of psychological distress compared to fear for one's own safety or dealing with the emotions associated with the traumatic event of covid- . nevertheless, more research is needed to further explore the nature of the relationship between income and psychological distress. since only % of the sample reported existing mental illness, mainly depression and anxiety, this may also explain the insignificant predictability of this variable on psychological distress. coping self-efficacy (cse) as a protective factor against psychological distress is congruent with studies on natural disasters. for example, in the study of benight et al. (l ) on hiv positive men following hurricane andrew, cse accounted for % for ptsd this article is protected by copyright. all rights reserved symptoms (benight et al., ) . cse was also a significant predictor of psychological distress among flood and fire survivors (benight & harper, ) . cse had a direct negative pathway to acute psychological distress among survivors of hurricane andrew (benight, ironson, klebe, et al., l ) . similarly, pritchard and gow ( ) found that greater coping self-efficacy was associated with lower trauma-related psychological distress among survivors of the queensland flood in australia. although this study is considered the first to investigate the prevalence of asd among nurses during covid- , and to explore predictors of psychological distress, it has some limitations. this study is cross-sectional in nature and relied on measuring asd, coping self-efficacy and psychological distress using an online self-administered survey. longitudinal research is needed to explore the magnitude of the study variables over time. another limitation is the descriptive nature of the study, which limits having detailed and rich understanding of nurses' psychological well-being during covid- outbreak. further research is needed to examine this phenomenon employing different research methodologies (i.e., qualitative or mixed-methods design). our findings show that nurses experience significant asd and psychological distress amid the covid- pandemic. coping self-efficacy is found to ameliorate the effect of psychological distress on nurses' traumatic experience. such findings warrant intensive efforts from healthcare institutions to provide psychosocial support services for nurses. nurse managers can take a leading role in implementing stress-reduction strategies for nurses through providing consecutive rest days, rotating allocations of complex patients, arranging support services, and being accessible to staff. of importance, nurse managers need to take an active role in ensuring the personal safety of their staff through working closely with their hospital's management in securing and providing personal safety measures. they also may undertake briefings to ensure their staff's physical and mental well-being. steps to improve nurses' coping self-efficacy are considered another avenue where nurse managers can intervene. self-efficacy is found to correlate positively with adaptive coping and thus reduces individual's psychological distress (park, folkman, & bostrom, ) . nurse managers can improve nurses' self-efficacy through verbal persuasion (i.e., providing positive feedback on the tasks that are accomplished appropriately and safely) and act as role models in handling the crisis of covid- in an empowering way. given that individuals suffer from asd are this article is protected by copyright. all rights reserved aging and emotional memory: the forgettable nature of negative images for older adults a validity and reliability study of the coping self-efficacy scale amultinational multicenter study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid- outbreak age differences in depression and anxiety symptoms: a structural equation modeling analysis of data from a general population sample coping with post-traumatic stress: young, middle-aged and elderly comparisons biostatistics: a foundation for analysis in the health sciences the brief symptom inventory: an introductory report factor structure of the acute stress disorder scale in a sample of hurricane katrina evacuees acute stress disorder as a predictor of posttraumatic stress disorder in physical assault victims polyvictimization, psychological distress, and trauma symptoms in college men and women gender differences in mental health: evidence from three organizations this article is protected by copyright. all rights reserved key: cord- -jtid g p authors: vigouroux, marie title: over the rainbow: navigating the covid- pandemic while living with ptsd date: - - journal: j patient exp doi: . / sha: doc_id: cord_uid: jtid g p nan i survived the mass shooting at dawson college in montreal, canada, in september ( ) . this single event turned my life inside out in deeper and more unexpected ways than i can describe in this short essay. i have lived with posttraumatic stress disorder (ptsd) ever since. throughout the years, i have learned to manage my condition effectively through treatments which have helped me in different ways. until a few weeks ago, i felt like the worst might be behind me. then, the world became engulfed in the coronavirus disease (covid- ) pandemic, which required people everywhere to make drastic changes to their lives in order to protect themselves and others against this novel virus. these changes, and the global malaise surrounding the pandemic, have heightened some of the ptsd symptoms that i had learned to cope with efficiently. i have experienced varying degrees of a range of ptsd symptoms such as recurring intrusive memories, nightmares, night terrors, avoidance, persistent guilt, alienation, memory loss, irritability, hypervigilance, reckless behaviour, difficulty concentrating, and sleep disturbance, thus hitting all clinical symptom clusters ( ) . over the years, these symptoms have felt anywhere between manageable and debilitating depending on my life circumstances. similar to what is described in the literature about chronic pain, ptsd is my dance partner ( ) . while it has certainly led some dances in my life, i have successfully managed to lead others. cognitive behavioural therapy allowed me to develop skills to respond to triggering situations by grounding myself in the present and reminding myself that i am safe. "you are not back there, you are here, now," i tell myself. most recently, eye movement desensitization and reprocessing has helped me de-escalate triggering situations by replacing a negative thought with a positive one. while these techniques may not be effective for everyone living with ptsd, they significantly increased my quality of life. of course, my coping skills and mechanisms are not perfect. i still do not feel completely at ease in crowded spaces. i always look around to make sure i know where the exits are located and i still jump at loud noises. in march , particularly stressful circumstances emerged as the covid- epidemic evolved into a pandemic. to be faced with the remote, yet real, possibility of me or my loved ones contracting and dying from the virus brought me back to the day i outran bullets. intuitively, you might think that social distancing measures would be great for someone like me who dislikes crowds, and you would be right. it has been a welcome change to not have to take public transit and sit in crowded classrooms. however, the constant underlying feeling of danger has reignited a hypervigilance that i only feel at my worst. hypervigilance brings sleep disturbances, which in turn bring tiredness that leads to avoidance. just like that, within weeks of social distancing measures being put in place, i found myself expanding considerable energy managing these symptoms. this means i have less energy to spend on my work, which i am expected to perform from home while caring for and homeschooling my son. mental energy is a finite resource and i currently feel like i do not have enough of it to complete the tasks i performed fairly easily just a few weeks ago. i know now that this is not a personal failure. i am simply navigating my current life circumstance with a chronic condition. however, this acceptance came after living with my condition for over a decade; others with less experience may not be so gentle with themselves. another surprisingly challenging aspect to manage is the positivity that emerged in quebec, my home province. Ç a va bien aller (it's going to be alright) gets drummed everywhere you go, on social media, and any news station you watch. while i understand that people need a positive outlook on the situation in order to keep hope, i cannot help but think about those of us for whom it is just not going to be alright. some of us will lose loved ones and some of us will die. we don't know what our lives will look like in the coming months. a return to normal seems further and further away with social distancing measures being prolonged. we are worried for our loved ones. we will need to mourn our dead. we will need to mourn our pre-covid- lives. rainbows and positive talk will not change that. words that are meant to be comforting can have the opposite effect on grieving people and can exacerbate feelings of alienation ( ) . this is what i feel. as i mourn a period of my life that felt so sweet and accept this new chapter that feels so strange and uncertain, being bombarded with "it's going to be alright" is just not helpful. it dismisses my legitimate fears and concerns about the situation and closes the door to meaningful conversation. through the trauma i survived, i learned that things can go dramatically wrong on any given day. this thought process still guides many of my behaviors and is why, even in my best state, i look for exits in crowded places and jump at loud noises. it is difficult for me to share this perspective as the pandemic is ongoing and my symptoms are currently further away from "manageable with little effort" than they have been in a long time. it is challenging for me to focus on writing for longer than a few minutes at a time, and even more challenging to be writing about my condition-the simple mention of which reminds me of why i live with it today. i have the immense privilege of being a master's student in a health-related field, which has trained me to write about health and, more specifically, lived experiences linked to chronic health conditions. i can only imagine that it is just as hard, if not harder, for others to share their stories when their symptoms are heightened. i hope that this paper will help clinicians pay particular attention to those patients who are experiencing symptoms indicating a relapse of ptsd, acknowledge their pain and fears as real and valid, and, where appropriate, refer them to a service provider who is experienced with the condition. i also hope that sharing my experience will spark a conversation among health care workers about ptsd, as they are themselves currently dealing with immense stress and trauma. woman, gunman dead in montreal school rampage posttraumatic stress disorder: overview of evidence-based assessment and treatment learning to live with osteoporosis: a metaphoric narrative it's ok that you're not ok: meeting grief and loss in a culture that doesn't understand. sounds true i would like to thank my thesis supervisor, dr. richard hovey, for his continued mentorship. he kindly encouraged me to submit this manuscript and share my story, and supported me through the writing and editing process. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. marie vigouroux https://orcid.org/ - - - marie vigouroux is currently a graduate student under the supervision of dr. richard hovey, pursuing a msc at the faculty of dentistry at mcgill university. she is working on different projects examining the lived experiences of people living with chronic conditions, such as chronic pain and scoliosis. key: cord- -iwueedmm authors: chan, c.h.; tiwari, a.; fong, d.y.t.; ho, p.c. title: post-traumatic stress disorder among chinese women survivors of intimate partner violence: a review of the literature date: - - journal: int j nurs stud doi: . /j.ijnurstu. . . sha: doc_id: cord_uid: iwueedmm background: post-traumatic stress disorder is one of the most prevalent mental health sequelae of intimate partner violence, and as a result, it has been extensively documented in western literature. however, whether abused women from non-western cultures experience similar post-traumatic responses to intimate partner violence is less documented. objectives: the objectives of this paper were ( ) to review the literature for information about post-traumatic stress disorder among chinese women survivors of intimate partner violence; ( ) to provide a synthesis of the literature on post-traumatic stress disorder among abused chinese women; and ( ) to identify implications for practice and to suggest directions for research relating to post-traumatic stress disorder among abused chinese women. design: a systematic review of the literature. data sources: following a systematic search for relevant literature in computerized databases and manual searches of english and chinese language publications, five papers reporting on four studies conducted in china, taiwan, malaysia, and the united states were included in the review. review methods: abstracts meeting the inclusion criteria were reviewed independently by two of the authors and any discrepancies were resolved by discussion. full papers for selected abstracts were then retrieved and assessed independently by the same reviewers. results: the present literature review revealed a paucity of information relating to post-traumatic stress disorder symptoms or diagnoses in abused chinese women. nevertheless, a link between post-traumatic stress disorder and intimate partner violence was demonstrated by the reviewed papers. conclusions: caution should be exercised when making comparison of the findings across the four studies because of the inherent methodological differences. also, as the assessment tools have not been validated for culture-bound interpretation of trauma and symptom manifestation, comparisons of findings for chinese women to women in western literature should be undertaken with due consideration. implications for practice and recommendations for future research are discussed. a universal post-traumatic reaction to intimate partner violence cannot be assumed. cultural beliefs may influence abused women's interpretation of trauma and their expression of posttraumatic stress disorder symptoms. there is a paucity of information relating to posttraumatic stress disorder symptoms or diagnoses in abused chinese women. this review highlights the need for ethno-cultural and qualitative research in order to facilitate culture-bound interpretations of trauma, symptom expression, and coping in abused chinese women. the review identifies suggestions for providing culturesensitive care in relation to intimate partner violence and post-traumatic stress disorder in the chinese context. intimate partner violence (ipv), also known as domestic violence, is one of the most common forms of violence against women. ipv consists of any one, or combination of, the following acts: physical violence, psychological abuse, sexual assault, controlling behaviors such as limiting resources or social contacts, intimidation, or creation of emotional dependence where the perpetrator is a current or former intimate partner (saltzman et al., ) . ipv is a global problem. the world report on violence and health found that between % and % of women had been physically assaulted by an intimate partner at some time in their lives in population-based surveys world-wide (krug et al., ) . ipv occurs across social, economic, religious and cultural boundaries. even in cultures that emphasise social harmony, such as the chinese culture, ipv against women is pervasive. for example, prior year prevalence of ipv victimization was reported to range from % to % in china (chan et al., ) . not only is ipv pervasive, it is also a major public health problem, with negative physical and mental health consequences (campbell, ) . specifically, ptsd has been recognized as one of the most prevalent mental health sequelae of ipv (silva et al., ; coid et al., ) . ptsd, an anxiety disorder which develops after traumatic exposure, is characterized by distressing memories or emotions about the trauma, avoidance of trauma reminders and elevated arousal (green and kimerling, ) . golding ( ) , in a meta-analysis of the prevalence of mental health problems among women with a history of ipv, reported a pooled prevalence of . % in studies of ptsd, compared to estimates of lifetime prevalence of . % to . % in general populations of women (resnick et al., ; kessler et al., ) . a dose-response relationship was also suggested, as severity or duration of ipv was associated with the prevalence or severity of ptsd (golding, ) . in recent studies conducted in north america, ptsd was found to mediate the association between intimate partner aggression and physical health symptoms (taft et al., ; wuest et al., ) while ptsd avoidance symptoms predicted physical health problems in women abused by an intimate partner (woods et al., ) . the current body of knowledge related to trauma and ptsd is mainly based on research conducted in western nations (bedard et al., ) . it is not so clear whether people from non-western societies have similar reactions compared to those of their western counterparts (tang, ) . there is even an argument that ptsd is a euro-american culture-bound syndrome that does not apply to those in traditional cultures (summerfield, ) . although these views are expressed about reactions to trauma in general, the same considerations could also apply to women's reactions to ipv, long recognized as a traumatic event (houskamp and foy, ) . it is important, therefore, not to assume a universal post-traumatic reaction to ipv. instead, there is a need to understand ipv and ptsd in culturally sensitive ways so that appropriate interventions can be developed for ipv survivors in culturally diverse populations. this paper aims to contribute to the development of increased awareness by presenting a comprehensive review of the literature on ptsd among chinese women survivors of ipv. for the purpose of this review, ptsd includes the diagnosis of ptsd and ptsd symptoms. the objectives of this paper are as follows: . to review the literature for information about ptsd among chinese women survivors of ipv (hereafter known as abused chinese women). . to provide a synthesis of the literature on ptsd among abused chinese women. . to identify implications for practice and to suggest directions for research relating to ptsd among abused chinese women. the authors conducted a systematic search for relevant english language publications in computerized databases (pubmed, medline, psychinfo, cinahl, embase and google scholar) using the keywords intimate partner violence, domestic violence, partner violence, sexual abuse, physical violence, abused women, battered women, posttraumatic stress disorder, ptsd, ptsd symptoms, trauma, traumatic stress, post-traumatic responses, mental disorder, and chinese or asian, with date restrictions from to june . an electronic search of websites of government departments, and women's health or domestic violence organizations in mainland china, hong kong, and taiwan, was undertaken for relevant materials or citations. manual searches of reference lists of relevant articles found in the primary search were also performed. in addition, a search for chinese-language papers in the china journals full-text database was conducted using the above keywords. the authors contacted the corresponding authors of relevant research studies in order to obtain more information or check for possible omissions. papers were included for full review if the main focus of the study was on ptsd (diagnoses and/or symptoms) among chinese women abused by an intimate partner. the authors also included articles in the review if abused chinese women were part of a diverse cultural group of participants. abstracts of articles found were reviewed in accordance with the inclusion criteria, that is, reports on ptsd diagnoses and/or symptoms related to chinese women with a history of abuse by an intimate partner. the abstracts were reviewed independently by two of the authors (chc and at). discrepancies between the review authors were resolved by discussion. consensus was achieved after two meetings. full papers for selected abstracts were retrieved. each of the articles was assessed independently by the same review authors against the inclusion criteria. there were no disagreements between the reviewers about the appropriateness of a paper for inclusion in this review. a flow chart of studies from search to inclusion is shown in fig. . of the potentially relevant abstracts retrieved, papers were eventually included in this review. two of the five included papers reported on different aspects of the same study (hou et al., (hou et al., , . the reason for the large number of studies being excluded was that many of them addressed either ptsd or ipv but not both ipv and ptsd. the five papers are summarized as follows. . . post-traumatic responses to domestic violence in taiwan (hou et al., (hou et al., , hou, wang, and chung assessed the post-traumatic responses of chinese women to domestic violence in a cross-sectional survey. the women were recruited from the kaohsiung area of taiwan and were included if they had suffered physical, psychological, and/or sexual abuse from their husband, ex-husband, or former or current intimate heterosexual partner within the last year. a item post-traumatic response scale (ptrs), a chinese version translated from horowitz et al.'s ( ) impact of event scale (ies), was used to measure the subjective impact of marital violence on abused women within the past week. in their paper, hou et al. reported that most ( . %) of the participants had scores of indicating a high level of post-traumatic response. they also found that the standardized mean score of the intrusion subscale of the ptrs was higher than that of the avoidance subscale. the significance of the high intrusion score was compared to an earlier study by houskamp and foy ( ) in which ptsd was predicted by high intrusion reaction. based on this observation, hou and colleagues concluded that the women in their study had a higher rate of developing ptsd. in their paper, hou et al. reported that most ( %) of the women faced life-threatening situations in their abusive intimate relationships. also, the more dangerous the life-threatening situations faced by the women, the greater their overall post-traumatic response scores, a finding similar to those reported in western literature (houskamp and foy, ) . (huang et al., ) in a study of chinese female prisoners randomly selected from the hunan female prison in china, huang, zhang, momartin, cao and zhao used structured psychiatric interviews and a clinician-administered ptsd scale (caps) (blake et al., ) to arrive at a diagnosis of ptsd as specified by the dsm-iv. a history of ipv was reported by . % of the participants and was found to be one of the most predictive factors for ptsd. specifically, survivors of ipv in the younger age group were nearly five times more likely to develop lifetime ptsd while those in the older age group were twice as likely to develop lifetime ptsd. despite their high exposure to traumatic events, which included ipv, the lifetime and current rates of ptsd for this chinese sample of female prisoners, at . % and . % (chandra et al., ; leahy et al., ; yoshihama and horrocks, ; yoshihama and horrocks, ) . respectively, were much lower than those found in western literature (cauffman et al., ; ruchkin et al., ) . differences between the chinese and western study subjects were suggested as a possible reason for the discrepancy in the prevalence of ptsd, although the researchers did not elaborate on the differences. interestingly, not only were the rates of ptsd lower than those in western literature, they were also lower than those reported in colleagues' ( , ) study of women in a community in taiwan. what may have accounted for the apparent difference in ptsd scores between female prisoners in mainland china and community-dwelling women in taiwan? could this be due to differences in coping strategies or personality hardiness that may have insulated the female prisoners from developing ptsd? as huang et al.'s study did not elaborate on the participants' coping strategies or personality hardiness, it was not possible to draw a conclusion. . . cross-cultural assessment of post-trauma reactions among abused women (phillips et al., ) chinese women seeking refuge in a domestic violence shelter in malaysia were included in a study conducted by phillips, rosen, zoellner, and feeny, to examine posttraumatic reactions in abused women from non-western cultures. seventeen female residents at a domestic violence shelter, consisting of indian, malay and chinese, completed semi-structured interviews and standardized measures for the assessment of post-trauma psychological morbidity. the -item ptsd-sr symptom scale-self-report (pss-sr, foa et al., ) and the -item revised impact of events scale (ries, sundin and horowitz, ) were administered. a majority ( . %) of the women met the criteria for ptsd symptoms on the pss-sr, and . % of the women also met, or exceeded, a recommended cut-off score of on the ries. additionally, the participants' reports of post-trauma reactions were comparable to those of a sample of women in the united states who experienced partner violence. in their discussion of the findings, phillips and colleagues identified several limitations of the study including the small sample size, the use of the western construct of ptsd in non-western cultures and the omission of comorbidity. specifically, they raised their concern about imposing western ptsd symptomatic criteria on the participants in their study whose cultural experience of trauma might be different to trauma victims in the west. also, although phillips and colleagues did not elaborate on the issue of comorbidity, they nevertheless highlighted the importance of including comorbidity when assessing the psychological status of trauma victims. . . effects of social support and coping strategies on ipv and psychological outcomes in asian and caucasian women in this study, the potential mediating effects of social support and coping strategies on the relationship between ipv and psychological outcomes of ptsd symptoms and depression were investigated. a sample of caucasian women and asian women were recruited from nine domestic violence agencies located in texas and california. the asian women consisted of chinese, vietnamese and koreans. the ptsd checklist-civilian version (pcl-c; weathers et al., ) , the perceived social support scale (pss; norris and kaniasty, ) , and the revised ways of coping checklist (wccl; vitaliano et al., ) were used to measure ptsd symptoms, perceived social support, and coping efforts, respectively. analysis of the combined caucasian and asian groups revealed that there was an indirect effect of the level of violence on psychological outcomes via the mediating variables of perceived social support and passive coping strategies. however, ethnic group comparisons indicated differences between caucasian and asian women. specifically, in the asian group, the effect of ipv on the women's psychological distress was entirely direct. thus, the higher the levels of ipv experienced, the more severe the ptsd and depression symptoms. neither social support nor coping mediated the impact of ipv on the asian women's psychological health. based on the findings, lee et al. suggested that asian women may be more vulnerable to adverse psychological outcomes following ipv. as the results were drawn from a diverse group of asian participants, they should be interpreted with caution with regard to generalizability. the present review demonstrated a paucity of information on ptsd among abused chinese women. this is consistent with the current state of ptsd research in chinese societies that, to date, has mainly focused on the post-traumatic impact of natural disasters such as earthquakes and flooding (for example, zhang and zhang, ; zhao et al., ; liu et al., ) . however, relatively little is known about the post-traumatic impact of human-instigated disasters. additionally, caution should be exercised when making comparisons across the reviewed studies because of the methodological differences. for example, the use of different assessment tools could account for the variability in the rates of ptsd across the studies. specifically, the differences may be due to measuring ptsd diagnosis versus severity scores or the use of self-reports versus clinician-administered measures. for instance, the use of the clinician-administered ptsd scale (caps) in huang et al.'s ( ) study to measure the diagnosis of ptsd could have led to lower rates of ptsd because the caps is not a self-report measure and the participant has to answer questions face-to-face. it is possible that some of the participants may be reluctant to admit psychological difficulty to another person, but would have more highly endorsed mental health problems on a self-report measure. despite the variability, a link between ptsd and ipv was demonstrated in the reviewed studies. the studies included in this review used measurement instruments developed in the united states to assess abused chinese women's ptsd (symptoms and/or diagnosis). evaluation of the translated measurement instruments was described in one of the papers (hou et al., ) , which focused only on surface validity and reliability. none of the papers provided adequate evidence regarding the scientific rigor with which the translated instruments were evaluated and revised in the chinese context. indeed, phillips et al. ( ) expressed their concern about imposing the western construct of ptsd in non-western cultures. such concern is consistent with that expressed by tang ( ) about the widespread use of translated instruments from the west in an imposed-etic approach when measuring ptsd in chinese trauma survivors. also, by assuming that ptsd is a relevant and meaningful construct in chinese culture, researchers conducting ptsd research in abused chinese women could fail to recognise omissions of emic constructs that are central to chinese ways of conceptualizing life adversity, expressing symptoms of post-trauma reactions, and coping with life's vicissitudes. therefore, future research should adopt more rigorous validation procedures when translated instruments are used. for example, back-translation should be used to ensure that the underlying meaning of the original wording is preserved after translation. further, the translated version of the instrument should be reviewed and agreed by a committee of bilingual members who have not participated in the translation process. validation efforts should also include testing the translated instrument with a sample made up of members of the target culture as well as submitting it to a full psychometric evaluation (polit and beck, ) . the expression of ptsd by the participants in the reviewed studies should be contextualized in the traditional chinese health beliefs. this is because, unlike western medicine, there is no clear distinction between physical disorders and mental disorders in chinese medicine. as such, internal organs are viewed as centers for combined physiological and psychological functions and vital organs such as the heart, lungs and kidneys are often used by chinese people for colloquial expression of feeling states (lin, ) . it has been suggested that such beliefs, together with the stigma associated with mental illness in chinese societies, may be responsible for chinese patients presenting with somatic symptoms (e.g. headache, back pain) rather than expressing their mental health problems (e.g. depression) (tang, ) . interestingly, in hou and colleagues' ( ) study, somatization was the fourth most common symptom expressed by the participants. in huang et al.'s ( ) study, where the prevalence of ptsd in chinese female prisoners was found to be lower than that in the western studies of female prisoners, somatization was not assessed. to what extent was the apparent lower prevalence of ptsd an artifact of the chinese women prisoners' health beliefs? in other words, could some of the participants have expressed their ptsd in the form of somatic symptoms? such a question cannot be answered because the measures in huang et al's study did not include somatization. this shows the need for future research to include the assessment of somatic symptoms when studying ptsd in abused chinese women previous studies on the psychological status of trauma survivors in western populations have identified the need to consider the issue of comorbidity (boudreaux et al., ; stein and kennedy, ) . specifically, stein and kennedy have found major depressive and post-traumatic stress disorder comorbidity in female victims of ipv. despite this, with the exception of phillips et al. ( ) , none of the reviewed studies have identified the need to address comorbidity when assessing psychological responses of chinese ipv survivors. interestingly, studies on natural disasters in china and taiwan have found comorbidity of ptsd and other mental health problems (mainly depression) among adult community survivors (lai et al., ; wu et al., ) , long-term survivors (zhang and zhang, ; zhang et al., ) and rescue workers (chang et al., ) . in addition, comorbidity of ptsd and depression, as a result of the severe acute respiratory syndrome (sars) outbreak, was also found among patients in china (yan et al., ) , health care workers in taiwan (chong et al., ) , and survivors of sars in hong kong (cheng et al., ) . in light of such findings, future research should also consider psychiatric comorbidity when investigating the psychological responses of abused chinese women. since ipv is still considered to be a private matter and victim-blaming attitudes are still prevalent in asian communities (yoshioka et al., ) , it is important to educate the community as a first step in the promotion of primary prevention of ipv. nurses can, through public education programs, teach members of chinese communities that ipv reflects the community's normative acceptance of violence against its members, which goes against the confucian teachings of respect and harmony. furthermore, the psychological damage caused by ipv, not only to the survivor but also to the family and the community as a whole, should be emphasized. by raising public awareness of the problem of ipv and by promoting community involvement in the prevention of ipv, nurses can help to ensure that abused chinese women are not revictimized when they seek assistance from their informal social networks. as identified by hou et al. ( ) , chinese women survivors of ipv are at risk of developing ptsd if no support or intervention is provided. thus, detection of ipv is an important step to prevent deterioration of these women's mental health. in view of the fact that ipv is considered to be a family shame in the chinese culture and would not be disclosed to outsiders (tang et al., ) , nurses should be sensitive to chinese women's reluctance to discuss their abusive relationships, and their reluctance to accept help from formal services. earlier studies have found that, in a safe and trusting environment, chinese women were prepared to disclose their abuse experiences to nurses who had been trained to elicit such sensitive information (tiwari et al., (tiwari et al., , . it is, therefore, important that culture-sensitive training on screening for ipv be provided if nurses are to conduct assessment for ipv in chinese women. in the cases of abused chinese women with physical problems, their mental health should also be assessed because somatic symptoms may be reported instead of psychological symptoms (tang, ) . although none of the studies reviewed focused on the relationship between psychological abuse and ptsd in chinese women, an earlier study of japanese-american women found that those women who had experienced emotional, but not physical, violence reported increased post-traumatic stress symptoms relative to those with no history of partner violence (yoshihama and horrocks, ) . previous studies of ipv among chinese women have found a predominance of psychological abuse, in the absence of physical or sexual violence (leung et al., (leung et al., , tiwari et al., tiwari et al., , , but no assessment for ptsd was conducted in these cases. in light of yoshihama and horrocks' findings, consideration should be given to screening chinese women, who have experienced psychological intimate partner abuse, for the possibility of ptsd as well. in their analysis of the apparent vulnerability of asian women to adverse psychological outcomes (ptsd being one of them) after exposure to ipv, lee et al. ( ) suggested that the existing social support systems, that were not consistent with asian cultural beliefs, might not be helpful to asian women. reluctance to utilise formal services was not only confined to abused chinese women, but it was also noted that chinese survivors of natural disasters were also reluctant to seek outside help. for example, only - % of those who reported ptsd symptoms after the chi-chi earthquake in taiwan in used the available mental health services (kuo et al., ) . when offering assistance to abused chinese women, nurses should be aware that these women may be hesitant to accept help from individuals outside their families, especially if they perceive that such help would bring shame to their family reputation or threaten their family unity. thus, reassurance should be given in a culturally appropriate manner. also, as chinese women are more likely to seek help from informal social networks, nurses may consider collaborating with such networks in providing abused chinese women with social support. when deciding which of the interventions would be appropriate for abused chinese women at risk for developing ptsd, nurses should ensure that the chosen intervention is evidence-based as well as culturally appropriate. a recent review of advocacy interventions for abused women provided comprehensive information about the effects of advocacy interventions in reducing post-traumatic stress (ramsay et al., ) . if advocacy interventions are to be used for chinese women, it is crucial for nurses to recognise that ''empowerment'' is a socially constructed term and may not be compatible with the traditional chinese values of sacrificing one's needs for the greater good of the family (yick, ) . care should be taken not to encourage the women to end their abusive relationships. instead, time and effort should be spent to assist them to resolve their self-blaming attitudes, and to acknowledge their dilemma of wishing to end the abuse, yet wanting to keep their family together (yick et al., ) . furthermore, nurses can empower abused chinese women by affirming their coping behaviors and supporting them in developing their own resources. research conducted in developed nations has shown that ipv is associated with ptsd in women survivors (resnick et al., ; kessler et al., ) . for chinese women, as demonstrated in this review, relatively little is known about the post-traumatic impact of ipv. even though trauma research has a relatively short history in chinese societies and the research focus is mainly on natural disasters, there is already an accumulation of evidence of ptsd within chinese survivors (tang, ) . future ptsd research should broaden the scope to include not only the mental health impact of ipv but also the possible differential relationship between types of ipv (e.g. psychological abuse, physical violence, or sexual assault) and ptsd symptoms or diagnoses. additionally, the use of cross-sectional design precludes an examination of causality between ipv and ptsd in chinese women. by adopting a longitudinal approach within the chinese context, a more reliable conclusion can be drawn regarding the causal process (if any) from ipv to ptsd. the use of convenience samples in the studies reviewed has restricted the generalization of the results to other abused chinese women. in order to enhance representativeness of the sample, stratified probability sampling should be considered. as well, the ethnic makeup within the asian participants in two of the reviewed studies (phillips et al., ; lee et al., ) may be too diverse, thus confounding the overall results. for example, in lee et al.'s study, chinese, korean and vietnamese women made up the asian group. china has not seen warfare or combat for more than half a century, whereas vietnam's experience of warfare is more recent. therefore, it should not be assumed that traumatic life events for the chinese and vietnamese women are similar. although it is often assumed that korean, vietnamese and chinese people are influenced by confucian beliefs, in fact, because of the different political, social and economic conditions in these countries, the actual confucian influence may not be the same. thus, future research should clearly delineate the post-traumatic impact of ipv on different ethnic groups. as discussed earlier, the studies in this review adopted an imposed-etic approach (berry, ) by using translated assessment tools from the west. cross-cultural differences in terms of psychometric properties or interpretation have not been considered. thus, the assessment instruments may be appropriate for the culture where they were developed but may not be appropriate in a different culture where they may be applied. indeed, tang ( ) has argued for the need to obtain emic constructs that are appropriate for chinese societies when conducting trauma research among chinese people. future research should consider using ethno-cultural or qualitative approaches in order to collect, interpret and compare perceptions of, and reactions to, the same traumatic life events from chinese and non-chinese survivors. it is hoped that using ethnocultural or qualitative approaches will facilitate culturebound interpretations of trauma, symptom expression, and coping, in the chinese context. in recent western studies, people who report ptsd symptoms, but who do not necessarily meet the diagnostic criteria, have been found to have impaired functioning (grubaugh et al., ; jeon et al., ) . in some cases, the reporting of ptsd symptoms has been shown to be a predictor of delayed onset ptsd (carty et al., ) . there is a need to validate whether the findings of impaired functioning also apply to chinese people and to assess how such information may inform the choice of interventions for abused chinese women. finally, there is a need to investigate the role played by ptsd in mediating the relationship between ipv and physical health problems among abused chinese women. despite an increased understanding about the relationships between ipv, physical health problems, and ptsd (wuest et al., ; woods et al., ) , the specific relevance for abused chinese women remains unknown. this needs to be addressed so that appropriate preventive strategies for chinese women can be instituted in a timely manner. a search of the existing literature has identified five papers reporting on ptsd symptoms or diagnoses in abused chinese women. the studies were conducted in china, taiwan, malaysia and the united states, with chinese women being the sole participants, or participants as part of a mixed asian group. interview schedules and/or rating scales utilized to assess the women for ptsd at diagnostic or symptomatic levels, were exclusively developed in western countries. the present review has revealed a paucity of information about ptsd among abused chinese women, and has also highlighted the methodological differences across the studies. furthermore, the studies utilized assessment tools that have not been validated for culture-bound interpretation of trauma and symptom expression; therefore, comparing the findings with those in the western literature should be undertaken with care. implications for practice and suggestions for future research are discussed. none. international publication trends in the traumatic stress literature introduction to methodology clinician-administered ptsd scale for dsm-iv, current and lifetime version criminal victimization, posttraumatic stress disorder, and comorbid psychopathology among a community sample of women health consequences of intimate partner violence delayed-onset ptsd: a prospective study of injury survivors posttraumatic stress disorder among female juvenile offenders understanding violence against chinese women in hong kong: an analysis of risk factors with a special emphasis on the role of in-law conflict women reporting intimate partner violence in india: 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symptoms of post-traumatic stress disorder in abused women in a primary care setting cross-cultural perspectives on the medicalisation of human suffering impact of event scale: psychometric properties major depressive and post-traumatic stress disorder comorbidity in female victims of intimate partner violence posttraumatic stress disorder and physical health symptoms among women seeking help for relationship aggression assessment of ptsd and psychiatric comorbidity in contemporary chinese societies breaking the silence: violence against women in asia identifying intimate partner violence: comparing the chinese abuse assessment screen with the chinese revised conflict tactics scales a randomised controlled trial of empowerment training for chinese abused pregnant women in hong kong the ways of coping checklist: revision and psychometric properties the ptsd checklist (pcl): reliability, validity, and diagnostic utility. paper presented at the annual convention of the international society for traumatic stress studies physical health and posttraumatic stress disorder symptoms in women experiencing intimate partner violence survey of quality of life and related risk factors for a taiwanese village population years post-earthquake abuse-related injury and symptoms of posttraumatic stress disorder as mechanisms of chronic pain in survivors of intimate partner violence survey on mental status of subjects recovered from sars feminist theory and status inconsistency theory: application to domestic violence in chinese immigrant familes partner violence, depression, and practice implications with families of chinese descent posttraumatic stress symptoms and victimization among japanese american women the relationship between intimate partner violence and ptsd: an application of cox regression with time-varying covariates relationship between emotional numbing and arousal symptoms in american women of japanese descent who experienced interpersonal victimization asian family violence report: a study of the cambodian, chinese, korean, south asian and vietnamese communities in massachusetts. asian task force against domestic violence long-term effects of tangshan earthquake on psychosomatic health of paraplegic sufferers psychological consequences of earthquake disaster survivors prevalence and correlated factors of ptsd in adolescents months after earthquake this review was supported by a small project funding (# ) from the university of hong kong. key: cord- - mv j w authors: zvolensky, michael j.; garey, lorra; rogers, andrew h.; schmidt, norman b.; vujanovic, anka a.; storch, eric a.; buckner, julia d.; paulus, daniel j.; alfano, candice; smits, jasper a.j.; o'cleirigh, conall title: psychological, addictive, and health behavior implications of the covid- pandemic date: - - journal: behav res ther doi: . /j.brat. . sha: doc_id: cord_uid: mv j w • the public health impact of covid- on psychological symptoms and disorders, addiction, and health behavior is substantial and ongoing. • an integrative covid- stress-based model could be used to guide research focused on the stress-related burden of the pandemic. • this work could provide a theoretical and empirical knowledge base for future pandemics. around some of the most clinically important psychological disorders, addictive behaviors, and health behaviors for well-being. in the first section, we describe the covid- implications for mental health focusing on (a) anxiety/stress and mood disturbance, (b) obsessive compulsive symptoms and disorders, and (c) posttraumatic stress. such mental health problems, although certainly not exhaustive of the scope of psychological disorders impacted by covid- , are some of the most common mental health issues in the general population and are frequently comorbid with chronic illness. in the second section, we focus on addictive behaviors, including (d) tobacco (combustible and electronic), (e) alcohol use and misuse, and (e) cannabis. these forms of drug use represent the most prevalent types of substance use and are frequently associated with chronic illness and premature death. in the third section, we spotlight health behavior and chronic illness by discussing the role of (f) sleep health and behavior, (g) chronic illness using the example of hiv/aids as an illustrative model, and (h) physical activity. health behaviors represent vital targets for the mitigation of covid-related disease and may play a key role in psychological adjustment and recovery. in the final section, we highlight sociocultural factors (e.g., race/ethnicity, economic adversity), developmental considerations, and the role of individual difference factors for psychological, addictive, and health behavior and chronic illness. we conclude by offering an integrative covid- stress-based model that could be used to guide research focused on the stress-related burden of the pandemic. fear is an adaptive defense mechanism that is fundamental for survival and involves several psychological and biological processes of preparation for a response to potentially j o u r n a l p r e -p r o o f threatening events. covid- represents a true threat, with many unknowns. if you are infected, there is a chance you could die, regardless of your current age, sex, or health status. as such, fear is a natural and adaptive response to this pandemic. on the other hand, every year tens of thousands die from influenza as well as many other preventable or unexpected causes. this raises the key question regarding the degree to which we should be anxious and fearful of . how much anxiety is reasonable? since even basic knowledge about covid- is undeveloped, it will be difficult to clearly discriminate between normal, adaptive fear responses and less adaptive responses. that said, such an overarching true threat and the concomitant stressors such as social isolation, economic uncertainty and so forth could in fact recalibrate what is considered a normal level of anxiety in the general population. research has demonstrated that trait levels of anxiety have increased in the us in recent decades, though the cause of such increases is unknown (twenge, ) . the covid- pandemic is likely to contribute to these basic levels of trait anxiety, thus creating a "new normal" level of anxiety. if we consider the likely general increase in anxiety and stress in the context of diathesisstress conceptualizations of mental illness, we expect that such a salient and broad reaching stressor to increase the incidence of pathological anxiety. anxiety conditions are already highly prevalent (bandelow & michaelis, ) , and we may see an increased incidence of anxiety psychopathology if the pandemic serves to push vulnerable individuals toward the expression of maladaptive levels of anxiety. moreover, those with preexisting conditions are likely to have their symptoms intensify. one could further speculate that forms of pathological anxiety will increase. first responders and hospital personnel, particularly in affected areas are already showing troubling signs of stress and psychopathology (joob & wiwanitkit, ) . it is highly j o u r n a l p r e -p r o o f likely that we will see increased rates of generalized anxiety and posttraumatic stress related to the pandemic and its sequelae. beyond the somewhat vague notion of covid- acting as a stressor to increase both normal and pathological anxiety, it is interesting to consider the specific mechanisms that play a role in this process. there are several well-established parameters that relate to the genesis and maintenance of anxiety that seem highly relevant to the current situation. these processes include perceptions relating to predictability/certainty and controllability of threat (barlow, ) . coming across a shark while swimming is quite different from viewing the same shark in an aquarium since a potential threat in the wild is far less predictable or controllable than one in an enclosure. historically, epidemics and pandemics were considered divine punishments that were essentially uncontrollable. although medical understanding of pathogens has advanced, globalization now facilitates the spread of pathological agents, which diminishes the degree to which we can control them. similarly, naturally occurring mutations and adaptation of viruses ensure that novel pathogens like covid- will emerge and spread. these conditions leave us in a state of uncertainty, except that we can be certain that covid- and other infectious agents will persist. thus, covid- affects many of the core anxiety generating mechanisms since it leads to a sense of diminished predictability and controllability along with increased uncertainty relating to a true threat. ultimately, the covid- pandemic creates an ideal environment for the onset, maintenance, and exacerbation of anxiety symptoms and syndromes. the dsm- posttraumatic stress disorder (ptsd) criterion a (american psychiatric association [apa] , , p. ) defines trauma as "exposure to actual or threatened death." individuals who are closer to that exposure --providing healthcare to those infected, witnessing j o u r n a l p r e -p r o o f the deleterious and perhaps deadly effects of the virus on patients or loved ones, enduring losses of patients, family, or friends --might experience the crisis as potentially traumatic. people on the frontlines of the pandemic, including healthcare personnel, first responders, grocery store clerks, and other essential workers, encounter the threat of possible exposure to the virus regularly and on an ongoing basis. similarly, incarcerated populations and those who might feel compelled, financially or otherwise, to work in close quarters without adequate personal protective equipment (e.g., factory workers) may be exposed to the covid- virus for extended periods without perceived or actual recourse and suffer negative mental health repercussions as a result. covid- survivors, particularly those who might have struggled through various medical procedures and prolonged hospitalizations, may emerge with unique or shared constellations of mental health reactions from risk to resilience. additional high-risk groups include healthcare professionals or first responders who may have experienced significant moral injuries (jinkerson, ; joannou, besemann, & kriellaars, ; williamson, stevelink, & greenberg, ) as a result of making unfathomable decisions on the job (e.g., providing admission or ventilator access to one patient at the sacrifice of another). yet, in addition to considering direct impacts of the novel covid- virus on our population, it is imperative to understand the secondary potentially traumatic effects of the pandemic on individuals and communities. the combination of prolonged stress, close quarters, and self-isolation guidelines has increased risk of domestic violence, child abuse, and substance use (abramson, ; national institute on drug abuse, ; santhanam, ; taub, ) . indeed, physical and sexual violence may escalate without the regular societal checks provided by employers, schools, and loved ones. furthermore, such violence may stem from and/or intensify more unbridled substance use (carter et al., ) emerging from a context where j o u r n a l p r e -p r o o f uncertainty and unpredictability are high, practical stressors (e.g., unemployment, financial stress, food insecurity) may be difficult to problem-solve, and social supports may be distant. furthermore, in this pandemic, issues of grief and loss are inevitably interwoven with those of potential trauma. spiritual and emotional grief processes to honor and emotionally mourn the losses of loved ones may be interrupted by this pandemic, potentially exacerbating or prolonging grief, traumatic bereavement, or ptsd reactions. to understand the effects of covid- on the mental health of those who experience it as potentially traumatic, we need to recognize first that the impacts of trauma may not be fully determined nor completely recognizable until after the traumatic stressor has concluded. the covid- crisis is going to have a long, yet undetermined course, and thus our ongoing reactions to it are dynamic but indicative of peri-traumatic rather than post-traumatic coping (bell, boden, horwood, & mulder, ; lapid pickman, greene, & gelkopf, ) . based upon decades of research, we can expect the majority of the population, regardless of level of proximity to or interaction with covid- , to demonstrate resilience and to recover psychologically in the aftermath of the pandemic (alisic et al., ; kilpatrick et al., ) . a relative minority, the proportions of which are unknown, may emerge from the crisis with clinical or subclinical ptsd or with exacerbation in pre-existing ptsd symptoms and related mental health conditions (e.g., depression, substance use disorder). women are at heightened risk of ptsd following potentially traumatic events (gaffey et al., ; rattel et al., ) and racial/ethnic minority populations may be especially impacted due to socioeconomic inequities and health-related disparities with regard to financial security and access to healthcare and treatment (asnaani & hall-clark, ; cross et al., ; sibrava et al., ) . the intersections of trauma and the covid- pandemic are complex. many constellations of interweaving risk and protective factors, learning histories, and life circumstances can affect how trauma histories and potentially traumatic experiences during the covid- crisis can affect individual journeys of recovery. for example, more unbalanced, negative individual interpretations of the covid- crisis and related changes in beliefs about oneself, others, or the world may have lasting deleterious effects (e.g., "i am damaged"; "people cannot be trusted"; "the world is dangerous and unsafe"; beierl, böllinghaus, clark, glucksman, & ehlers, ; bernardi & jobson, ; köhler, goebel, & pedersen, ; losavio, dillon, & resick, ; scher, suvak, & resick, ) . similarly, avoidance of thoughts or emotions related to the covid- crisis may increase the risk of developing ptsd symptoms and/or exacerbating or maintaining pre-existing trauma-related symptoms (e.g., orcutt, reffi, & ellis, ) . additional risk factors for the development or exacerbation of ptsd symptoms include a prior history of trauma or mental health disturbances, depressed or anxious mood, significant concurrent life stressors (e.g., financial problems, job loss, relationship stress), low social connectedness or support, sleep disturbance, substance use, and emotional numbing or detachment (colvonen, straus, acheson, & gehrman, ; cusack et al., ; germain, mckeon, & campbell, ; hancock & bryant, ; shalev et al., ; steenkamp et al., ; vujanovic & back, ) . navigating the covid- crisis requires a tolerance of uncertainty that is challenging for all, but especially trauma survivors who may have endured, sometimes over months or years (e.g., combat, childhood abuse), unfathomable circumstances that were, by definition, unpredictable and uncontrollable (e.g., raines, oglesby, walton, true, & franklin, ; vujanovic & zegel, ) . undoubtedly, social connection and a sense of community and collectivism, hope, psychological awareness, and healthy coping will j o u r n a l p r e -p r o o f differentiate risk versus resilience trajectories during and after this crisis (bernardi & jobson, ; long & gallagher, ; thompson, fiorillo, rothbaum, ressler, & michopoulos, ) . learning who suffers long-term negative effects of the covid- pandemic, why, and under what circumstances will help us to understand how to intervene most effectively to psychologically support trauma survivors in the aftermath of this and future societal crises. indeed, reactions of trauma survivors to the covid- crisis are also likely to be as diverse as the traumas and individuals themselves with the possibility of emergent themes. theoretically, individuals with histories of being directly impacted by natural disasters, people recovering from severe medical conditions, and those with histories of imprisonment or captivity may feel especially emotionally reactive to the large community-level impact, the social distancing and quarantining aspects of weathering covid- , and the continual perceived health threat inherent to the pandemic. individuals with interpersonal trauma histories may experience a solidification or exacerbation of maladaptive beliefs relevant to trust, safety, or power. others may feel increased social detachment or engage in increased harmful, self-injurious, or suicidal behaviors, particularly those with mood or substance use disorders. for some trauma survivors, following social distancing and self-quarantine guidelines may lead to less frequent exposure to trauma-related reminders in the outside world and/or a lower perceived interpersonal threat due to social-isolation, but increased trauma-related avoidance during the covid- crisis in turn may exacerbate ptsd symptoms in the long-term. a high-risk subset may emerge who are slow or reluctant to heed public health guidelines due to a reaction against efforts to control, an increased risk-taking propensity, all-or-none thinking, or helplessness resulting from a history punctuated by traumatic, uncontrollable events. this may lead to incessant attempts, by some, to attain perceived control via closely monitoring news, stockpiling food, or supplies, and maintaining constant vigilance. for those affected by trauma prior to and/or during the covid- crisis, the current, chronically stressful global atmosphere where uncertainty reigns may feel especially overwhelming. for others, this crisis may foster growth and resilience as they endure and overcome a crisis of epic and unimaginable proportions. obsessive-compulsive disorder (ocd) is a common ( - % incidence; (nestadt, bienvenu, cai, samuels, & eaton, ; ruscio, stein, chiu, & kessler, ) , disabling mental health condition characterized by presence of obsessions and/or compulsions (american psychiatric association, ; markarian et al., ) . symptoms present in a heterogeneous fashion across a number of dimensions, including contamination/cleaning, taboo obsessions (i.e., sexual, aggressive content), symmetry/repeating/ordering, and checking (mckay et al., ) . childhood onset occurs in over % of cases and symptoms run a chronic course without adequate intervention (pinto, mancebo, eisen, pagano, & rasmussen, ) . clinical presentation is further characterized by frequent comorbidity (stein et al., ) and variable degrees of insight (hamblin, park, wu, & storch, ) . the covid- pandemic is likely to have a number of effects on those with ocd, as well as those at risk. this includes the potential for symptom exacerbation and increased incidence of ocd cases, as well as having implications for assessment and treatment post-covid- . patients with ocd commonly present with contamination obsessions and associated cleaning compulsions (mataix-cols, do rosario-campos, & leckman, ; pinto et al., ) . some individuals with contamination related ocd have reported that their symptoms have worsened in light of public health recommendations for increased cleaning behaviors (e.g., washing, wearing masks) and other safety behaviors (e.g., social distancing, wearing masks), j o u r n a l p r e -p r o o f which may be difficult for some patients to maintain within recommended guidelines. covid- has become a feared outcome for many patients with contamination-related ocd similar to other what has been observed with other infectious diseases (e.g., hiv). outside of contamination-focused symptomology, other obsessive-compulsive symptoms may be affected such as harm obsessions whereby someone fears that they may have unintentionally spread covid- . stress has an established relationship with worsened obsessive-compulsive symptoms (adams et al., ; brander, perez-vigil, larsson, & mataix-cols, ) , and availability of coping strategies is taxed for many; this may further impact ocd symptom presentation as well as comorbidity patterns. although systematic data have not been presented, clinical accounts support symptom worsening for some affected individuals while, on balance, many others have not experienced negative symptomatic change. beyond worsening of symptoms in those with ocd, there is the possibility that there will be increased cases in the near future. this may involve those with subclinical symptoms or other risk factors experiencing onset or worsening of symptoms. the behavioral cycle of ocd/anxiety highlights the role of negative reinforcement in which rituals/avoidance are reinforced by distress reduction and creating a cognitive sense of control (i.e., not getting covid- is due to compulsions; rector, wilde, & richter, ) . in this scenario, a person with or at risk for ocd may engage in rituals/safety behaviors in response to obsessional distress which in turn reduces anxiety and is perceived as reducing the risk. reduction in distress may motivate further safety behaviors which, for some at risk, could begin to exceed recommended guidelines. while ordinary levels of risk have risen requiring increased hygiene, it remains to be seen what happens when risk levels decline. that is, do cleaning behaviors likewise decline or remain at elevated states thereby impacting diagnosis rates? assessment approaches should continue to capture j o u r n a l p r e -p r o o f obsessive-compulsive symptoms that are impairing, distressing and excessive relative to current risk levels and not count symptoms that reflect behaviors consistent with accepted public health standards. there are also treatment implications. the gold standard psychological treatment for adult and childhood ocd is cognitive behavioral therapy with exposure and response prevention (erp; mcguire et al., ; olatunji, davis, powers, & smits, ) . this treatment involves gradual exposure to triggers that evoke obsessive-compulsive symptoms while refraining from completing rituals or other avoidance behaviors. a core element to this treatment is that exposure to triggers involves exposure to 'ordinary' levels of risk. covid- understandably has shaken what is perceived as ordinary; fortunately, adept therapists have shifted their practice to utilize exposures that reflect this new normal such as relying on imaginal exposures or exposures targeting rituals in excess of public health agency recommendations. at the same time, some clinicians have negative attitudes towards exposure (meyer, farrell, kemp, blakey, & deacon, ) which is related to reduced practice of this core therapeutic technique (farrell, deacon, kemp, dixon, & sy, ) . it will be critical to provide guidelines established by expert erp clinicians for how providers integrate realistic covid- concerns into their ongoing practice, as well as that in the future. a concerning possibility is that erp treatment post-covid- is diluted by virtue of therapists not practicing exposures to the actual level of risk. cigarette smoking remains the leading cause of preventable death and disability globally. smoking may confer worse covid- outcomes given extensive evidence for the negative impact of smoking on lung health and respiratory function (tonnesen, marott, nordestgaard, j o u r n a l p r e -p r o o f bojesen, & lange, ). indeed, emerging evidence has identified smoking as a possible risk factor for adverse covid- prognosis and disease progression (patanavanich & glantz, ; vardavas & nikitara, ) . in the largest study of covid- patients, . % of severely affected patience were current smokers relative to . % of non-severe patients (guan et al., ). an inverse pattern emerged with non-smokers such that a greater proportion of nonsevere patients identified as a non-smoker relative to severe patients. moreover, . % of covid- patients who either needed mechanical ventilation, were admitted to an intensive care unit, or died from complications related to the disease were current smokers relative to . % of those not experiencing these outcomes. similar disparities in covid- severity across smoking status have been observed in other samples (w. j. zhang et al., ) . thus, these data, albeit preliminary and limited by sample size, indicate that smoking is a risk factor for covid- progression (w. . taking a biological perspective to understand why smokers are more susceptible to severe covid- symptoms, recent research has proposed that smoking and covid- susceptibility and symptom severity may be related to an upregulation of the angiotensin-converting enzyme- (ace ) receptor (brake et al., ) . ace , a membrane-bound aminopeptidase that plays a vital role in cardiovascular and immune systems, is highly expressed in the heart and the lungs (turner, hiscox, & hooper, ; wang, luo, chen, chen, & li, ) . studies have established that ace is a receptor for the covid- virus (j. , and greater ace gene expression has been observed in smokers compared to non-smokers (brake et al., ; cai, ; emami, javanmardi, pirbonyeh, & akbari, ; tian et al., ; wan, shang, graham, baric, & li, ; zhao et al., ; . the upregulation in ace creates an environment that allows greater potential for covid- to j o u r n a l p r e -p r o o f infect human cells among smokers through more opportunity to bind to this receptor (olds & kabbani, ; zuluaga, montoya-giraldo, & buendia, ) . in part, this biological mechanism may help explain observed sex differences in covid- . specifically, covid- symptom severity and mortality rates in china indicate worse outcomes for men than for women, where . % of men and . % of women are current smokers (parascandola & xiao, ; sun et al., ) . it is possible that the elevated smoking rates among men in china, and therefore greater upregulation in ace , contributed to significant gender difference in covid- incidence and severity (j. . in addition to combustible cigarette smoking, there also is growing concern for the impact of electronic cigarette (e-cigarette) use on covid- infection and disease progression (lewis, ) . although it is believed that the worldwide distribution and adoption of ecigarettes has the potential to increase population-level vulnerability to respiratory infecting diseases (olds & kabbani, ) , such as covid- , no studies have assessed e-cigarette use among covid- patients (farsalinos, barbouni, & niaura, ) . given evidence for the impact of various e-cigarette formulations on lung health and functioning (viswam, trotter, burge, & walters, ) as well as the fact that most e-cigarette users are former or current combustible cigarette users (mirbolouk et al., ) , it is possible that product use will critically impact the course of covid- among users. additionally, similar to combustible cigarette use, it has been theorized that e-cigarette use may engage an upregulation in ace that parallels that of combustible cigarette use and increases the likelihood of covid- infection (brake et al., ) . further research on these products and their influence on covid- outcomes is urgently needed. a final point to consider is the effect that the covid- pandemic itself has on smoking. one of the leading reasons for smoking is stress management (baker, piper, mccarthy, majeskie, & fiore, ; garey et al., in press) . the psychological effect of the current global environment, characterized by feelings of fear, uncertainty, isolation, and stress (mertens, gerritsen, salemink, & engelhard, ) , coupled with limited availability of adaptive coping tools due to regulations and consequences of covid- (i.e., social distancing, financial hardship) likely increases the risk for smoking onset, increased intensity, and relapse (patwardhan, ; stubbs et al., ) . smoking initiation and severity, in turn, increase susceptibility for covid- and worse disease-related outcomes. behavioral scientists must engage in targeted efforts to support current smokers and former smokers in achieving and maintaining cessation during this particularly challenging time. there are promising initial findings from smoking cessation programs implemented in smokers managing other infectious disease that may help guide some of these initiatives . as more is learned about covid- , it is imperative that health care providers assess smoking (and e-cigarette) use status as well as relapse potential among former users and provide appropriate education and intervention to help mitigate the potential risk of this health behavior on disease infection and course. the (mis)use of alcohol is a leading risk factor for global disease burden and preventable death (degenhardt et al., ; organization, ) . alarmingly, alcohol use, high-risk drinking, alcohol use disorder (aud), and alcohol-related deaths were increasing before the covid- pandemic (grant et al., ; white, castle, hingson, & powell, ) . despite the widespread belief that moderate alcohol consumption may confer health benefits (diaz et al., ; j o u r n a l p r e -p r o o f et al., ) , more recent work suggests that any alcohol consumption is associated with health risks (griswold et al., ) . in fact, given the immunosuppressing effects of alcohol both generally and in the respiratory system specifically (molina, happel, zhang, kolls, & nelson, ; szabo & mandrekar, ) , it is germane to consider the role that alcohol consumption, whether chronic or in acute response to the ongoing crisis, may have on contraction of the covid- virus. in addition to the direct physiological impact of alcohol consumption on the body, the disinhibiting properties of alcohol (kumar et al., ; oscar-berman & marinković, ) may put individuals at risk for other risky/poor decisions (george, rogers, & duka, ) . for example, those under the influence of alcohol may be more likely to violate social distance protocols, exhibit poor hand washing procedures, or refuse/forget to wear a face covering in public, leading to potential exposure to and/or spreading of the virus. importantly, impulsivity has reciprocal relationships with alcohol such that consumption increases impulsive behaviors and individuals with greater trait impulsivity (mis)use alcohol to a greater extent (dick et al., ) . moreover, the effects of impulsivity on alcohol (mis)use can be amplified by other factors, such as stress, to confer greater risk for alcohol (mis)use (fox, bergquist, gu, & sinha, ) . it is well-documented that stress, both acute and chronic, is a trigger for alcohol (mis)use (becker, lopez, & doremus-fitzwater, ; blaine & sinha, ) . the covid- pandemic has brought about both acute (e.g., work displacement, limited availability of cleaning supplies) and chronic stress (e.g., financial difficulty, isolation) that likely will contribute to alcohol (mis)use for coping. it also is reasonable to expect that alcohol (mis)use will worsen during the crisis in response to the stress and uncertainty. for example, during the - economic recession, although there was a decrease in prevalence of alcohol use overall (i.e., increase in j o u r n a l p r e -p r o o f abstainers), there was an increase in prevalence of binge drinking (bor, basu, coutts, mckee, & stuckler, ) . this suggests that there may be a realignment/concentration of problematic drinking such that a greater segment of those who do consume alcohol may be doing so in a maladaptive or harmful way. although sales to restaurants and events have reduced markedly during the pandemic, sales of online and to-go alcohol have skyrocketed (nielsen, ) . given shelter in place orders and limits on socializing, it is possible that greater amounts of alcohol are being consumed at home/solitarily relative to social contexts. solitary drinking can, in some circumstances, lead to greater alcohol consumption than social drinking (kuendig & kuntsche, ) and is associated with greater alcohol-related consequences overall (christiansen, vik, & jarchow, ) . for many, the covid- pandemic has led to significant social isolation with in-person socializing virtually eliminated and many working from home (if at all). these conditions may also exacerbate a common reason for alcohol-related relapse: boredom (levy, ) . without other adaptive ways to manage stress, socialize, or simply occupy one's mind, it is possible that craving for alcohol may intensify. finally, there are important treatment implications for alcohol (mis)use during covid- . individuals already report numerous barriers to seeking drug/alcohol treatment (mcgovern, xie, segal, siembab, & drake, ) . in the wake of the pandemic additional barriers may arise such as the perception that one's treatment is not a priority during a 'life or death' pandemic or not worth the risk of leaving one's home. alternatively, for those seeking treatment, there may simply not be local resources available or treatment facilities may have waitlists. although the use of telehealth services are growing in general (dorsey & topol, ) , there is more work to be done, with specific considerations for low-income individuals (e.g. recently unemployed) who j o u r n a l p r e -p r o o f may be reluctant to spend money on treatment, perceive treatment to be a luxury, or not have technological resources or a private location to engage in telehealth. affordable computer-based treatments without the need for a provider that focus on stress and alcohol use (paulus, gallagher, neighbors, & zvolensky, ) could be particularly pertinent during this pandemic. administration center for behavioral health statistics and quality, ) presumably due at least in part to legalization of recreational and/or medical marijuana at the state level (johnston, o'malley, miech, bachman, & schulenberg, ) . notably, cannabis users report using more cannabis during times of heightened distress following national disasters such as the september , terrorist attacks, a pattern that was especially prominent among individuals who experienced post-traumatic stress disorder and depression (vlahov et al., ) . it therefore follows that cannabis use and associated problems may increase during the covid- pandemic. cannabis use increases during times of distress to manage negative affect. in support of this contention, cannabis users report relaxation and tension relief as one of the most common reasons for use (copeland, swift, & rees, ; hathaway, ; reilly, didcott, swift, & hall, j o u r n a l p r e -p r o o f ). data from experimental studies support these self-reports. to illustrate, current cannabis users were randomly assigned to an anxiety-induction or non-anxious control condition and cannabis craving increased from before to during the task among participants in the anxiety condition, but not among those in the control condition (buckner, ecker, & vinci, ) . these data indicate that cannabis users were especially vulnerable to wanting to use cannabis during an anxiety-provoking situation, which has direct implications for the covid- pandemic characterized by heightened stress. notably, this effect was specific to cannabis craving and was not observed for craving for alcohol or cigarettes in this sample of cannabis users. coping motives are the most common reasons cited for wanting to use during laboratory-induced anxiety (buckner, zvolensky, ecker, & jeffries, ) . prospective data collected via ecological momentary assessment also confirm that anxiety is positively, significantly related to cannabis craving at the momentary level, and is related to greater subsequent craving (buckner, crosby, silgado, wonderlich, & schmidt, ) . further, although positive and negative affect were greater immediately prior to cannabis use compared to non-use episode, negative affect increased at a significant rate prior to cannabis use, and decreased at a significant rate following cannabis use; changes in positive affect were not significantly related to use (buckner et al., ) . further, the stress associated with the covid- pandemic may serve as trigger for lapse and/or relapse among individuals undergoing a cannabis quit attempt. in a qualitative interview following cannabis quit attempts, situations involving negative affect and exposure to others smoking cannabis were among the most difficult situations individuals reported in which to abstain (hughes, peters, callas, budney, & livingstone, ) . among cannabis users undoing a self-guided quit attempt, data from ecological momentary analysis indicated that although positive and negative affect were significantly higher during cannabis lapse episodes compared j o u r n a l p r e -p r o o f to non-use episodes, when negative and positive affect were analyzed simultaneously, negative affect, but not positive affect, remained significantly related to lapse (buckner, zvolensky, & ecker, ) . again, the most common reason for use cited during lapse episodes was to cope with negative affect. not only could covid- increase cannabis use, but cannabis use may exacerbate covid- symptoms given that smoking cannabis damages the lungs. respiratory toxins (including carcinogens) in cannabis smoke are similar to that of tobacco smoke but notably the smoking topography for cannabis leads to higher per-puff exposures to inhaled tar and gases (tashkin & roth, ) . further, respiratory symptoms such as chronic cough, sputum, and airway mucosal inflammation are also similar between cannabis smokers and tobacco smokers. the impact on respiratory functioning of cannabis smoke has led for the consideration of cannabis use as a pre-exiting condition that could increase the likelihood of more severe complications should one contract covid- (national institute on drug abuse, ). sleep is a fundamentally restorative process, but it is also highly responsive to stress (irwin, ) . during times of increased stress, sleep, quite paradoxically, serves both as a major line of defense and as a source of heightened vulnerability. these relationships derive from the fact that sleep and immunological functioning are reciprocally related: sleep promotes healthy immune responses and healthy immune responses (e.g., to infectious agents) promote deeper, more restorative sleep (opp, ) . precise mechanisms are of course complex, but several specific links are noteworthy. immune-signaling proteins called cytokines, such as tumor necrosis factor (tnf) and interleukin- (il- ) directly target infection and inflammation but are j o u r n a l p r e -p r o o f also known to promote sleepiness and non-rapid eye movement (nrem) sleep (jewett & krueger, ) . the hormone melatonin, which provides an endogenous marker of circadian phase peaks during the nocturnal sleep period but also has important immunomodulatory effects. conversely, the hypothalamus-pituitary-adrenal (hpa) axis and the sympathetic nervous system (sns), two primary stress response systems, are down-regulated during sleep, decreasing immune-regulating cortisol levels (besedovsky, lange, & born, ) . however, when sleep is inadequate or disrupted, alteration in these systems is readily observable. experimental sleep research provides overwhelming evidence for the detrimental effects of chronic sleep disruption on immune responses including increases in multiple inflammatory markers such as c-reactive protein, diminished immune response to vaccination, and enhanced susceptibility to bacteria and toxins (besedovsky et al., ) . rather than representing enhanced immunity, elevated levels of inflammation are associated with a range of health risks including cardio-pulmonary disease (libby, ) . sleep's inextricable role in human immunological functioning clearly place it at the forefront of critical behaviors during a pandemic. unfortunately, multiple aspects of the covid- pandemic threaten healthy sleep patterns which in turn endanger both physical and mental health. widespread uncertainty, -hour media coverage (including misinformation), fear for one's own health and the health of loved ones, and potential loss of employment/wages are but a few of the significant sources of stress present during these unprecedented times. heighted psychological and physiological arousal elicited by such stress falls in direct odds with a calm, quiescent state necessary for sleep onset and maintenance. further, common behaviors aimed at managing increased stress and anxiety such as smoking, alcohol consumption, and decreased physical activity can give rise to or worsen sleep disruption via known negative effects on sleep j o u r n a l p r e -p r o o f duration and quality (irish, kline, gunn, buysse, & hall, ) . moreover, sleep deprivation can amplify inflammatory responses (bollinger, bollinger, oster, & solbach, ) , increasing the risk for poor outcomes in covid- as unrestrained inflammation is implicated in the pathophysiology of the disease (gamaldo, shaikh, & mcarthur, ) . although predisposing (e.g., genetics) and precipitating (e.g., trauma) factors play a role, stress is considered a primary cause of insomnia (morin, rodrigue, & ivers, ) and among insomniacs, perceived inability to sleep often becomes a major source of stress in its own right. studies that have systematically examined incidence and severity of insomnia symptoms during a global pandemic are unavailable despite ubiquitous anecdotal reports and cautions from health professional regarding the immunosuppressive effects of poor sleep. however, in a recentlypublished study conducted between january and february , , c. zhang et al. ( ) surveyed medical staff responding to the covid- pandemic in china using the insomnia severity index (isi; morin, belleville, bélanger, & ivers, ) . more than a third of workers ( . %) endorsed symptoms indicative of clinical insomnia and those with insomnia reported elevated levels of depression. insomnia is well-known to herald the onset of depression both acutely and years later even among those who have never been depressed (baglioni et al., ) . studies directed at uncovering precise mechanisms of affective risk during the covid- pandemic must therefore consider the presence and severity of insomnia symptoms. the covid- pandemic also has upended daily routines and associated 'cues' that serve to maintain regular sleep schedules. working from home, altered mealtimes, increased sedentary behavior, social distancing, and increased "screen time" are only some of the changes that hold potential to disrupt circadian rhythms that govern sleep-wake patterns. other factors such as social activities also can affect sleep-wake patterns. the human internal circadian clock j o u r n a l p r e -p r o o f runs slightly longer than hours and therefore needs to be 'entrained' to the -hour day via internal and external cues (czeisler et al., ) . sunlight is the most potent exogenous cue that aligns our internal rhythm to the external environment, but quarantine measures and greater time spent indoors means that many individuals are receiving inadequate dosages of light exposure. although public health guidelines center on sufficient sleep duration (watson et al., ) , sleep timing is equally critical for overall health and well-being. misalignment of the sleep period with the body's 'biological night' is routinely linked with a host of serious risks, including anxiety, depression, suicide, cardiac events, and several forms of cancer (baron & reid, ) . healthcare workers who are working long hours and night shifts during the covid- pandemic are therefore a particularly high-risk group for circadian shifts and associated comorbidities. considering sleep's role in immunological function, this represents an area of priority for future research. the intersection of covid- with pre-existing chronic medical illness (e.g., cardiovascular disease, diabetes, hiv) raises additional challenges to the patient for managing multiple treatment cascades. these challenges are exacerbated by the poorer survival and disease course for patients with underlying medical conditions (emami et al., ) which in turn seems to be driving, in part, the alarming covid- racial disparity (laurencin & mcclinton, ) . the overlapping epidemic of covid- with hiv, for example, presents unique challenges for hiv access to care, hiv treatment engagement, and prevention. infection or if it exacerbates the likelihood of poor covid- outcomes. however, people living with hiv may have other comorbidities, such as cardiovascular disease and chronic lung disease, j o u r n a l p r e -p r o o f that increase the risk for a more severe course of covid- illness (guaraldi et al., ; guo et al., ) . there is also a concern that individuals who are immunocompromised, such as those with hiv, may be at greater risk for severe covid- symptoms (cdc, a; duffau et al., ) . in the u.s., most people living with hiv (plwh) are tested, linked to hiv care, well engaged in antiretroviral treatment, and achieve hiv viral suppression thus ensuring their optimal health and protecting the public health by containing onward transmission (cdc, b). however, structural and individual barriers to treatment and prevention create enduring inequalities and significantly increase the risk of infection, reduce access to, and engagement in, hiv care, and compromise participation in hiv biobehavioral prevention among particular risk groups. gay and bisexual men (particularly hispanic and african american men) are most impacted by hiv and account for nearly % of new hiv cases. hiv incidence rates in the u.s. are also significantly higher for those who are homeless or living in poverty (denning & dinenno, ) . with respect to individual barriers to care, plwh are disproportionally affected by traumatic life experiences, anxiety, depression, and substance use (brandt et al., ; nanni, caruso, mitchell, meggiolaro, & grassi, ; c. o'cleirigh, magidson, skeer, mayer, & safren, ) . each of these also have been associated with poorer engagement in hiv care, worse antiretroviral medication adherence, and poorer hiv disease course. their co-occurrence and interaction significantly increases both the risk for hiv infection (mimiaga et al., ) and poorer hiv disease management among those already infected (harkness et al., ; pantalone, valentine, woodward, & o'cleirigh, ) . these mental health barriers to full engagement in hiv care may well be exacerbated by increased levels of covid- specific anxieties and j o u r n a l p r e -p r o o f increases in general health-related anxieties. the requirements of social distancing also may contribute to feelings of isolation and loneliness which may in turn contribute to increased depression or depression-related withdrawal. both anxiety-related avoidance and depressive related withdrawal will likely have negative consequences for self-care generally and for hiv care specifically. these increases in distress will occur at a time when access to behavioral health services is already severely restricted. some plwh who become co-infected with covid- will already be struggling with hiv disease management (e.g., missed medical appointments, sub-optimal medication adherence) and may require additional supports to manage care and treatment at a time when many routine supports may not be available due social distancing and lack of routine medical services. protecting access to care and treatment among those already struggling with the complexities of the hiv care cascade who must now manage the additional burdens of the covid- illness is a robust clinical concern. here, we underline the importance of community (carrico et al., ) and health worker based approaches (operario, king, & gamarel, ) to hiv treatment and protecting access to care through innovative and virtual care models. many of those at risk for being lost to care during this covid- pandemic also may be vulnerable to perceived stigma (krier, bozich, pompa, & friedman, ; logie, ). many will have multiple stigmatized identities with respect to hiv status, covid- status, substance use, sexual or gender minority status, and others. keeping our community members and peers involved in our service delivery will help ensure our treatments are delivered in stigma-free contexts. empirical support for integrated treatment platforms that address mental health (ironson et al., ; safren, o'cleirigh, skeer, elsesser, & mayer, ) and substance use issues (mimiaga et al., ; safren et al., ) to protect engagement in hiv treatment and j o u r n a l p r e -p r o o f prevention (mayer et al., ; conall o'cleirigh et al., ) are available to guide these initiatives. in addition, protecting access and supporting engagement (virtual or otherwise), to mental health and substance use treatment will be critically important. these approaches may be particularly key for protecting access to hiv prevention services (i.e., hiv testing, access to preexposure prophylaxis [prep]) for those at risk for hiv. access to these services may be particularly important for those whose behavioral risk profiles and risk appraisals may be disturbed because of the impact of social distancing on usual patterns of substance use or sexual behavior. although much remains unknown about covid- and the mental health consequences of the pandemic, it is likely that regular physical activity offers protective effects. regular physical activity reduces risk of and helps manage conditions that appear to increase risk of adverse outcomes of covid- (e.g., obesity, cardiovascular disease, diabetes; lee et al., ) , and improves immune function (nieman & wentz, ) which likely positively affects the progression of covid- . it also buffers the effect of stressors and (in part thereby) can prevent the onset of mental health conditions (harvey et al., ; jacquart et al., ) . further, diminished physical activity can disrupt sleep quality (buman & king, ; youngstedt & kline, ) , which increases susceptibility to infection and mental and physical illness (see sleep section). hence, establishing or maintaining a regular physical activity habit has the potential to mitigate the impact of the pandemic both at a personal and societal level. establishing and maintaining a regular physical activity habit has proven to be challenging. indeed, only % of adults meet the guidelines set forth by the department of health and human services (whitfield et al., ) . the covid- pandemic has impacted j o u r n a l p r e -p r o o f several factors, including a change in the daily routine and increased stress and anxiety, that can affect the intent of or ability to engage in behavior change. it is important to acknowledge the relationship between factors such as stress or changes in routine and physical activity participation can vary in strength or direction (i.e., negative or positive) depending on the individual and their context. for example, for some routine changes have created barriers for exercise participation, while for others changes to the daily structure have opened opportunities to engage in regular exercise. similarly, stress and anxiety at the "right" level can be motivating for some make exercise part of their daily routine, but when stress and anxiety become overwhelming, automated emotion action tendencies often cause people to move away from healthy (coping) behaviors such as exercise (otto et al., ) . importantly, such relationships may further vary within and across individuals depending on other individual difference variables (e.g., risk factors, protective factors, [mental] health diagnosis) and contextual factors (e.g., job loss, financial stress, isolation). research aimed at understanding the relationship between covid- and physical activity mostly likely will benefit from considering the importance of individual differences and the influence of contextual factors. comprehensive assessment batteries and statistical models that include the testing of these complex moderation effects are key. this perspective that acknowledges nuance in the relationship between covid- (pandemic) and physical activity also will aid efforts to develop or fine-tune intervention programs for physical activity uptake. the covid- pandemic, although still ongoing and presently under investigated from a behavioral health perspective, is apt to impart acute and potentially chronic exacerbations in psychological symptoms and disorders, addictive behavior, and health behavior and chronic j o u r n a l p r e -p r o o f illness. across various phenotypes overviewed in the current essay, previous scientific work and theoretical models predict covid- , regardless of acquisition of the virus, has and will continue to have a strong negative psychological impact on negative mood states, various forms of substance use, and sleep, chronic illness, and physical activity. although many of these relations would be expected, theoretically, to be negative, select subgroups will certainly adaptively respond to covid- related stress (e.g., improve their physical fitness, improve self-care routines, quit/reduce maladaptive behaviors that place them at risk). in this final section of the paper, we discuss sociocultural considerations, developmental issues, and the role of individual difference factors for covid- -related psychological, addictive, health behavior and chronic illness. we conclude by offering an integrative covid- model that could be used to guide research focused on the stress-related burden of the pandemic. certain subpopulations and contextual factors (e.g., loss of work) are likely to signify a vulnerability gradient for covid- in terms of mental health, addictive behavior, and health behavior. although there are numerous possible sociocultural factors that could be relevant, we highlight first responders and medical professionals, economic adversity, and racial/ethnic factors as three prototypical factors of public health importance. of all the sectors of the population, first responders and front-line healthcare professionals are arguably at the greatest risk for at least acute disruptions in anxiety, stress, and negative mood. first responders and healthcare professionals at the front line of the covid- pandemic have at their core mission to protect and preserve life (prati & pietrantoni, ) . these groups, although engaging in a diverse range of specific occupational activities (e.g., direct medical care, transport, public safety j o u r n a l p r e -p r o o f enforcement), share in common that they are among the first to respond to the covid- crisis and take primary responsibility for attending to covid- related health issues. first responders and healthcare professionals are undoubtedly experiencing emotionally challenging and unpredictable situations that can place their lives in danger. the acute emotional effects of managing covid- cases is likely to be amplified by heavy work schedules and reduced access to and isolation from social support systems (e.g., self-isolation after finishing a shift). it is likely that first responders and healthcare professionals working with covid- cases in hospitals will be exposed to potentially traumatic events, the greater-than-usual experience of life-threatening situations, working with emotional strain related to isolation of patients from their families (e.g., compassion stress in the form of offering emotional support to patients in a manner that family or caregiver of patients would typically offer), and exposure to the struggle to life and death. these experiences are apt to challenge the coping resources of even the most seasoned professionals, which can result in higher degrees of anxiety, stress, and depressed mood (lafauci schutt & marotta, ) . such elevated stress levels are likely to be related to changes in cognition and physical health, including emotional exhaustion, fatigue, sleep dysfunction, and problems with interpersonal relationships (kronenberg et al., ; lane, lating, lowry, & martino, ) . cognitive-based beliefs about personal safety and health can be altered and memories of potentially traumatic events engrained (setti & argentero, ) . collectively, the covid- related stress burden, as discussed in several sections of the current essay, will have a high likelihood of being related to increased risk of anxiety and depression for first responders and medical professionals working at the front line. moreover, consistent with past literature of these populations, the regulation of affect will be associated with addictive and health behavior to modulate such affect (e.g., physical activity, substance j o u r n a l p r e -p r o o f use). although some regulatory behavior will be adaptive (e.g., increasing sleep where possible to aid in recovery, engaging in regular physical exercise), others may be less adaptive (e.g., smoking to reduce stress) and promote the risk for other health problems (e.g., physical illness). economic adversity. economic hardship related to covid- is already evident at numerous levels of analysis, including job loss, reduced earnings, higher debt relative to assets ratio, inability to pay mortgage and bills, meeting governmental guidelines for poverty status, and worry about financials resources going forward due to the turbulent nature of the economy. past work has shown that economic hardship is related to behavioral health problems, including psychological disorders, addictive behavior, physical health problems, and interpersonal dysfunction in adults and children (k. j. conger et al., ; sareen, afifi, mcmillan, & asmundson, ) . for instance, economic adversity has been linked to reduced social competence and elevated physiological markers of stress (k. e. bolger, patterson, thompson, & kupersmidt, ; evans & english, ) . further, economic hardship is related to selfregulation capacity and the corresponding difficulty in dealing with additional responsibilities. for example, past work has found limited socioeconomic resources are related to harsher parenting behavior and greater substance use (r. d. conger & donnellan, ) . the negative effects may be particularly profound when economic hardship is severe or chronic (dearing, mccartney, & taylor, ; magnuson & duncan, ) . the totality of worsening economic conditions for individuals and families in the larger context of an uncertain economic future are apt to be related to elevations in anxiety, stress, and depression as well as other negative emotional states (e.g., anger, frustration, fatigue; newland, crnic, cox, & mills-koonce, ) . such emotional symptoms and problems are likely to be related to elevations in substance use and other maladaptive behavior (e.g., less supportive interpersonal behavior, less affection) and j o u r n a l p r e -p r o o f may exacerbate chronic health conditions. other work has found that these processes also disrupt social interconnections (scaramella, sohr-preston, callahan, & mirabile, ) . primary care givers who have children home from school, are unlikely to be able to work at their full capacity even with added flexibility in schedules. although certain occupations have decreased activity, many have not. therefore, it could be expected that for individuals with added responsibilities of educating their children at home occupational stress may be greater compared to those without such responsibilities. further, it is possible that the accumulation of occupational responsibilities that are not addressed for persons with additional educational responsibilities will accumulate and make it more challenging to recover when going back to 'normal,' resulting in a greater degree of occupational stress. grappling with lower socioeconomic states related to covid- will, for certain segments of the population, offer an additional psychological challenge. indeed, past work has repeatedly documented that lower socioeconomic status is related to adverse health outcomes for chronic illness and mortality rates (adler et al., ; adler, boyce, chesney, folkman, & syme, ) . moreover, harms faced by people who cannot afford not to work in dangerous settings can exacerbate the psychological and health risk associated with coid- . further essential workers are more apt to be persons of color (handerson, mccullough, & treuhaft, ) . certain groups will be more likely to recover than others, which past work indicates is related to poorer health outcomes even at higher socioeconomic levels (kraus, borhani, & franti, ) . moreover, research has found that lower socioeconomic persons experience more chronic stress and negative life events (stansfeld, north, white, & marmot, ) . additionally, lower socioeconomic status is related to cognitive biases for threat (chen & matthews, ) , which engender greater degrees of interpersonal conflict and heightened negative emotional states j o u r n a l p r e -p r o o f (matthews et al., ; stansfeld, head, & marmot, ) . it would be expected that such negative emotional experiences will be related to maintained direct relations with poorer health behavior and health outcomes (mcewen & stellar, ) . in fact, research has consistently found that lower socioeconomic status is related to greater degrees of anxiety, stress, and depression when compared to those higher in socioeconomic status (mcleod & kessler, ) . this heightened stress reactivity may be at least in part attributable to having fewer resources. consequently, those struggling with a lower socioeconomic status due to covd- may be more contexts in which they must utilize their emotional resources and be less likely to be in a sociocultural context wherein such resources can be replenished (holahan, moos, holahan, & cronkite, ) . this perspective is in line with past work that has found that when persons are exposed to chronic stress, emotional resources are challenged, and there is a greater risk for future emotional distress (n. bolger & zuckerman, ; ensel & lin, ) . there is broad band evidence that significant health disparities exist for persons of racial/ethnic minority in the u.s. and beyond prior to covid- for psychological, addictive behavior, and health behavior as well as chronic illness. for example, african american/black individuals experience a disproportionate burden in disease morbidity, mortality, disability, and injury (mechanic, ; mensah, mokdad, ford, greenlund, & croft, ) . indeed, african american/black individuals remain significantly and consistently more at risk for early death than do similar non-latinx white individuals (williams, neighbors, & jackson, ; williams, yu, jackson, & anderson, ) ; overall early death rates of african american/black individuals are comparable to those observed among non-latinx whites in the u.s. decades ago (levine et al., ; williams & jackson, ) . differences in prevalence and rate of growth of chronic illness are not accounted for solely by j o u r n a l p r e -p r o o f exposure to lower income environments (franks, muennig, lubetkin, & jia, ) . indeed, social determinants of health (e.g., racism; krieger & sidney, ) , addictive behavior (e.g., tobacco use; sakuma et al., ) , and stress represent robust and consistent factors related to health inequalities among african american/black individuals and those from other underrepresented racial/ethnic groups. the covid- pandemic has appeared to strike racial and ethnic minority populations (e.g., african american/black) hard and with possible longerterm consequences. for example, less access to health care services for chronic illness, addictive behavior, and mental illness could exacerbate covid- related symptoms or promote a greater degree of stress-related burden associated with the pandemic (e.g., worry that loved ones, if infected, cannot access care). consequently, addictive behaviors (e.g., smoking, alcohol misuse) and health behaviors (e.g., disrupted sleep, emotional eating) may be used in the short-term to cope with such covid- related stress, increasing the longer-term risk for more severe negative emotional symptoms and health complaints (e.g., pain) and chronic health problems (e.g., obesity). additionally, situations characterized by mass fear and confusion, such as the current pandemic, also can elicit a human instinct to resolve the confusion and mitigate the fear by identifying a culprit for the introduction or spread of the disease (bard, verger, & hubert, ; bromet, ) . asian american persons are one group that has been singled out as responsible for the covid- . the misdirection of fear and/or anger related to covid- toward a racial or ethnic group instead of the disease, however, can perpetuate fear and contribute to racism and stigma. several reports have already documented the rise in violent crimes and discrimination experienced by asian american persons related to covid- beliefs (e. liu, ) . covid- specific language, such as referring to covid- as 'the chinese virus,' has created a platform j o u r n a l p r e -p r o o f to propagate stigma and discrimination towards asian americans. it is likely that stigma and discrimination experienced by asian americans in response to covid- will increase emotional distress, coping-oriented addictive behavior, and may alter health behavior or exacerbate chronic illness. it would also be remiss to not call explicit attention to the fact that societies marked by greater economic and social inequality experience far more medical, psychological, and social pathology than do societies where such wealth inequalities are less pronounced (wilkinson & pickett, . further, such adverse effects occur across social classes, not merely among the most disadvantaged. yet, the adverse effects of economic (and thus social) inequality hurt everyone, although the poorest or most marginalized are affected the most (pickett, kelly, brunner, lobstein, & wilkinson, ; wilkinson & pickett, ) . there are far-reaching implications for psychological health, addictive behavior, and health behavior from a developmental perspective. for children, despite covid- appearing to have less severe symptoms and lower mortality rates than other age groups, are among the highest risk groups (sinha et al., ; zimmermann & curtis, ) . estimates suggests that there are over billion children not in school (cluver et al., ) . the economic impact of covid- will likely be related to greater risk for children to be utilized to offset such financial hardship (e.g., selling merchandise on the street, forced begging for food and goods) and be a more likely to be abused (campbell, ) . for example, it is possible that children will be more likely to be used for child labor and be exploited for sexual behavioral and experience corresponding risk for sexual disease and pregnancy as well as serious psychological distress. interpersonal violence and child abuse will affect children at a significant rate, especially under j o u r n a l p r e -p r o o f conditions wherein there is no oversight from educational systems due to quarantine. world health organizations are already predicting an increase in children who will be orphaned and exposed to abuse and neglect (cluver et al., ) . child abuse is less likely to be detected during the covid- pandemic because the reduction or lack of child protection agencies monitoring cases, and teachers less able to detect signs of abuse. further, children who received meals at school through government programs such as the national school lunch program may now no longer have access to nutritious food, which can negatively impact their development. the lack of structure from schooling and missed education will have a lasting impact on well-being and apt to be related to increased anxiety, depression, and stress about educational attainment and progress going forward (van lancker & parolin, ) . although on-line school may help offset some of these challenges, disparities will exist for those who are most vulnerable, including those who lack internet access or cannot afford technology. older children and young adults may be more likely to drop out of school to help offset family needs. children and youth also may be engaging in more on-line behavior in general or due to emotional distress (e.g., loneliness due to social isolation) and be increasing the chance for solicitation from others who prey on their emotional vulnerabilities (peterman et al., ) . lacking access to physical activity due to quarantine protocols may reduce fitness levels and immunological response as well as decrease psychological wellbeing (rundle, park, herbstman, kinsey, & wang, ) . children and youth in juvenile systems, such as orphanages, already were exposed to high density living conditions and often lack access to proper medical or psychological care. the covid- pandemic is likely to place pressure on such systems (e.g., more children) and the physical environments of these settings may be amenable to the spread of infection. likewise, refugee or otherwise displaced children and youth often live-in high-density environments j o u r n a l p r e -p r o o f wherein social distancing is challenging if not impossible. further, lack of access in these settings to cleaning supplies and water can catalyze the spread of covid- or even the basic fear of acquiring the virus. to the extent the covid- challenges the medical system, it is possible other forms of medical care necessary for child welfare (e.g., routine exams, immunizations) will be reduced, as was the case during other pandemics such as ebola (mupere, kaducu, & yoti, ) . collectively, covid- places an enormous stress on children and youth, placing them at an increased risk for psychological disturbances and physical health vulnerability (j. j. liu, bao, huang, shi, & lu, ) . covid- also will affect ranges of the lifespan, including adults and older adults. the well-publicized health risks for older adults place an obvious psychological and health pressure on this group. older adults are among the most likely to have a chronic illness (e.g., diabetes, cancer, cardiovascular disease) and consequently they maintain an increased vulnerability to deteriorating health and death from covid- . however, even in the absence of exposure to the virus, the fear and worry about contracting the disease is apt to be significant for this group, especially when in homecare facilities such as nursing homes or hospitals (armitage & nellums, ) . this group also is at significant risk for lacking transportation for food, which could challenge the quality of nutrition and have a negative effect in immunological function. similarly, older adults are among the least physical active groups, which again, will have the potential for decreasing psychological wellbeing and immunity. although not specific to older adults, the potential for disruption in grief and loss of others also is a significant psychological stressor. during the pandemic, regular methods of grieving such as funerals have been limited if not all together impossible. the inability to grieve with others or as traditionally done may spur escalation in psychological distress (e.g., sadness, j o u r n a l p r e -p r o o f depression) and complicate the grief process (wallace, wladkowski, gibson, & white, ) . to the extent that grief is impaired, individuals may engage in maladaptive addictive behaviors (e.g., alcohol misuse) to cope with the aversive experiences. similar types of emotional reactions may occur when parents are separated from their children due to quarantine protocols and disruptions in travel (e.g., cannot travel to see children located in another region). there are several individual difference factors at a psychological level of analysis that will place people at an increased or decreased risk for psychological problems, addiction, and poor health behavior, and chronic illness during and after the pandemic. research over the past few decades has theorized and found consistent empirical support for emotional symptoms and disorders as well as addictive behavior being explained by individual differences in transdiagnostic processes (sauer-zavala et al., ) . transdiagnostic factors may contribute to onset, maintenance, and exacerbation of emotional symptomatology and addictive and health behavior. a core aspect of transdiagnostic models is that they seek to identify basic processes underlying multiple, usually comorbid, psychopathologies or addictive behavior. one set of transdiagnostic factors relevant to covid- may be those that are "reactive" vulnerabilities; that is, individual differences that reflect a heightened emotional response to stressful stimuli. such vulnerabilities influence emotion experience by enhancing or diminishing the normative response to emotion stimuli and states, resulting in an excess or deficit, respectively, beyond typical emotional functioning; or altering the type of response to emotion stimuli and states (gratz & roemer, ; reiss, ; zvolensky, bernstein, & vujanovic, ) . in both instances, such reactive processes may be maladaptive because they serve to j o u r n a l p r e -p r o o f reinforce the intensity and frequency of future emotional symptoms. for example, when faced with negative emotion states, individuals with an emotional vulnerability factor that limits their capacity to handle distress may be more apt to execute behaviors that preclude habituation to negative emotion states, which could ultimately increase the intensity of future negative affect and solidify beliefs and learned responses that interfere capacity to adaptively respond to distress. to illustrate, a transdiagnostic factor that may be especially relevant to covid- related stress responsivity, substance use, and physical health is anxiety sensitivity (taylor, ) . anxiety sensitivity is a malleable, cognitive-affective factor reflecting the tendency to respond to interoceptive distress with anxiety (mcnally, ) . anxiety sensitivity is related to, yet distinct from, negative affectivity and trait anxiety (keough, riccardi, timpano, mitchell, & schmidt, ) . anxiety sensitivity has demonstrated racial/ethnic, gender, age, and time invariance (ebesutani, mcleish, luberto, young, & maack, ; farris et al., ; jardin et al., ) . given covid- can produce physical sensations and even when not infected, covid-related stress can elicit a range of interoceptive sensations, persons higher in anxiety sensitivity may be more be emotional reactive to such stimuli and engage in behavior to dampen stress symptoms (e.g., using tobacco, alcohol). for example, persons may interpret the onset of aversive bodily sensations (e.g., runny nose, cough, fever) as intolerable or catastrophic, exacerbating the experience of such interoceptive symptoms. further, interoceptive symptoms might be particularly salient to persons with higher anxiety sensitivity who are prone to health inequalities (e.g., racial/ethnic minorities, persons in financial stress), as they may be more apt to perceive these internal sensations as uncontrollable because resources to regulate symptoms (i.e., adaptive cognitive and behavioral skills) are likely diminished due to chronic stress exposure j o u r n a l p r e -p r o o f (e.g., low socioeconomic status, discrimination). in turn, persons higher in anxiety sensitivity may be motivated to use substances to reduce emotional and interoceptive distress, elevating their chance for physical illness and compromised immune system function. although this illustrative example represents only one of many possible transdiagnostic amplifying factors, it draws attention to the fact that individual differences in psychological processes are apt to play a central role in the relation between covid- related stress and mental health, addictive behavior, health behavior, and chronic illness. individual difference factors also may play roles in offering resilience to covid- related stress. that is, individual differences may contribute to the likelihood of a resilient response to covid- in the short and long term. thus, in addition to the many situational and contextual factors, individual difference factors will likely shape the level of resiliency to covid- pandemic. here, it is likely individual difference factors that de-amplify stress responses will play a central role in offsetting relative risk for psychological, addictive, and health behaviors problems and exacerbation of chronic illness (pidgeon & keye, ) . as with affect amplifying factors, such as anxiety sensitivity, there most certainly is a range of factors of potential importance, including flexible coping repertoires, mindfulness, self-efficacy, selfcompassion, and proneness to experience positive affect. to illustrate, individual difference in the capacity to accept difficult covid- related stress may offset the potential escalation of anxiety, stress, and depression and mitigate the need for addictive or unhealthy behaviors (e.g., emotional eating) to delimit aversive internal experiences (ranzijn & luszcz, ) . consequently, the corresponding risk for health complaints or worsening of chronic health conditions can be offset. indeed, there is a large theoretical and empirical literature that suggests the capacity to accept difficult emotions experiences is related to psychological well-being and j o u r n a l p r e -p r o o f adaptation. for example, one of the reasons meditative practice is related to decreased stress is via change emotional acceptance (teasdale et al., ) . this type of work has robust implications in efforts to intervene on covid- related stress in the immediate context and for those that struggle to regain stability and growth in the future in terms of mental health, addictive behavior, and health behavior. despite the present lack of systematic empirical work on covid- in terms of behavioral health problems, there is good theoretical basis from past scientific work to hypothesize that covid- related stress burden, due to a myriad of sources, may play a major vulnerability role in terms of mental health, addictive disorders, and health behaviors as well as chronic illness. for some, the stress-related burden of covid- may elicit fundamental changes in risk potential and serve as a fertile basis for future behavioral health problems. for others, the ability to adapt to covd- will offer a different course; one that is characterized by greater stability, speed of recovery, and growth. further, it is important to recognize that the adaptation process to covid- related stress is apt to be non-linear in many instances. that is, contextual factors (e.g., future life stressors, access to social support) can influence the degree of risk for future problems. research described in this essay provides a basis to develop a theoretical model that could be used to evaluate covid- related stress burden on psychological, addictive, and health behaviour problems. we therefore begin this section by briefly outlining a general model that can be used as a heuristic for understanding the complex issues at hand. see figure for a graphical depiction of the model. in general, we predict individual differences in affect amplifying and de-amplifying factors will predict the course of psychological, addictive behavior j o u r n a l p r e -p r o o f and health behavior and chronic illness even when considering differences in exposure to covid- experiences (e.g., time of quarantine, acquisition of virus). we would predict, based on past work that transdiagnostic affect amplifying factors will influence addictive and health behaviour, which in turn, will increase (or decrease if de-amplifying) the risk of chronic illness and psychological problems and their comorbidity. further, we can expect that this type of perspective will be moderated by daily stress in the future and access to stress-dampening resources (e.g., social support). accordingly, certain subgroups more prone to greater and more chronic stress, such as first responders and racial/ethnic minorities and orphaned children, may be particularly vulnerable. this conceptual model predicts that the associations which exist between are reciprocal and dynamic. although the model offered here is purposively general and is offered only as a heuristic, it is presumed that there is, in fact, specificity between specific affect amplifying and deamplifying factors, moderators, mediators, and various forms of psychological and chronic illness. that is, a specific type of individual difference factor like anxiety sensitivity is linked to a particular type of problem (e.g., anxiety disorder, worsening of a chronic respiratory illness, severity of hazardous drinking) via a specified mediating process (e.g., smoking, sleep disruption) in the context of certain moderating variables (e.g., higher levels of covid- stress burden). the core idea being that the underlying mechanism in this hypothetical example may be quite different from that explaining other problems. the above theoretical model requires empirical testing, and if it is confirmed, one next logical step would be to intervene in it to reduce the burden of mental health, addictive disorders, poor health behaviours, and chronic health conditions related to covid- stress burden. ideally, this type of intervention approach would target the root of the pathway, including affect j o u r n a l p r e -p r o o f amplifying (i.e., decreasing levels) and de-amplifying (i.e., promoting growth). however, intervention efforts sit in the fact that the healthcare system will continue to shift and adapt to treatment delivery, including the uptake of digital health technologies. digital health, including mobile health (mhealth), telemedicine/telehealth, and health information technology (e.g., mobile phones, wearable sensors), can be used to develop scalable interventions to promote adherence public health guidelines for mitigating the spread of covid- . they also can be combined with greater attention to affect amplifying (i.e., decreasing levels) and de-amplifying (i.e., promoting growth) factors that govern many psychological, addictive, and health behaviour processes. here, there is great opportunity for growth of digital health interventions to offer standalone clinical grade therapeutic tactics and as an adjunct to face-to-face interventions. this type of work can close the gap in access to care and offer evidence-based interventions to large segment of society. for example, digital interventions can be used to combat resistance to public health measures at the level of individuals and institutions with a consideration of individual difference factors that affect emotional and behavioral self-regulation. indeed, the public's response to public health measures is itself a potential risk and protective factor for many of the psychological, addictive, and health behavior problems reviewed in this essay. the public health impact of covid- on psychological symptoms and disorders, addiction, and health behavior is substantial and ongoing. there is a need for financial and social investment in research to better understand how covid- affects the onset, maintenance, and relapse potential for some of the most common, costly, and chronic behavioral health conditions in the general population. further, there is a need for the study of the role of psychological processes, addictive behavior, and health behavior in terms of the onset and maintenance of j o u r n a l p r e -p r o o f covid- infection and stress burden. there most certainly will be a demand for preventative and intervention efforts for managing the impact of covid- among individuals with elevated negative mood symptoms and disorders, addictive behavior, and certain health behaviors (e.g., sleep disorders) and chronic illness. this work is important to offset the current and projected burden to personal, system, and societal entities, and for providing a theoretical and empirical knowledge base for future pandemics. we presented a heuristic model, which posits that covid- related stress and mood, addictive, and health behavior may, in fact, exacerbate each other via several distinct mechanisms. future research in this emerging area has the potential to refine both theory and application with respect to covid- and its relation to affect, addiction, and health behavior as well as chronic disease. j o u r n a l p r e 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prevention options in children. the pediatric infectious disease journal are the high smoking rates related to covid- outbreaks? distress tolerance: theory, research, and clinical applications we wish to draw the attention of the editor to the following facts which may be considered as potential conflicts of interest and to significant financial contributions to this work zvolensky receives personal fees from elsevier, guilford press, and is supported by grants from nih he receives research support from nih, texas higher education coordinating board, rebuild texas and greater houston community fund. he receives travel support and honorarium from iocdf for training in ocd treatment schmidt is supported by the military suicide research consortium (msrc), department of defense, and visn mental illness research, education, and clinical center buckner receives funding from the u.s. department of health & human services' graduate psychology education (gpe) program (grant d hp ) smits reports grants from cancer prevention and research institute of texas; personal fees from big health, ltd., personal fees from aptinyx, inc., personal fees from elsevier vujanovic receives book royalties from routledge press and is supported, in part cleirigh is supported by grants from the nih and the centers for disease control and prevention we confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed he/she is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. we confirm that we have provided a current, correct email address which is accessible by the corresponding author and which has been configured to accept email from mjzvolen@central key: cord- -xpa sxt authors: mcfee, robin b. title: gulf war servicemen and servicewomen: the long road home and the role of health care professionals to enhance the troops' health and healing date: - - journal: disease-a-month doi: . /j.disamonth. . . sha: doc_id: cord_uid: xpa sxt nan become more familiar with these illnesses such as malaria, leishmaniasis, brucellosis, and others given the likelihood our returning troops may be so infected and requiring timely diagnosis and appropriate treatment. , , , , , , , the roles of women in the military have changed. , , , unlike in prior wars, there are significant numbers of women in all military branches of service deployed overseas and in combat theaters, performing a wide array of operating specialties beyond medical and communications. although women have typically been assigned to activities that were not considered direct combat roles during times of war, albeit females have done dangerous jobs including being pilots during world war ii to the present, in the current war in the persian gulf, the distinction between combat and noncombat roles have become almost meaningless given adversaries do not wear uniforms, and confrontation has become urban warfare using guerilla tactics against any us troop, convoy, or post regardless of military designation. as such, women, thought to be in "safer" roles such as convoy drivers, find themselves in the "front lines" facing ied and other weapons just like their male counterparts. in addition to combat-related injuries and the stressors of war, women face discrimination and many are at risk for sexual abuse, victimization, and assault, often from servicemen. , , , of note, male servicemen have reported sexual abuse. nevertheless, women in the persian gulf face a complex array of biopsychosocial stressors not necessarily faced by their male counterparts. these new threats can pose significant challenges to female military, warranting the attention of civilian and military medical professionals. from substance abuse, combat, infections, sexual abuse, and mental illness, troops about to be deployed to or returning from the persian gulf, as well as their families, face potentially significant medical, psychological and financial challenges. , [ ] [ ] [ ] , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in an era of limited surge capacity, the complex needs of our returning troops will require civilian health care professionals (hcp) to provide much of the care and fill looming voids. physicians and other clinical hcp have long been taught that one of the keys to evaluating and effectively treating a patient is having an appropriate framework or pathway for diagnosing, and treating, which includes referral to specialist care, and follow-up. context is critical and no less so for our patients who are about to leave for or return from the persian gulf war. these patients face enormous threats and are at risk for a complex array of biomedical and psychosocial morbidities, some of which may go undiagnosed and impair the patient's return to normal social function. beyond devastating wounds, the sometimes more subtle injury-tbi, which is becoming a significant and important pattern of injury in the current pgw, tbi can negatively impact social and work functions. , , , , , [ ] [ ] [ ] posttraumatic stress disorder (ptsd), tbi, and other biopsychosocial injuries may be contributing to the worrisome rate of homelessness that is afflicting returning pgw ii troops. , , given our goal as hcp should be to facilitate the returning servicemember's ability to reenter society and to function in daily life, learning about the threats they faced, the medical issues requiring care, and the resources they will need is essential. taking the time to obtain a thorough history is critical to assessing the symptoms and ultimately making the correct diagnosis. a comprehensive physical examination can help the hcp, given many biomedical exposures or injuries, such as tbi, present with symptoms similar to psychiatric illnesses like ptsd. patients may have both-yet each require highly specialized care and long-term follow-up. civilian medical resources are often untrained in the nuances of military care. the following monograph describes and discusses many of the challenges our persian gulf troops will face in the hope it will better prepare civilian health care professionals provide appropriate services, address gaps in resources, promote collaboration between biomedical and psychosocial professional disciplines, and ultimately assist our patients to successfully reenter society. war, adolescents, and the middle east (figs and ) "never in the field of human conflict was so much owed by so many to so few."-winston churchill these words were uttered by prime minister churchill at parliament in tribute to the pilots of the royal air force (raf); an iconic speech in its historical significance and, perhaps cautionary or prescient in wisdom. many of those raf pilots were adolescents, frighteningly outnumbered by the luftwaffe, but were nonetheless, able to protect great britain and defeat the nazis. the fate of the world often rests on the shoulders of our youth. the cause of freedom often depends upon our younger generations. indeed, throughout history, awesome responsibilities have been placed on adolescents. many of the servicemen and servicewomen participating in operation iraqi freedom (oif) and operation enduring freedom (oef) are between the ages of and ; adolescents by medical definition. , such incredible responsibilities undertaken far from home, while experiencing new and vastly different cultures, and being subjected to dangers and violence on a scale beyond comprehension, are the reality of these warrior-adolescents. no one could debate the horrors these young people see on a daily basis, nor the impact-physical, psychological, and social-that they face on their tours of duty and will continue to cope with upon their safe return, god willing, to the united states, great britain, or other coalition nation. they age from adolescent to adult in the first battle. yet they are still adolescents. when they return, we must adapt the health care we deliver to address this hybrid of battle-tested adolescent-adult, addressing the full realm of needs and helping this individual to be able to return to some developmentally appropriate normalcy. [ ] [ ] [ ] the major spheres of influence of an adolescent must be addressed and restored-family, friends, career, close relationships, personal development, health behaviors. [ ] [ ] [ ] however, adolescents are not the only ones who fight wars. adultssingle, married, parents, male, and female. most of us imagine the return home to be joyous and fulfilling, will it be if someone has been wounded? , , , , , , [ ] [ ] [ ] or if someone has lost their job? or has lost the loved one who was supposed to be waiting at home? or meeting children who in return are facing a stranger because they were babies when dad (or mom) deployed? what readjustments will those returning face that we can assist as their health care provider? , while ptsd is expected, so should substance abuse. tobacco use among troops is highly prevalent. often they smoke non-u.s. cigarettes; what health risks beyond the norm would be expected from smoking local tobacco products? do our communities have the resources for returning troops? the veterans administration (va) cannot and will not take care of all the returning troops. what can we do as physicians to fill the voids? the role of the physician has and should always be, in its noblest form, both healer and patient advocate. in our daily practices delivering high-quality health care can be a challenge in the midst of a seemingly dizzying array of insurance plans, financial and time constraints, and a host of other competing issues that impact upon access, cost, and quality. the most dedicated clinicians often aide their patients in fighting for coverage, care approvals, or access to medications even when "the system" seems stacked against the patient. now imagine an adolescent who has returned from battle, having seen the horrors of war, only to find his or her job has not been preserved, or medical care-physical or psychological-is beyond reach because of either cost, access, or quality? it is challenging enough for adults with good jobs and years of life experience to often obtain appropriate care; think about the returning soldier, sailor, or marine returning from a war zone! we often consider medical care of the military to be the responsibility of military facilities like the va hospitals, base infirmaries, and the department of defense (dod) manage care support contract (tricare). yet over one-third or our military in the persian gulf are reservists, not full-time active duty military. these are our neighbors, coworkers, and fellow citizens who thus obtain their health care from the nonmilitary medical worldprobably us! as such, they are likely to return to our practices when they come home from war. how many of us in health care have been in the military or in a war zone? yet we will be called upon to help our patients come to grips with such experiences. moreover, how familiar are we with the many challenges these people will face-interacting in a "peaceful" society, returning to work "business as usual," receiving appropriate psychosocial and medical care attuned to the risks and threats of living in the middle east or other far off lands? as of april there were over . million active duty men and women in the u.s. armed services and over . million reservists. , , almost % are women across the various services, with the highest percentages in the air force, navy, and army. there are over , u.s. troops in the persian gulf-most are in iraq but there are thousands in afghanistan, kuwait, bahrain, turkey, and other countries in the middle east. most of the troops are men. however there are a significant number of women serving in uniform as well. while women are generally not assigned direct combat missions, the nature of the urban or guerilla warfare in iraq, especially, brings the battle to posts and roles not designated as combat operations. nevertheless, the carnage is real; so are the injuries-mental and physical. women serving in the gulf as elsewhere must deal disproportionately with sexual abuse and gender discrimination within the u.s. military and often make accommodations to local cultural customs discriminatory against women that these servicewomen would not face in the u.s. the military operations in afghanistan and iraq represent the largest and most sustained ground combat involving u.s. armed forces since vietnam. unlike world war i and ii, where large forces engaged each other, in uniform and en masse, the modern wars our troops face employ guerrilla warfare tactics using surreptitiously deployed weapons that include the omnipresent roadside ieds and combat against enemies that do not wear a uniform and can be indistinguishable from the majority of the civilian population. in addition, some of the troops have had multiple tours of duty. the likelihood of surviving wounds that in prior wars would have been fatal sets the stage for troops seeing and possibly experiencing horrific wounds, scarring, burns, blindness, or multiple amputations. , , , this type of warfare sets the stage for increased medical and psychological illnesses including ptsd, depression, and substance abuse. unlike previous wars where the number of deaths mirrored closely the number of wounded, improved battlefield medicine has allowed seriously wounded troops to survive, albeit with loss of limbs or multiple limbs. are our practices attuned to the special needs of multiple-prosthetic amputees? how many patients with traumatic amputation have we treated? their needs go beyond stump maintenance-self image, ptsd, retraining for a career, and living with a lifelong disability will be essential components of the long-term care. in addition, there are numerous potential toxic and infectious exposures our troops face that are uncommon in the u.s. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] while the u.s. military may be sensitive to environmental toxicants, the local practices of developing nations may preclude such safety concerns. moreover, abandoned chemicals, the intermingling of pesticides, motor oils, and other potential toxicants can impact patients variably. are there health effects from depleted uranium and, if so, who do we contact? would we be able to identify intermediate syndrome? how would we approach oif/oef patients with diverse symptoms of unrecognized etiologies, and do we have appropriate resources such as a toxicology service? the desert region has numerous endemic illnesses ranging from parasites and bacteria, even unusual outbreaks of potentially deadly viruses. [ ] [ ] [ ] [ ] [ ] , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] how many of us have seen a case of dengue or leishmaniasis except in a textbook or lecture? , , , , , or treated a case of q fever? , would we be able to differentiate the neurobehavioral effects of brucellosis from the symptoms of ptsd in a returning gulf warrior? , , , , [ ] [ ] [ ] [ ] [ ] how long should we be vigilant for signs and symptoms of malaria from a returning soldier who presents with fever? , most of the troops have folks at home who love, depend upon, and worry about them. what is the impact of the gulf war on families? , are we the health care provider to someone who has a son or daughter, husband or wife, brother or sister, close friend in uniform and in a war zone? what special needs do/will they have that we should anticipate and provide? these may include acts of kindness, not just biomedical care. a random call "how are you doing? have you heard from (the person in uniform)? need to talk? got a support network (friends, family, clergy)?" as physicians, we are in a trusted position to ask and a leadership position to try and help. these are times that call upon us to go beyond the mere medical care. yes, we all perform in an era of multiple competing demands. many of our colleagues may even be against the u.s. participation in the gulf. however, we should learn from the lessons of vietnam and separate our feelings about the war from those for the warrior-our patient. in the following sections we will discuss the changing nature of battlefield injuries and the impact on survivors and their families, the endemic illnesses of the persian gulf, approaches to ptsd and other threats to health, psychosocial issues, as well as emerging resources under development and yet to be realized for the care of our returning troops. military personnel receive medical care based upon a variety of factors often associated with their "status"-active or career military, reservist/national guard, retired, or veteran of a war. families are often included. of note, many receive their care from the civilian health care community owing to the fact a significant proportion of troops and their families are not active military but in fact drawn from reserve and national guard units. , [ ] [ ] [ ] [ ] [ ] , , many military families also receive their health care off base. lessons learned from gulf war i raise the question, will the va and domestic military health care facilities have the capacity to treat the complex and often highly specialized needs of all the returning troops? , , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] military health care includes tricare/champus (civilian health and medical program of the uniformed services) and champva (civilian health and medical program of the department of veterans affairs), as well as care provided by the department of veterans affairs. , , tricare/champus. tricare or champus is a military health care program for active duty and retired members of the uniformed services, their families, and survivors and certain former spouses worldwide. as a component of the military health system, tricare brings together the health care resources of the uniformed services and supplements them with networks of civilian health care professionals, institutions, pharmacies, and suppliers to provide access to health care services while maintaining the capability to support military operations. to be eligible for tricare benefits, it is necessary to be registered in the defense enrollment eligibility reporting (deer) system. tricare offers several health plan options. currently there are about . million enrolled beneficiaries. military treatment facilities (mtf) available for tricare beneficiaries include military hospitals, medical clinics, and dental clinics. some civilian medical facilities and health care providers also accept tricare but not universally. in the event a va or mtf is not available to certain returning troops or their families, it is important to work in the community to assist with access to care, especially given the expected biomedical and psychosocial morbidities associated with the current gulf war. champva. champva is a medical program through which the department of veterans affairs helps pay the cost of medical services for eligible veterans, veterans' dependents, and survivors of veterans. veterans administration. the u.s. department of veterans affairs is responsible for providing a wide range of benefits to over million u.s veterans and their families. this includes the almost , u.s. men and women who served in the first gulf war build-up and combat from august to june . currently there are approximately va facilities, although the actual number of hospitals, medical sites, and clinics is much less. according to the va, a "medical facility" includes a va health system facility, va medical center, outpatient clinics, community-based outpatient clinics, and veterans' centers, the latter being a place for "counseling" for servicemember and his/her family. excluding these veterans' centers, there are approximately facilities where medical treatment can be obtained. major benefits provided by the va include health care and disability compensation for illnesses and injuries incurred on military service. the disability compensation includes monthly monetary distributions based upon the degree of disability for service-related injuries or diseases among veterans. a stipulation of benefits is the identification of health risks during military service. the demonstration of such risks can be straightforward such as battlefield wounds or contentious as continues to be seen by the gulf war i health effects controversy which will be discussed in the next section. gulf war syndrome. during the first gulf war of - (pgw i) nearly , u.s. troops were deployed to the persian gulf region. , , [ ] [ ] [ ] , , , , of concern, a significant proportion of these troops began presenting with a wide array of medical complaints in the years following the end of the war and their return to the u.s.-often referred to as gulf war syndrome (gws). gws is sometimes referred to as chronic multisystem illness (cmi). , over in u.s. veterans has sought federal health care and % of united kingdom gulf war veterans describe themselves as suffering from gws. , gw veterans' health problems began to emerge in the early s, often soon after their return to the u.s. [ ] [ ] [ ] [ ] [ ] [ ] [ ] , however the majority of research was not initiated until or later. [ ] [ ] [ ] moreover, many of the veterans' concerns and symptoms were invalidated or attributed to psychiatric illnesses. information about possible exposures to chemicals or other environmental risks was also delayed, including information about the detonation of a chemical weapons facility. these delays may compromise some of the value of research results. therefore one important lesson learned is to value the concerns of returning troops. after numerous studies, including a -year follow-up, cmi continues to be more prevalent among deployed than nondeployed veterans. of concern is cmi, which has yet to be adequately characterized or diagnosed, nor have etiologies been clearly identified; will it become a problem among current or gulf war ii troops? whether called gws or cmi, symptoms usually include but are not limited to fatigue, musculoskeletal pain, sleep disturbances, cognitive dysfunction, moodiness, and other symptoms. these symptoms also had an impact upon veterans being able to sustain employment and impacted activities of daily living. among those with persistent medical complaints, approximately , have been enrolled in a variety of registry and examinations programs. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] similar symptoms have been experi-enced by british, australian, danish, and canadian troops deployed during pgw i. most of these studies and registries report increased numbers and severity of virtually all symptoms when compared with personnel not deployed in the persian gulf region. numerous potential culprit etiologies have been suggested. concerns arose within the veterans administration and department of defense (dod) whether veterans of gulf war i have a medical illness of undetermined etiology? conspiracy theorists opined that dod was withholding information about possible exposures and undisclosed chemical or other weapons of mass destruction (wmd) operations and that the u.s. government had much to lose by admitting an illness since a military-associated medical illness would result in an enormous cost of benefits given the va provides monetary and medical benefits for military-related disability. the government did not divulge the destruction of a nerve agent chemical plant at khamisiyah until a few years after the war. nevertheless, the dod and va expended enormous resources and undertook numerous studies including collaboration with the institute of medicine-a highly regarded scientific organization and other prestigious, independent research organizations such as the national academies of science, the uk royal society and medical research council. , , resulting research suggested that gws was not an easily defined, known disease entity, nor was it, as initially thought, a classic psychiatric disorder. ptsd was present but not in sufficient quantity to account for what was emerging as a significant health problem. what has been observed, and persists, is a large number of symptomatic veterans in ill health. concerns were also raised about undisclosed biological and chemical weapons as well as countermeasures. military planners expected biological and chemical weapons. as a result, the dod authorized a variety of countermeasures be administered to the troops. these included the controversial anthrax vaccine. the british provided their troops with vaccines against anthrax, plague, and pertussis. in some epidemiologic studies, an interaction between unexplained symptoms and receipt of anthrax vaccine, receipt of multiple vaccines and place of vaccination were discovered. , evidence of cellular immune activation in a cohort years after pgw i was also detected. not all ill health were accounted for by these findings. it is well known in health care that no medical intervention-be it antidote or preventive measure, is a free ride; virtually all carry side effects. moreover, while individual countermeasures may have been studied by their manufacturers and other medical researchers and evalu-ated by the food and drug administration, the potential for adverse events by the concomitant administration of multiple countermeasures has not been well tested. troops in the gulf may ostensibly become a vaccine-adverse event research cohort. some coalition forces also received pyridostigmine bromide to counter the threat of nerve agents and pesticides, the latter being used throughout the theater of operations to reduce the enormous threat of insects and the diseases they transmit. the military also provided n,n-diethylm-toluamide (deet) and permethrin insect repellants. a study at duke university conducted animal experiments on the combination of countermeasures and insect repellants-deet and permethrin used by the various militaries. they found that the insect repellants and the nerve agent preventive agent pyridostigmine bromide (bp) were harmless when used alone but could be highly toxic when combined. the researchers suggest that their findings explain the symptoms reported by an estimated , gulf war i veterans. these symptoms include respiratory complaints, digestive and skin disorders, fatigue, and memory loss. some exhibit limb pain or numbness and recurring rashes. the researchers suggest the combination can cause neurological defects. their results are consistent with a study by the university of glasgow that identified in a small group of subjects a pattern of nerve damage. another study demonstrated damage to their immune system in some pgw i troops. scientists agree it is unlikely there is a unique disease to account for gws but more likely several etiologies based upon exposures and other yet to be identified influences. also worth noting is the wide array of insect repellants used by locals in the desert who do not have access to safer, modern alternatives; these older agents can behave like weakened nerve agents. sarin originated as an organophosphate pesticide. those exposed to organophosphates, especially over time, or nerve agent victims, even when treated rapidly and appropriately, may exhibit long-term sequelae that include nightmares and personality changes. some allied troops were potentially exposed to the chemical warfare agents sarin and cyclosarin when the munitions facility was detonated in khamisiyah, iraq. numerous studies have been conducted to evaluate the possible association between proximity to khamisiyah and a wide array of symptoms from troops in that area at the time of detonation. except for a trend towards more diagnosis of any type of cancer, no other long-term health effects were associated with the detonation at khamisiyah. the battlefield by definition is a dangerous place, made so by ubiquitous chemicals, oil well fires, depleted uranium, pesticides, explosion plumes, aerosolized dust and fumes, and other hazards. depleted uranium has been implicated for some of the health effects of gws but it alone cannot account for these given troops in rear areas or sailors-both groups without exposure to depleted uranium experienced similar symptoms to those in proximity to depleted uranium. multiple chemical sensitivity and mycoplasma species have also been suggested. again, studies fail to implicate these in all but a few cases. with the magnitude of troops in pgw i experiencing the variety and severity of symptoms, clearly there is a problem. what the answers are to the gulf war health problem remain elusive. to be sure, the etiology(s) of gws is not a one-size-fits-all answer and the links between cohorts or the ability to assign etiologies to groups has been difficult even after years of research. troops were exposed to chemicals, infections, and combinations thereof, which have not been experienced on such a scale in the past and thus the science must in effect catch up with the symptoms. with the dizzying array of chemicals and potential combinations of environmental contaminants, toxicants compounded by the horrors of war, continued research is necessary. nevertheless, a key lesson learned from pgw i that can be applied to the current persian gulf experiences is to give the returning troops the benefit of the doubt, obtain a thorough medical, exposure, travel, and occupational history. infections, military medical countermeasures, environment or battlefield chemicals, and the experience of war can create a dynamic interplay of multiple morbidities confounding diagnosis. often there is tremendous therapeutic "relief" that results from validating the patients' concerns. the dod and va have developed a variety of resources included web-based risk communication and clinician implementation support (http://www.pdhealth.mil) and complementary tool kits (http://www.pdhealth.mil/clinicians/pdhem/ toolkit/view/ /guideline_ver . .doc) and practice guidelines (http:// www.oqp.med.va.gov/cpg/cpg.htm). returning gulf war ii troops may pose complex diagnostic challenges and require long-term medical and psychosocial support and care but data suggest early treatment offers the greatest promise for enhanced quality of life and likelihood of recovery. biomedical issues. there are over , troops deployed in the persian gulf. according to a cnn review of pentagon figures, u.s. servicemembers have died so far in . the next highest death toll was in , when were killed. combat-related injuries are typically the most severe and dramatic health risks encountered during military conflicts. of note, historically it has been the noncombat injury and illnesses that have had a significant impact on military missions. , in this section we will discuss the combat-related injury, especially tbi and those resulting in amputation, followed by infections that may manifest in illness either in the gulf or when the serviceman or woman returns home. , , [ ] [ ] [ ] [ ] , , , , , large numbers of u.s. troops are returning from southwest asia, an area where numerous endemic infectious illnesses, desert illnesses, and insect-borne diseases are pervasive. our returning troops may present with infections that are not common to the u.s. but may have initial symptoms that could be misattributed to common, relatively harmless domestic illnesses. studies suggest clinicians do a poor job of inquiring about recent travel and diagnosing travel-related illness. in fact, less than % of patients with a confirmed travel-related illness were asked about travel; this resulted in delayed or missed diagnosis. [ ] [ ] [ ] this is a cautionary tale to remind us to inquire about deployment, military experiences-even the monthly and yearly obligatory domestic deployments of reservists, and travel out of the war zone, realizing each country presents an often unique set of risks. as it is likely civilian physicians will provide care for a significant proportion of returning gulf war troops, a familiarity with the medical problems they face-combat and noncombat-is essential to anticipating the needs of the troops and ultimately providing the best biopsychosocial care. combat-related injuries. much of our knowledge concerning combat wounds has been derived from prior gulf war and other military operations. operation iraqi freedom is the first large-scale combat operation since pgw i that involves the u.s. marines. one of their combat surgical companies has provided updated information for consideration; most wounds were the result of high-explosive weapons/munitions such as mines and grenades, with % of the wounds to the extremities. of note, military blast exposure, mostly in the form of roadside ied, continues to be the primary mechanism of injury. , , [ ] [ ] [ ] [ ] in , the u.s. military reported , ied attacks; an average of /day. new combat body armor can protect troops from penetrating ballistic injury such as bullets but does not provide significant protection against ied, especially blast overpressure, which will be discussed in the following section. [ ] [ ] [ ] explosives and blast injury (fig ) . bombings and the use of explosives represent the majority of terrorism-related mass casualty incidentsdomestic and foreign, as well as a significant proportion of injuries in oif and oef. explosives inflict damage by creating a rapid release of energy in the form of gases and heat, depending upon the type of explosive used. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] from a terrorism perspective, there are four categories of explosives ranging from ( ) projectiles such as missiles; ( ) those set to explode when triggered by a target such as land mines; ( ) passive weapons detonated remotely; and ( ) weapons (usually of category ) designed and placed to produce the greatest degree of physical and psychological damage. the latter two are used most often in modern insurgencies. there is also a phenomenon referred to as "overpressure" with high explosives. , , the flames, "rush of air," and pressure changes all cause injuries. the chain of events beginning with the initial blast determines the general and neurological injuries that the victim sustains. the mechanism of injury resulting from explosives includes (fig ) primary blast injury, secondary, tertiary, and quaternary blast inju- ries. [ ] [ ] [ ] [ ] blunt, penetrating, and thermal injuries are all possible as well as psychological trauma. in addition, patients can experience exacerbation of underlying medical conditions such as asthma and hypertension. primary blast injury. conventional explosives generate a biphasic blast wave (friedlander wave form) that spreads from the primary point source. , the first phase is a high-pressure shock wave of very brief duration. it is followed by the second phase-the blast wind, which is air in motion, and how the phrase "winds of war" emerged during the civil war, when observers found some of the dead on the battlefield did not have visible wounds. injuries from the initial blast are the direct result of blast overpressure on tissue; the outcome differs comparatively concerning hollow or solid organs. [ ] [ ] [ ] [ ] , , among the organs most susceptible from blast overpressure are the ears, the lungs, the gastrointestinal tract, and the brain. these organs are most affected as a result of the interface between a solid or liquid and air. as the pressure wave passes through the tissue, the molecules of the solid or liquid are thrown into the gas media. , , bowel perforation can be acute or delayed as a result of blast injury. the colon is more susceptible than the small bowel, owing to the relative air in the former. of note, the patient who may have lung or brain injury from primary blast injury may not appear to have been injured! stories from ww ii of troops found dead with apparently no injuries, when autopsied, were found to have extensive pulmonary and/or brain primary blast injury. pulmonary barotrauma is the most fatal of the primary blast injuries. , , disruption caused by pressure differentials across the alveolar-capillary interface can lead to hemorrhage, pulmonary contusion, which on chest x-ray results in the classic "butterfly" or bihilar pattern, pneumothorax, pneumomediastinum, and subcutaneous emphysema. these can also lead to air embolism resulting in ischemia and hypoxia. , , disseminated intravascular coagulopathy is possible (dic). the ear is the most vulnerable to blast overpressure. , , , rupture of the tympanic membrane (fig ) is a sentinel finding of blast exposure and can occur at a relatively low pressure differential. recall the "ear pain" during the landing of an airplane. as little as psi above atmospheric pressure can rupture the human eardrum. the injury is dependent on the orientation of the ear to the blast. , , middle ear and inner ear damage can also occur. some key signs that may not have been disclosed in the war zone but may be revealed at home include vertigo, tinnitus, otalgia, hearing loss, and bleeding from the external canal. partial or total hearing loss can complicate triage since the victims will have difficulty following verbal commands and difficulty answering questions. in a recent study of battlefield blast injury victims in iraq, researchers noted a significant association between tympanic membrane perforation and loss of consciousness. , this association between barotraumatic tympanic membrane perforation and concussive brain injury suggest clinicians encountering patients with ear-related complaints should have a high index of suspicion for concomitant neurologic injury including tbi. , , , secondary, tertiary, and quaternary blast injuries. secondary and tertiary blast injuries can result in penetrating wounds. secondary blast injury results from flying debris. , , this also results in blunt injuries; penetrating injuries result from fragmentation. approximately % of blast survivors will have eye injuries. signs and symptoms include pain, irritation, foreign body sensation, hyphema, globe damage, altered vision, and periorbital swelling. in tertiary blast injury the patient becomes a missile and can become impaled or hit a hard surface. , , , this can result in a combination of penetrating and blunt injuries such as fractures, closed and open, brain injuries, etc. quaternary blast injuries are the most random of blast injuries and are caused by circumstances associated with the explosion, such as structural collapse, release of dust, toxins, chemicals, even effects of fire. carbon monoxide and/or cyanide from incomplete combustion of synthetic materials used in new construction is possible. therefore, in addition to the blast effect, thermal injury is possible and can cause first-, second-, and/or third-degree burns in addition to other traumatic injuries. traumatic injuries and traumatic brain/neuro injuries are discussed in the following sections. [ ] [ ] [ ] [ ] , while there are many other mechanisms of injury associated with explosives-ranging from crush injury, traumatic asphyxia, and others, they are beyond the scope of this monograph. , , however, the use of combination weapons that include chemicals has resumed in iraq. in early april , several chlorine gas suicide attacks occurred in iraq, including a truck bomb explosion in ramadi, releasing chlorine and killing at least people. these attacks have resulted in numerous injuries and deaths and raise the specter of greater use of chemical weapons by terrorist groups worldwide. chlorine is the prototypical moderately water-soluble irritant gas. it has been reported that hamas used pesticides, rat poison, cyanide, and even infectious agents as part of their improvised explosive devices. traumatic injury/amputations. injuries resulting from war can produce a myriad of emotions. , [ ] [ ] [ ] [ ] [ ] [ ] , the needs of those who suffer amputations are interrelated but distinct from other injuries. , [ ] [ ] [ ] , , amputations or blindness result not only in the loss of body function, which is significant in itself, but also are dramatic insults to the patient's psychological sense of body integrity, self-image, competence, and worth. in addition to the loss of sight or limb(s), these wounded must often endure other injuries and psychological traumas, which cannot be underestimated or underemphasized. attendant to these wounds are fears of persistent threats, anxiety about military career being curtailed, and response from loved ones. reactions to past experiences in addition to the above set the stage for complex, tumultuous emotional struggles. while any of these challenges can overwhelm a person's psychological equilibrium, taken in totality, all of these set the stage for exceptionally devastating physical, psychosocial hurdles. studies reveal a variety of emotions after the initial trauma and throughout the rehabilitation process in the amputee-depression, anxiety, resentment, anger, fear, helplessness, hopelessness, grief responses, relationship difficulties, and body image problems. , , , , also phantom pain is likely in some. changes in physical appearance may complicate personal relationships. family members may need extensive assistance in adapting. patients have fewer emotional problems and good social support had better outcomes adjusting to prostheses. clearly a biopsychosocial approach to the blinded or amputee is necessary to promote psychological and physical healing and a successful return to family and society even with the new limitations. newer and more advanced prosthetics have been developed which increasingly mimic much of the natural function of native limbs. we are, however, a distance from the "bionics" and superreal prosthetics made famous on a variety of television shows. nevertheless, amputees face better opportunity for increased function than in the past. notwithstanding, the road is long and rehabilitation often painful, discouraging, time consuming, and potentially expensive even with benefits. evidence suggests, after a traumatic lower extremity amputation, admission to a specialized inpatient rehabilitation program significantly improves functional and vocational outcomes, as well as reduces bodily pain. , the u.s. military has two major centers for amputees-walter reed army medical center including their psychiatric consultation liaison service and brook army medical center in texas. reservist/ national guard troops will likely receive their care, at least initially, from the military. however, civilian clinicians may be called upon, as the patient transitions home, as well as caring family members. amputees go through a variety of emotional and physical rehabilitative changes in addition to social ones. amputees often are concerned about if and how relationships with friends and family will change. their anger may manifest in different ways and be targeted to family, friends, even health care professionals. patients must be allowed to find healthy ways to communicate but hcp should be able to tolerate the expression, especially early in the aftermath as a normal response to a horrific, life-changing event. later, amputees may start expressing fears about sexual functioning. , , [ ] [ ] [ ] allowing the patient to address these issues openly, and, facilitating such dialogue among partners, is enormously helpful. amputee patients can more effectively be treated if addressing the needs of the patient's family. loved ones may want to spend time with their injured family member. of concern, they may not, and reasons should be addressed. , these include fear of what to say, guilt, squeamishness looking at the wound, and other issues. children, though often more resilient than given credit for, should nevertheless be assisted in understanding and integrating the experience in a less traumatic fashion before encountering the amputee. , , [ ] [ ] [ ] a variety of resources are being developed to care for the traumatized patient. the va and other military medical facilities are improving their mental health services and emphasizing the need to collocate them with orthopedic and other medical services. different rules may apply to disability benefits concerning active duty compared to reserve or national guard. whether military or civilian, it is important to address patient concerns and their future goals. moreover, it is important to assist them in achieving realistic goals. some do not want to give up their uniformeither out of duty or out of fear of losing career and being unable to support their family. traumatic brain injury (tbi). tbi may become the "signature wound" of the global war on terror and pgw ii given the ubiquitous nature of explosions, especially in iraq. [ ] [ ] [ ] [ ] blast injury is the most common cause of war injuries; different than in prior wars such as vietnam when ballistic projectiles caused a significant proportion of injuries. according to the defense and veterans brain injury center, tbi afflicts between and % of military service members. so far, several thousand have been treated for it, while thousands are believed to be undiagnosed. , primary blast injuries to the brain and spinal cord include blast wave induced concussion as well as barotrauma caused by acute gas embolism, which can produce ischemia and infarction. loss of consciousness and contrecoup/coup injuries are possible. of course, the severity of wounds will differ depending upon proximity to explosion, body armor, and other factors. there are many causes of head trauma. these include blast exposure, gunshot wounds, and motor vehicle injury. according to military data, troops in iraq experience one explosion a month, on average. each blast raises the risk that the next one will do harm. a blast creates a sudden increase in air pressure followed by a rapid decrease in pressure. [ ] [ ] [ ] [ ] , [ ] [ ] [ ] [ ] these pressure shifts can injure the brain directly, producing contusion or concussion. air emboli can also occur, resulting in infarcts. neurological injuries resulting from explosions are the result of a complex cascade of physical and biological events. a pressure wave from the blast courses through the brain, initiating the damage. while severely injured troops are supposed to be screened for head trauma, others who were not obviously injured but were nevertheless rendered unconscious may not present for care nor be considered victims of head injury. however, the group of troops who are rendered unconscious are at risk for tbi and may develop difficulty concentrating, manifest increased irritability or other signs and symptoms but remain undiagnosed. because behavior-related injury such as ptsd has been considered a disorder associated with malingering, the symptoms of unrecognized tbi can as well, further confounding the situation. much of what we know about head injuries are from prior wars, sports concussion patients, and civilian tbi literature. lessons learned from oif and oef will undoubtedly provide additional information. diagnosis. while there are screening/assessment tools available, diagnosing tbi, especially combat-related, is imprecise. the diagnosis remains largely based upon clinical signs and symptoms in addition to a thorough history that includes detailed information about how the patient is adapting to and conducting activities of daily living and, of course, if in proximity to an explosion. different syndromes are identified relative to the effects of the trauma and resulting hemorrhage, barotrauma, edema, and tissue disruption. dyspraxia, dysphasia, executive dysfunctions, paralysis, deficits and dysfunctions of the special senses, and mood disorders can occur and evolve. , , , symptoms include frequent headaches, dizziness, and difficulty with concentrating and sleeping. depression, irritability, and confusion may occur. some patients may be easily provoked or distracted. speech and/or vision may be impaired. many of these symptoms overlap with ptsd. , , - , , - some tbi victims have been misdiagnosed with personality disorders and lost their jobs upon returning to the u.s. because of unrecognized and thus untreated symptoms. fortunately most tbi are mild and most patients recover within a year. however, one of five troops with these "mild" injuries may still have prolonged, even lifelong symptoms requiring continuing medical care, according to military estimates. walter reed army medical center categorizes the severity of tbi according to the duration of loss of consciousness and posttraumatic amnesia as follows: • mild tbi: an injury causing x loss of consciousness for Ͻ hour or x amnesia lasting Ͻ hours x patients usually do not have visible abnormalities on brain imaging • moderate tbi produces x loss of consciousness lasting between and hours or x posttraumatic amnesia for to days • severe tbi causes x loss of consciousness for more than hours or x posttraumatic amnesia for more than week brain imaging studies. of note, patients with moderate or severe tbi may have punctate hemorrhages visible in the corpus callosum and other regions, as well as evidence of bleeding or swelling on brain imaging studies. , , , patients with minor tbi may not have visible abnormalities. nevertheless, such testing should be obtained and consultation with neuroradiologists, neurology, and neuropsychology specialists in brain injury is important and should be done early. it is important to remember that troops are proud and thus may be reluctant to seek help for what is seemingly an innocuous injury on par with "getting your bell rung" in a football game. nevertheless, it is important to ask patients who have been in a war zone, especially oif and oef, about exposures to explosive events and perform a thorough evaluation, documenting the functional status. although not considered combat troops, it is important to screen female troops as well; many have been exposed to ied. if in doubt, consider referral to health care facilities specializing in tbi. treatment. the usual approach to tbi patients is to work on specific symptoms and deficits-headaches, anxiety, vision problems, memory, and attention span. , , , , , to date, there is no "cure" for the injury itself. a multidisciplinary approach is required and clinicians should be knowledgeable about local resources to refer suspected brain-injured patients, neurological and psychological hcp with expertise in the treatment of such patients. it is important to explain to the returning pgw ii patient that you are not sending him/her away, that you are enlisting the services of experts but are going to be engaged in the process and help both the family and the patient through this. [ ] [ ] [ ] [ ] [ ] medications as needed can be utilized to manage epilepsy and headaches; those with fewer cognitive side effects are preferred compared to older ones, which can compound patient challenges. given that the diverse nature of the neuropsychiatric sequelae of tbi and that the trajectory of recovery can continue for several years, medications should be selected that take into consideration adverse effects and impact on daily living. mood disorders, epilepsy, and memory deficits can develop within the first years of injury. psychosis can arise up to years and dementia can occur later during the lifespan of the patient. it is worth recognizing that poverty and disability are interconnected. social, familial, and financial support are important, in addition to appropriate medical and neuropsychiatric care. some states are being very proactive; illinois officials have implemented a plan that would screen members of the state's national guard for tbi and provide a -hour hotline with psychological counseling and other interventions. stories persist of troops who were in close proximity to explosions but were considered "unwounded" because they did not have obvious injuries. these troops are now developing behavioral and memory problems and have clearly been injured by the blast. given there can be a time delay between blast and neuropsychiatric symptoms, the astute clinician will be attuned to this issue when caring for returning troops. in the majority of cases, explaining what is occurring, helping the patient and friends cope with some of the challenges, referring to appropriate care, and conveying "tincture of time"-time to heal, is the normal course of illness can be very reassuring. prevention. can tbi be prevented? newer body armor and kevlar helmets have allowed troops to survive attacks. the current helmets utilized among the four services in oif and oef were designed to protect against ballistic projectiles and shrapnel, not necessarily blast injuries. as a result, open head injuries have been significantly reduced; closed head injuries as discussed above now outnumber penetrating ones, which, for obvious reasons, are easier to diagnose. some of the standard issue padding is either uncomfortable or inadequate in providing appropriate stability, protection, or comfort. as a result, either the troops do not wear the helmets or the equipment may not provide adequate protection during an explosion. upgrades are being developed. a civilian charity-operation helmet-has been providing free of charge advanced padding systems that troops can install in their helmets. research into new helmets designed to better protect against explosions is ongoing. infections. infections remain a leading cause of death worldwide. , , while the u.s. has been able to significantly control many of the infectious diseases and/or vectors that continue to afflict much of the rest of the world, global pathogens remain a threat to the u.s. nevertheless. , , , our troops will face two primary sources of risk for infection-wound-associated and endemic infectious diseases. [ ] [ ] [ ] [ ] [ ] [ ] , , , , what follows is an overview of the most important exposures that may persist in the patient post deployment and thus may be brought back into the u.s. for civilian physicians to diagnose and treat. wound infections/colonization. nosocomial infection with multidrug-resistant acinetobacter baumanii occurs in u.s. hospitals but has emerged as a significant problem among wounded troops and military medical facilities. , a. baumanii can cause wound infections, osteomyelitis, urinary tract infections, and respiratory infections. not surprising, there is a geographic component to infectious threats. multi-drug-resistant a. baumanii infections are described as epidemic among wounded in iraq, compared to afghanistan. of concern, nosocomial transmission of a baumannii within walter reed army medical center resulted in infections and four deaths. as a result, wounded patients are often isolated upon return to the u.s. until they are cleared of a. baumannii. infection control is good medical practice. it is important to address nosocomial infections, especially given the commonplace nature of this problem in u.s. hospitals. while the organism may be different in civilian health care facilities compared to combat hospitals, nevertheless, unnecessary deaths and protracted illness occur because of inattention to infection control measures as basic as handwashing and separating dirty from clean activities. endemic infectious diseases: overview. during u.s. military deployments over the last years, the four most commonly reported diagnosis categories have been non-combat-related orthopedic injuries, respiratory infections, skin diseases, and gastrointestinal infections. clearly infectious illness is a leading cause of morbidity in the gulf. , , , [ ] [ ] [ ] , , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] given hundreds of thousands of u.s. servicemembers have been deployed to afghanistan and iraq as well as other middle east and southwest asian nations since , it is important to discuss the common and/or chronic infections that may occur or persist upon the return of troops. , , , , of note, there are both similarities and differences in infection risk concerning iraq and afghanistan ; it is worthwhile inquiring as to the countries the returning serviceman or woman has been deployed to as well as countries visited on r and r, which can include qatar, bahrain, and other middle east locations, remembering that the incubation periods of endemic illnesses can be quite long-infection can occur in one region with symptoms evolving elsewhere. infection during deploy-ment may not manifest until return from overseas and the astute clinician will be alert to unusual signs and symptoms. what follows is a discussion of the infectious agents that already have caused illness or pose a significant threat especially if left undiagnosed. infectious diarrhea. during the early stages of oif and oef large outbreaks of norovirus and shigella infections resulted in severe gastroenteritis. , - seventy seven percent of personnel deployed to iraq and % of those deployed in afghanistan reported at least one episode of diarrhea. personnel in iraq tended toward more severe symptoms, longer duration of illness, and greater likelihood of multiple episodes that correlated with local food consumption. in the summer of a surveillance study revealed that % of troops in iraq had multiple episodes of diarrhea. , [ ] [ ] [ ] field tests found enterotoxigenic escherichia coli and enteroaggregative e. coli as the most common pathogens. entamoeba histolytica and other protozoans were found. in another outbreak of diarrhea involving u.s. troops revealed Ͼ % were infected with cryptosporidium species. soldiers who present post deployment with chronic diarrhea should be thoroughly evaluated including consideration of post infection irritable bowel syndrome and for parasites such as giardia, cryptosporidium, and entamoeba. leishmaniasis. , , , , , , , , , in Ͼ cases of cutaneous leishmaniasis (cl), and between and cases of cl and cases of visceral leishmaniasis were diagnosed in u.s. soldiers deployed in iraq, afghanistan, and kuwait. , , from march to june an estimated % of deployed u.s. ground forces were diagnosed with leishmaniasis. leishmaniasis is a sandfly-borne parasitic disease caused by protozoa that live inside mammalian macrophages. this is problematic given u.s. troops suffer intense vector exposures and report receiving numerous insect bites. the high season for insects runs from april to december. as part of a prevention strategy and control research over , sandflies were collected from sites throughout iraq; between . and . % of flies were infected with leishmaniasis. of concern, use of insect repellent seems to be problematic among troops. in one study of troops infected with old world cutaneous leishmaniasis (owcl), % said they used insect repellants but % said that appropriate vector control was unavailable at some point during their deployment. , in another study, . % reported using deet more than occasionally and . % never used it. only . % believed the product was safe. clinicians caring for reserve and national guard members should counsel their patients that deet, especially - %, is a safe and effective measure to reduce the risk of insect-borne illness. owcl is usually associated with the species leishmania major and leishmania tropica. leishmaniasis infection is characterized by diverse clinical manifestations ranging from asymptomatic infection to self-limited cutaneous disease to life-threatening visceral disease. , , there are three major clinical patterns of leishmania disease: ( ) visceral disease, in which the parasite replicates throughout the reticuloendothelial system (res); ( ) cutaneous disease, whereby the parasite replicates in the dermis of the skin; and ( ) mucosal disease, whereby illness involves the naso-oropharyngeal mucosa. cl or owcl is the most common of the three patterns. , , , , , in patients with cl, Ն skin ulcer (fig ) or nodule forms in the absence of fever, anemia, hepatomegaly, or splenomegaly. it may self-heal without medical intervention in to months. however, it can also, albeit uncommonly, disseminate locally with subcutaneous nodules or regional lymphadenopathy. l major and l. tropica can evolve into diffuse cutaneous leishmaniasis. the presentation of cl among u.s. troops is generally chronic, painless skin lesion(s), which are often ulcerative, with a dry, scaling eschar. of note, the appearance of the skin lesion can vary. old world visceral leishmaniasis disease (owvld) usually begins in the absence of recognizable skin lesions or scars. leishmania illness is associated with l. infantum and l. donovani. , these species are also more likely to cause chronic, reactivating illness. owvld can be asymptomatic, subclinical, or symptomatic. symptoms of owvld include irregular or chronic high fever, cough, weight loss, hepatosplenomegaly, lymphadenopathy, and fatigue, with labs consistent with anemia and pancytopenia. in the immunocompromised, those coinfected with immunosuppressing or other pathogens such as human immunodeficiency virus, in the malnourished, or in young children, visceral leishmaniasis can be fatal. among the troops infected with visceral leishmaniasis the incubation period is varied but could be prolonged as much as months after returning from the combat theater. specific parasitological diagnosis requires tissue biopsy specimens from bone marrow, liver, lymph node, or spleen; the latter should be avoided for risk of hemorrhage. treatment with liposomal amphotericin b has been effective. diagnosis depends on parasitological confirmation from skin scraping, slit skin smear, or biopsy. culture and polymerase chain reaction (pcr) permit speciation; species identification may have an impact upon management strategies. treatment for l. major, which is usually self-limited but can persist up to months, includes watchful waiting, cryotherapy, heat therapy, topical paromomycin, azoles such as ketoconazole or fluconazole, and the pentavalent antimonials, which can be administered intralesional and parenterally. , , however, systemic therapies such as the azoles are reserved for larger or multiple lesions as well as cosmetically problematic lesions. the clinician should be especially sensitive to the cosmetic and emotional needs of the returning troop and not assume the lesion is not bothersome visually. perception is reality and the serviceman or woman may assign more value to the lesion as part of an overall post combat emotional response. therefore it is important to take the entire context of their deployment experience-medical and psychological health-into account when providing care. in contrast to l. majo, other species are often treated more aggressively with systemic therapies. however, treatment may not eradicate leishmania infection as this is a persistent intracellular organism. nevertheless, systemic treatment can control clinical disease. leishmania can reactivate in patients who become immunocompromised. patients should be counseled against blood donation; military policy dictates lifelong deferral of blood donation for persons who are diagnosed with leishmaniasis whether treated or not. , , , , given some returning troops may be financially challenged and consider blood donation for funds, it is worth emphasizing that the donor can infect an innocent individual. it is also of value to identify patients who have returned from pgw ii who may be facing financial hardship and guide them to appropriate resources in the community. malaria. malaria is a serious global threat and potentially deadly parasitic illness resulting from the bite of an infected mosquito. , , moreover it remains a significant military challenge in endemic areas. in there were cases acquired in afghanistan and diagnosed among u.s. army soldiers; soldiers presented for care weeks to months after return to the united states. there were , malaria cases in afghanistan reported to the world health organization (who), of which % were plasmodium vivax (fig ) . an outbreak of p. vivax among army rangers was reported after deployment to eastern afghanistan. a case of acute respiratory distress syndrome occurred in a patient who may have developed primaquine-resistant p. vivax. p. falciparum is possible. the observed attack rate was . cases per soldiers with the diagnosis made from to days after return to the u.s. self-reported rates of mefloquine prophylaxis and primiquine prophylaxis were and %, respectively. clearly greater attention, education, and follow-up of prophylaxis are necessary to reduce the risk to our troops. given some troops will be treated by civilian health care professionals, malaria should be considered in patients with fever, chills, sweats, headaches, myalgias, fatigue, nausea, and vomiting. symptoms can occur to days after being bitten but this is variable. moreover, malaria may cause anemia and jaundice. p. falciparum species infection, if not treated, may cause kidney failure, coma, and death. malaria is a risk in all areas of afghanistan below altitudes of m from april to december. chloroquine is not an effective antimalarial drug in afghanistan but, according to centers for disease control and prevention, is recommended in iraq as the preferred antimalarial drug. risks for malaria in iraq are primarily in the nonurban areas such as basrah, dhok, erbil provinces, and areas below m. atovaquone/ proguanil, doxycycline, or mefloquine are recommended for prevention. troops should be counseled against self-medication and the use of locally acquired medications, based upon concerns about safety and effectiveness, especially halofantrine (halfin), which can cause serious heartrelated side effects including death. q fever. , , , , , , , [ ] [ ] [ ] q fever is an emerging infectious disease among u.s. soldiers serving in iraq and a worldwide zoonotic infection caused by the rickettsial pathogen coxiella burnetti. it is usually acquired from inhaling infected particle aerosols often after contact with reservoir hosts, which includes cattle, goats, and sheep, or after exposure to contaminated manure, straw, or dust-the latter being kicked up by vehicles or helicopters. other routes of transmission include ingestion of improperly prepared or raw milk, or tick bites. q fever has been identified as a potential biological weapon. , a report from the defense intelligence agency (dia) in suggested that endemic q fever posed a minor risk to military personnel under normal circumstances but might pose an increased threat to nonconventional forces. , in the dia tested blood samples obtained from iraqi military personnel in the gulf war: of tested positive for previous exposure to c. burnetti-these data suggest that q fever may pose more of a threat to u.s. forces in iraq than previously thought. an epidemic of q fever among coalition allies, czech republic soldiers, occurred in in soldiers stationed in bosnia and herzegovina. in , among cases of pneumonia in u.s. military members in iraq, had serological evidence suggesting c. burnetti as the etiology. the true incidence of infection is unclear and likely underestimated. c. burnetti is highly infectious-a single organism can cause illness. of concern, cases appearing at u.s. health care facilities resulting from infection in the persian gulf were initially misdiagnosed despite the unusual and severe nature of the presenting symptoms in otherwise healthy, strong war-fighters. again, the caveat is that returning troops may be infected with illnesses endemic to the middle east; vigilance is key and patients who have recently returned but have seemingly commonplace symptoms may warrant more aggressive investigation given recent exposures abroad. c. burnetti infection is often subclinical or mild and self-limited. clinically it sometimes resembles a "flu-like illness." common clinical presentations include a nonspecific febrile illness, which can remit and recur, and is consistent with atypical pneumonia and hepatitis. high fever, headache, myalgias, malaise, anorexia, and diarrhea are possible. , , chronic infection can occur and involves the heart, arteries, liver, and bone. laboratory findings include elevated liver enzymes and decreased platelet count. elevated erythrocyte sedimentation rate may occur. abdominal ultrasound may reveal diffuse echogenic portal triads sometimes referred to as "starry sky" appearance of acute hepatitis. chest radiographic findings can include infiltrates but a variety of findings are possible if pulmonary involvement occurs (fig ) . the most characteristic lesion of liver involvement is the fibrin-ring or "doughnut" granuloma-a fat vacuole surrounded by a ring of fibrin, epithelioid cells, giant cells, and neutrophils. differential diagnosis of infectious agents that can cause febrile illness and hepatitis include brucella species (brucellosis), francisella tularensis (tularemia), treponema pallidum, human immunodeficiency virus, cytomegalovirus (cmv), epstein-barr virus (ebv), the hepatitis viruses, histoplasmosis, coccidioides immitis, and toxoplasma gondii. , , serum can be sent for c. burnetti antibodies. the diagnosis of q fever is made primarily by serology; immunofluorescence assay is the preferred method. treatment of q fever can be successfully accomplished with month of doxycycline therapy. the regimen of month of doxycycline in combination with rifampin is also appropriate. , brucellosis. brucellosis is a zoonotic disease endemic in the middle east and caused by several species of brucella organisms that are highly infectious via the aerosol route. , the british referred to it as "undulant fever" in the mid s, and more recently it has been dubbed "flaky fever" because of the altered mental status that sometimes occurs as a result of the direct neurotoxicity. transmission is usually through contact with infected animals or ingesting inadequately prepared food or dairy products from sick animals. brucella can be ingested, inhaled, or percutaneously inoculated. it is estimated that inhalation of only to bacteria is sufficient to cause disease in humans. , the incubation can be as short as days but is variable and can be much longer with some cases developing into an insidious, chronic illness. from to there were three reports of brucellosis among u.s. troops. however, in the u.s., like overseas, brucellosis is often misdiagnosed and the number of cases underreported. worldwide estimates vary; some suggest / , persons. civilian clinicians should emphasize the importance of eating properly prepared foods including dairy products to their patients who are about to be deployed and/or counsel family members in the u.s. to warn loved ones in the middle east. sometimes this can be difficult given our troops are often encouraged to interact with local villagers; cultural norms and polite response to offers of food and hospitality are often challenging. nevertheless, the need to adhere to safe practices is of paramount importance. data suggest that, during world war i, brucellosis-a veterinary pathogen as well as a cause of human illness-was used as a bioweapon to inflict disease upon beasts of burden, in the hope of providing a military advantage in the pre-jeep era when munitions, men, and materials were transported largely with the use of animals. subsequently it was one of the first biologicals weaponized by the u.s. military. symptoms include irregular fever, headache, profound weakness and fatigue, chills, sweating, arthralgias, myalgias, depression, and changes in mental status. patients often complain of a few days of high fever, which subsides with treatment and returns shortly after completion of antibiotics. this is usually the result of incorrect diagnosis, inadequate duration of, and/or inappropriate antimicrobial selection. monotherapy should be avoided. treatments include doxycycline and rifampin for a minimum of weeks, or ofloxacin and rifampin. therapy with rifampin, a tetracycline, and an aminoglycoside is indicated for infections with complications such as endocarditis or meningoencephalitis. , it is worth remembering that certain biological illnesses and bioweapons, including brucellosis, may contain neurotoxins that directly or indirectly affect neurological function and alter behavior, even mimicking some of the early behavioral changes of ptsd. biological illnesses and bioweapons may present with or have deleterious affects on mental status, neurological function, or level of cognitive function, negatively impacting the ability to obtain an accurate history as well as mimicking delirium, dementia, or other age-related cognitive deficits or behaviors including "sundown psychosis." , , viral hemorrhagic fevers, the equine encephalitic agents, and even anthrax are associated with mental status changes. , while rates of ptsd among oif and oef troops are much higher than in prior conflicts, the astute clinician will also be vigilant for other etiologies and possibly comorbidities. , , , , , respiratory illness. in a self-reported survey was collected from Ͼ , homeward-bound members of the u.s. military. sixty-nine percent reported one episode of respiratory illness, while % experienced more than three episodes. , , of interest, almost % reported they smoked more than a half a pack of cigarettes per day, with % being first-time smokers or former smokers who restarted upon deployment. additionally, from march through march , several cases of severe pneumonia were reported with clinical symptoms including rapid onset of cough, shortness of breath with or without fever, and accompanied by leukocytosis. chest radiographs revealed bilateral alveolar infiltrates often requiring mechanical ventilation. of concern, some of these patients had acute eosinophilic pneumonia (aep), which is a rare idiopathic disease usually characterized by pulmonary infiltrates on chest x-ray, eosinophilic infiltration of the lung, and respiratory failure. during this timeframe, cases of aep were identified among the total military deployed in or near iraq, of which died. new-onset smoking was the only reported associated result from an epidemiologic study. there have been some association with smoking non-u.s. tobacco products. there have been additional cases of aep since this study period, one of which presented with symptoms month after returning to the u.s. early diagnosis is essential because prompt medical treatment with corticosteroids can result in favorable outcomes; late diagnosis can be fatal. this again underscores the concern that an illness can be initiated during deployment but manifest upon return to the u.s. the astute clinician must be mindful of travel-related and deploymentrelated illness. other illnesses. there are ongoing studies to assess the rates of other endemic, arboviral infection, including sand fly fever virus, west nile virus, sindbis virus, and rift valley fever virus. so far, seroconversion among troops tested has been Ͻ %. , , , , , , , , nevertheless, if troops return with unusual febrile illness, a thorough examination including consideration of middle east related infections is necessary given the wide range of incubation periods possible. while u.s. troops are vaccinated against typhoid fever, it remains a public health problem in iraq and afghanistan; the vaccine is not % effective and thus, in the proper context, patients with unusual febrile illness, including relative bradycardia, warrant a more in-depth evaluation. of concern, multi-drug-resistant (including ciprofloxacin-resistant) salmonella enterica typhi has been identified in iraq. according to the centers for disease control and prevention, measles continues to be reported in the region. polio has been reported in yemen in and, in - , india, pakistan, and afghanistan. highly pathogenic avian influenza (h n ) has been found in poultry in the middle east. pilgrims to the hajj in saudi arabia have acquired meningococcal infections by serotypes a and w- . other parasitic infections include schistosomiasis and echinococcus, which to date have not been problematic among u.s. troops. , , , cases of ophthalmomyiasis have occurred in iraq. this presents with abrupt onset of conjunctivitis and is caused by motile, mucoid, flatsegmented larvae with a size Ͻ mm and caused by oestrus ovis, the sheep nasal botfly, which can deposit larvae in the eye; it can also involve the globe, resulting in sight-threatening complications. tuberculosis [mycobacterium tuberculosis (tb)] is the second most common cause of death in the world, resulting in million deaths annually and million new cases a year and is endemic in central and southwest asia. , , it is also the most common opportunistic infection associated with human immunodeficiency virus. this is not just a global threat, but a domestic one, with drug, multidrug and extremely drug resistant tuberculosis continuing to be a significant public health concern. who estimates suggest cases per , persons in afghanistan are twice the number of cases per , persons in iraq. the u.s. military uses purified protein derivative of tuberculin to screen troops before and after deployment. the deployment-associated conversion rate is ϳ . %; the number of active cases of tb among u.s. troops serving in the persian gulf has been negligible. nevertheless, it is important to follow-up with troops deployed in endemic regions upon return to the u.s. to ensure that they have been appropriately screened or treated. overview. war-zone exposures may have considerable negative emotional and behavioral consequences. , , , , , , [ ] [ ] [ ] [ ] [ ] men and women evacuated from the war zone with physical injuries are at higher risk for developing ptsd and other trauma-related issues. , , given the mind-body connection often gets severed in current health care and collocation of mental and biomedical services is not often the case, clinical attention should not be solely aimed at the physical wounds of war. , , - some military members will develop chronic, debilitating mental illnesses as a result of traumatic exposures, either directly from patterns of injury known as tbi or psychiatric, as with ptsd, or from depression. [ ] [ ] [ ] , , during and after the persian gulf war in iraq and afghanistan, primary care providers may notice an increased number of veterans or even active duty personnel as well as family members, some of whom may have a loved one who was severely injured or killed. , , , , , , , , while the physical wounds of war are often hard to miss-prosthetics, casts, or bandages, psychological trauma and mental illness, even brain injury, may initially present with subtle clues that, if not early diagnosed, can evolve into significant morbidities. , , among the psychiatric morbidities, ptsd and depression are expected to have high prevalence rates among returning troops. while depression, anxiety, and other psychiatric disorders may occur, this monograph will provide more in-depth information on the neuropsychiatric illnesses like ptsd and tbi, especially given clinicians are likely to be more familiar with the early recognition of depression and anxiety disorders. it bears repeating that multiple psychiatric disorders are possible. patients want their primary care clinicians to acknowledge their traumatic experiences and responses. therefore hcp should be sensitive to the complex needs of service men and women returning from the gulf as well as their families and loved ones. of concern, most medical casualties will not seek mental health care and many veterans can be expected to be reluctant to acknowledge emotional distress as concerns arise about being diagnosed with a mental illness. therefore, clinicians should avoid pathologizing common stress reactions and be sensitive to these concerns, while being vigilant about psychopathology and ensuring proper mental as well as physical care is provided. mental health professionals and primary care clinicians may find themselves collaborating closer in the aftermath of pgw ii than previously with traditional civilian patients as opposed to their reservist or national guard civilian patients. it is worth noting that the mental health and primary care clinicians' task is further complicated by what may emerge as a "signature wound" in the gulf war and war on terror-tbi, which is discussed elsewhere in this monograph. , , the value of faith-based care cannot be underestimated. chaplain services are valuable partners that are considered trustworthy by troops, are often collocated in combat zones and thus considered participants in the stress environment, and are generally a regular presence throughout the military, including health care facilities. the old adage "there are no atheists in foxholes" may or may not hold true. nevertheless, faith-based professionals can be enormously helpful for family members; church members may provide a psychosocial and spiritual support network. inquiring about and arranging faith-based support should be part of the total care plan. studies support the importance of religion and spirituality as resilience and protective factors as well as being therapeutic in the recovery phase. general sherman's famous remark "war is hell" has never been disputed. death and destruction takes its toll on people in a variety of ways but it does ultimately take a toll. ptsd is an anxiety disorder that develops in individuals who have experienced a traumatic event. , , , the term "post traumatic stress disorder" first appeared in to describe a set of symptoms. however, this disease has been well described throughout history, often previously referred to as "shell shock" or "war neurosis." fortunately, greater attention to the actual science of the psychological impact war has on those serving in battle zones has led to a greater understanding of the psychopathology of ptsd and a better method of diagnosing and characterizing this illness. populations at risk. the following is a list of patients/groups at risk for and experiencing symptoms of ptsd: • veterans/active duty military personnel x witnessed frightening aspects of combat x participated in frightening aspects of combat • veterans/active duty military personnel who may have experienced military-related sexual trauma • family members may suffer traumatic stress by x hearing about frightening events that happened to loved ones x loss of loved one (dead, missing in action, prisoner) x fear of loss • non-pgw ii veterans may be reminded of frightening/upsetting experiences from past wars which can exacerbate traumatic stress responses. symptoms. unlike many infections and biomedical processes which may have specific laboratory tests to suggest or confirm the diagnosis, ptsd, as with other psychiatric illnesses, is based upon screening tools, patient history, and the careful evaluation of clinical signs and symptoms. , the clinical history of the patient must be accompanied by the occurrence of a traumatic event. a diagnosis of ptsd cannot be made without a history of a traumatic event. diagnostic criteria for ptsd. according to the american psychiatric association (apa), the following are symptoms and criteria for pstd in its diagnostic and statistic manual of mental disorders (dsm): • the person has been exposed to a traumatic event in which both of the following were present: . the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. . the person's response involved intense fear, helplessness, or horror. (note: children may express disorganized or agitated behavior.) • the traumatic event is persistently re-experienced in the following ways: . recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. (note: in young chil-dren, repetitive play may occur in which themes or aspects of the trauma are expressed.) . recurrent distressing dreams of the event. (note: in children, there may be frightening dreams without recognizable content.) . acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). (note: in young children, traumaspecific reenactment may occur.) . intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. . physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. • persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: . efforts to avoid thoughts, feelings, or conversations associated with the trauma. . efforts to avoid activities, places, or people that arouse recollections of the trauma. . inability to recall an important aspect of the trauma. . markedly diminished interest or participation in significant activities. . feeling of detachment or estrangement from others. . restricted range of affect (eg, unable to have loving feelings). . sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or a normal lifespan). • persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: . difficulty falling or staying asleep . irritability or outbursts of anger . difficulty concentrating . hypervigilance . exaggerated startle response • duration of the disturbance (symptoms in criteria b, c, and d) is more than month. • the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. (table ) . as of august more than , iraq and afghanistan veterans have been afflicted with ptsd. , , , [ ] [ ] [ ] [ ] [ ] [ ] according to the national center for post traumatic stress disorder, to % of returning soldiers experience ptsd, compared to % in the general population. it is not difficult to understand why so many returning troops from the gulf wars have ptsd: studies reveal % of soldiers in iraq are the victims of smalls arms fire; % knew someone who was seriously injured or killed; and % had handled or uncovered human remains. these traumatic experiences in addition to long exposures to violence in a foreign, often hostile land, far from home can make service men and women vulnerable. women serving in the military, especially combat zones, are not only subject to the dangers and violence of war but also are at risk of assault from fellow service members or their superiors. a study revealed approximately one in three female veterans who visited a va facility for health care reported being raped or subjected to attempted rape during their military service. sexual assault is well recognized as a risk for ptsd. add this to the psychological trauma of combat and exposure to war-this combination has led to an estimated % of servicewomen who will likely develop ptsd compared to % of male soldiers, who, statistically, are rarely sexually assaulted. it is worth mentioning that reporting sexual assault can have a chilling effect on the servicewoman's military career; often women do not report this to their superiors, again setting the stage for a variety of psychopathologies. servicewomen-reservists, national guard-who return to our practice should be queried about sexual abuse, gender discrimination, and their experience in addition to an overall history of their overseas deployment and travels. ptsd when identified and treated early has very promising outcomes whereby to % are expected to recover, underscoring the need to address the psychosocial issues of service as well as the biomedical. differential diagnosis. other conditions can cause some of the symptoms experienced in ptsd and these conditions must be ruled out. additionally, conditions such as substance abuse and depression may preexist or develop as complications of ptsd. some of the conditions in the differential include adjustment disorder, depression, and panic disorder. moreover, substance abuse must be addressed. the astute clinician will be alert for changes in their patients' behaviors, overall health, and/or concerns expressed by their family. the impact of war not only affects the warrior but the families as well. family members as well as the returning troops (wounded or not) may feel awkward and unsure how to communicate with each other about the events of war or injuries sustained. although generally considered a low percentage of returning pgw i and ii troops, it is worth remembering some may be malingerers. nevertheless, given the atrocities of war, especially on the shoulders of young people, it is better to presume legitimate illness until data prove otherwise. clinical course. the course of ptsd is often determined on the temporal relationship between the trauma and when the individual begins to experience symptoms. immediate onset • better response to treatment • better prognosis (ie, less severe symptoms) • fewer associated symptoms or complications • symptoms may resolve within months delayed onset • associated symptoms and conditions develop • condition more likely to become chronic • possible repressed memories • worse prognosis people who experience trauma sometimes repress their memories of the event to avoid the pain of thinking about it or remembering it. these so-called repressed memories sometimes resurface during therapy or may be triggered by something in everyday experience that reminds the patient of the traumatic event. treatment options. the chronic nature of ptsd mandates early diagnosis, appropriate treatment, and long-term care. a combination of psychotherapy and medication is commonly used to treat ptsd. psychotherapy. psychotherapeutic treatments include debriefing (ie, crisis intervention) and psychotherapy. psychotherapy can help the person address and manage painful memories until they no longer cause disabling symptoms. eye movement desensitization and reprocessing has also been tried. pharmacotherapy. almost all types of psychopharmacological agents have been used to help resolve the symptoms of ptsd. the use of medication in addition to psychotherapy has been shown to be beneficial in the treatment of ptsd. antidepressants. several types of antidepressants are used to treat ptsd , [ ] [ ] [ ] [ ] , : • monoamine oxidase inhibitors • selective serotonin reuptake inhibitors • selective norepinephrine reuptake inhibitors • tricyclic antidepressants each medication class offers a variety of options and side effects. given there is no "one size fits all" approach to the patient with ptsd and/or other psychiatric illnesses, it is suggested the clinician confer with psychiatric and mental health specialists; especially advantageous would be working with colleagues who have expertise in treating returning troops. one of the most important services primary care clinicians can do for returning troops, especially those suffering from ptsd, is to acknowledge the traumatic events and resultant responses. in a military survey, over % of patients indicated the traumatic event they experienced is important and relevant to their care. of note, in a va study, over % of patients in va primary care settings will have experienced at least one traumatic event in their life; most have experienced four or more! given the relationship between exposure to a traumatic event and increased health care, utilization appears to be mediated by the diagnosis of ptsd. health care professionals treating returning troops should be mindful of the essential features of ptsd (table ) . tables - offer some key domains and verbal prompts when interacting with patients who have returned from the gulf war. it is important to acknowledge that the health problems associated with ptsd may represent the dynamic interplay of neurological, psychological, and behavioral factors. ptsd can lead to neurobiological dysregulation, altering catecholamine, hypothalamic-pituitary-adrenocorticoid, endogenous opioid, thyroid, immune, and neurotransmitter systems. patients often take their cue from us as health care professionals. speak calmly, with a matter-of-fact voice in a nonjudgmental demeanor. reassure the patient that you will be there for him or her over the long haul and that treatments are available and will be provided either by you or by arranging appropriate care. remember, if you must refer out, remind the patient that you are still involved in the care and not abandoning him or her. keep a timeline so that as the patient makes progress, you can convey it visibly and encouragingly. if the patient experiences a flashback, remind them that they are in your office and state the date and location. offer water and other comfort measures as needed. battle-injured soldiers present another group of patients. a recent study examined the rates, predictors, and course of probable ptsd and these questions allow the hcp to acknowledge the relevance and importance of the event. • "have you recently returned from the persian gulf?" • "how has your adjustment been back home?" • "do you have family members or friends who are currently in the persian gulf?" • "how are you dealing with their absence?" • "how has the war in iraq or afghanistan (or name) affected your functioning back here?" regardless of their specific duties in or relationship to the war, the hcp should recognize and normalize distress that is associated with the conflict. • "i am so sorry you are struggling with this" • "this has to be a very difficult time for you" • "i have other patients who are struggling with what you are dealing with" use these as opening points to convey concern, validate their struggle. do not patronize. also, if you have not experienced war, do not say that you know what they are going through . . . you do not! another important group of returning troops from the persian gulf are health care providers. a recent study was conducted to determine the level of ptsd and depression among hcp deployed to combat settings. of respondents, % met the criteria for ptsd and % met the criteria for depression. albeit a small study, anonymous surveys revealed deployment exposures and perceived threats during deployment were risk factors for ptsd. of note, it appeared that exposure to wounded or dead patients did not increase risk. our colleagues are not immune to the mental or physical injuries of war; we should be alert to behavioral changes in hcp returning from the persian gulf. there remains a stigma associated with mental health. almost one in four americans will suffer from a mental illness per year, yet only a fraction will receive appropriate care or be effectively treated. stigma, shame, access to experienced mental health care in the community, concerns about abandonment, and cost are some of the issues facing persons with mental illness. as health care professionals, we can do much to help destigmatize their psychiatric disease and assist with proper referral and follow-up. increasingly, civilian hcp may be called upon to provide care to returning veterans. the president's commission on care for america's returning wounded warriors reported a lack of mental health professionals to serve military personnel and their families. as of march only of the va hospitals and clinics contained inpatient ptsd centers. of additional concern, there are only two va facilities that treat women exclusively. , , clearly the demand for mental health care for returning troops can be expected to increase dramatically in the coming months and years. the veterans of operation iraqi freedom and operation enduring freedom who are eligible for years of free military service related health care through the va. however, it is important to recognize the value of civilian health care, especially given the va may not be able to handle the increased demand. according to the office of inspector general of the department of veterans affairs, it appears that the va repeatedly understated wait times for injured veterans seeking medical care and in many serious cases forced them to wait more than days, counter to department policy. of concern, only three in four veterans received timely appointments albeit va reports to congress stated % of veterans received such care. in the immune globulin (ig) expressed concerns that over , veterans were on waiting lists. , , regardless of etiology, returning troops deserve prompt care. the va may not have the surge capacity to provide the access and quality required and thus military, va, and civilian medical communities will need to collaborate more closely over the coming months. with the new roles the military faces, the frequency of deployment into a threat zone or overseas has increased in the past years since the first persian gulf war. such deployments not only pose a threat to the troops but can be a challenge to the military families left behind. medical or emotional/behavioral problems as well as financial problems may preexist and with the resulting loss-temporary or permanent-of a parent or spouse can destabilize an already precarious situation, creating significant problems for the family. because the u.s. military is all volunteer, the heavy responsibilities are carried by two distinct sources of troops-the active military and reserve or national guard, who can and have been activated as well as deployed to combat areas. a significant proportion of those serving in iraq and afghanistan are from reserve or national guard units. do we inquire of our patients if they are active, reserve, or former military or in families of a deployed troop? such information is critical especially to assist us in anticipating challenges our patients and their families may undergo. while the active duty military family lives with deployment as part of their life, and often lives within military communities where a readymade support network of friends with similar issues and government services are nearby, reserve or national guard service members and their families reside in nonmilitary communities and work in civilian jobs generally remote from military resources or support groups. families of reservists can feel isolated and less supported. there are many commu-nities that have few or none being deployed in active duty and thus are neither familiar with nor equipped to provide the support necessary to a civilian family that has instantly become a military family. beyond the normal worries for a loved one in a war zone are the financial concerns, especially if deployment results in loss of income in the transition from a high paying civilian job to a lower paying military one. children can be impacted, especially if the community is demonstrably "antiwar"-adults can often separate the "antiwar" from the "antiwarrior" sentiments; children may not, thus causing a variety of emotional challenges that a savvy clinician should be attuned to and inquire about. [ ] [ ] [ ] [ ] according to the iraq war clinician guide nd edition, there are emotional cycles associated with deployment that have been divided into five stages, each associated with specific emotional issues that should be anticipated and addressed. these include the following: ( ) predeployment; ( ) deployment; ( ) sustainment; ( ) re-deployment; and ( ) post-deployment. pre-deployment. this occurs from the time the family is notified of deployment to when the military member leaves. it often involves psychological denial, intense mental and physical preparation, and anticipation of the departure. deployment. this is the phase from the time the member leaves through the first month of deployment. significant emotional turmoil can occur, especially if the military member is a parent and the family attempts to reach a functional equilibrium. a variety of feelings and emotions occur including numbness, sadness, feelings of isolation, and abandonment. family members may need to incorporate the roles filled by the deployed parent. critical is the communication from the deployed member of the family-providing a realistic appraisal of the new environment, which can be reassuring. from a clinical perspective, it is important for hcp to anticipate such phases and to realize family members will experience these phases differently depending upon their cognitive/developmental stage. sustainment. this is the phase that spans from month post deployment to month before the announced return date. it is usually marked by "settling into the new routine" and going on with life business as usual. if a family cannot return to this business as usual, especially in the absence of one parent, children may have an especially difficult time. moreover conflict between the service member and spouse can result, especially if communications are not widely available and thus preclude resolving disagreements or challenges. re-deployment. this phase occurs from the month before the expected return to the actual physical return of the service member. as one would expect, it is a period of intense anticipation, a variety of emotions, including fear, anxiety as well as excitement. post-deployment. this is the phase beginning with when the service member returns and ending when the family has reestablished equilibrium. this may take several months. although the homecoming can be a time of great happiness, it can also result in frustration and feelings of "let down" from unrealistic expectations about the reunion. the service member may also experience frustration in finding the family has made some changes or had experiences that he or she were not part of. the spouse/parent left behind may have emerged into a new role of leadership or independence that may conflict with the returning member who begins to exercise formerly held authority. marital couples may take time to reestablish physical and emotional intimacy. undiagnosed ptsd, substance abuse, the trauma of war, or other psychological morbidity can impact on the reestablishment of the loving partnership; the astute clinician will anticipate this and work with the family before and during the reunion. overall it is important that the deployed member reassert his or her role within the family to reestablish a healthy family equilibrium. not unexpectedly, children respond to deployment in very individualistic ways depending upon their age and psychosocial and cognitive developmental periods. infants (Յ months of age) tend to respond to changes in their environment, schedule, or presence and availability of their caregivers. worrisome signs include apathy, refusal to eat, even weight loss. toddlers ( - years of age) usually take their cues from their primary caregiver. as such, if the non-deployed parent is coping well and present, the toddler should be expected to cope well. signs of concern include new onset sullenness, temper tantrums, tearfulness, and sleep disturbances. clearly, socializing the child-play dates, support from other parents-is critical both for the toddler and for the remaining parent. preschool children ( to years of age) are more keenly aware of a parent's absence. worrisome signs include regressive behaviors in a variety of domains including toileting, thumb-sucking, separation anxiety/clinginess, and sleep disturbances. irritability, aggression, depression, or somatic complaints may occur. while these can also occur in nonmilitary children, nevertheless, the are worth follow-up. the parent and clinician should be vigilant for children who think their parent left because of something they did. these inaccuracies of thought should be addressed rapidly and in a matter-of-fact manner, discussing the deployment briefly but honestly. this is critical, especially if the military parent gets killed; children should not bear the guilt of their parent's death and thus feelings of responsibility about the deployment should be immedi-ately dispelled. increased attention by the remaining parent, conversations with images of the deployed parent about how much he or she loves the child, and maintaining family routines including physical and emotional warmth are critical. school-aged children ( to years of age) may manifest their emotional issues by "acting out" or exhibiting irritability, aggression, or complains and whining-which may be uncharacteristic of the child prior to the deployment. given children are increasingly being exposed to information through their friends, the internet, and other media, it is important to have regular discussions with the child, to allay their worries as opportunities for information sharing. ideally parents should limit the amount of media exposure children receive during times of war; in the information age, this may be easier said than accomplished. therefore, regular conversations with children are important to address their concerns factually and with love. the age of initiation of alcohol and tobacco occurs from to years of age. [ ] [ ] [ ] [ ] experimentation to chronic use can worsen in the child of a deployed parent. teenagers ( to years of age) may behave similarly to children in terms of irritability, rebelliousness, or other challenging behaviors. , good communications should be encouraged as their concerns about the deployed parent (and the possible impact losing a parent can have on them and the family) may manifest in destructive ways. helping the non-deployed parent to set clear and realistic expectations about behavior, school, and home life can provide supportive structure. the non-deployed parent should be counseled to observe for high-risk behaviors, sexual acting out, or changes in behavior that may result from substance abuse. clinicians can help their patients and families through these challenging times by anticipating these needs prior to deployment and assisting the remaining family members. , , moreover, underscoring the role of the remaining parent in promoting healthy family dynamics that include planning, encouragement, interaction, and education can make the deployment and sustainment phases less harrowing. young children can better visualize the time gap between deployment and return using a chart or timeline, perhaps with stars on the different days representing how helpful the child has been in the parent's absence, which can serve as a gift to the returning parent. other ideas and resources can be found in the references. the clinician should be mindful that the parent will need support and social encouragement as well. working with the family, identifying possible sources of support, and working with the patient as well as the organizations such as churches and other natural networks including the parent-teacher organizations can be highly beneficial. , , , , dostoyevsky once opined that a society can be judged by how it treats its prisoners. as physicians, we could argue as a take off on this concept that a society should also be judged by how it treats its veterans and those charged with protecting our freedoms. if this is the benchmark upon which a society should be judged great or glaringly wanting of moral clarity and direction, what does it say about the u.s. when nearly % of the homeless are veterans and that the rate of convergence for recently returning veterans of iraq and afghanistan, ie, from having a home to becoming homeless, is faster than at any other time in american history?! what does it say when the va office of the inspector general report states that returning veterans are receiving less than optimal care, and must wait an exceedingly long time for such care?! , , homelessness. according to the va, approximately , veterans of all ages were homeless on any given night during . , as if almost , veterans was not troubling enough, the fact that between , and , veterans are chronically homelessness-those who live either on the streets or in shelters for more than a year-is even more troubling. while veterans make up % of the population, they comprise % of the homeless on any given day. so far, more than veterans of the iraq and afghanistan war have turned up homeless in washington, dc. the va and other aid groups say there will be a surge in homeless veterans-returning troops-in the coming years. according to experts who work with war vets, and based upon the vietnam veteran experience, it often takes several years after separating from the military before veterans' problems evolve to a point that drives them into the streets. of concern, some veterans of iraq and afghanistan are already turning up at homeless shelters, and the amount expected could be enormous. as discussed earlier in this monograph, severely wounded troops who would not have survived their battlefield injuries in previous wars are returning home, albeit traumatized and often with chronic illness or disability. these disabilities include tbi, ptsd, prosthesis, hearing deficits, visual loss, or a combination. thus the special trait of this war and resultant "survivors" may contribute to the increased homelessness, especially ptsd and tbi, both of which can cause unstable behavior, and lead to substance abuse. these, plus perhaps the impact of longer tours of duty and recall of troops who should have separated from the military, which leads to protracted absence from families, may make reintegration into home and work more difficult. in oif more women were serving in combat zones and thus experienced ptsd. in addition, a significant number of women troops have experienced sexual abuse, which is also a risk factor for homelessness, as supported by a recent government survey that disclosed almost % of the homeless female veterans of recent wars reported being sexually assaulted by u.s. soldiers while in the military. , more than % of newly homeless veterans are women. of concern is the loss of jobs reservists have experienced upon their return. while by law their job must be preserved and await their return, employers are often ignoring this. as a result, sen. edward kennedy (d-ma) and other legislators are working in congress to enhance the protection for troops and increase the penalties of employers who ignore their responsibilities for profit. we should not tolerate such behavior in our communities. home costs and apartment rents may also contribute to the problem. according to the national alliance to end homelessness in washington report of november , among one million veterans who served after the september attacks, over , are paying greater than % of their incomes for rent, which leaves them highly vulnerable. nevertheless, the primary factors that enhance the risk for homelessness are untreated ptsd, substance abuse, depression, and other psychiatric illness. soldiers have a great deal of pride in what they do and who they are, and rightly so. this may also contribute to delays in seeking help. as discussed earlier, we may be the front line or perhaps the only line of defense for our patient with such mental health needs in our communities. what services-job training, home health, housing, social, and psychological-are available in your community and will they be enough if gulf war veterans start returning home? now is the time to lay the foundations and prepare for the needs of our troops. as physicians, we can and must be the catalyst for change and ensure the support services that enhance our care plans are in place or available whether by collaborating with other communities or reaching out to the va for remote services. some construction companies have dedicated resources to building low-cost homes or pro bono work in concert with volunteers to make a difference in their communities such as "homes for our troops" (see resources section). before , plus troops return to the u.s., we should assess our resources, address our care gaps, and prepare our communities now. a recent study of four returning combat infantry troops-three army units and one marine unit-were surveyed to months after return from iraq or afghanistan combat or security duty, both of which are highly hazardous assignments in those regions. the percentage of study subjects meeting criteria for major depression, generalized anxiety, or ptsd was significantly higher among those serving in iraq than afghanistan. of those who had positive responses consistent with a mental disorder, only to % sought mental health care. respondents indicated there were barriers to receiving mental health-waiting times, but most often the perception of stigma among those most in need of mental health care. given these troops are likely representative of their colleagues who continue to be involved in pgw ii, preparing our practices to address the mental health needs of returning troops is critical. the stigma of mental health is not isolated to military personnel; it remains a persistent challenge. moreover, patients can feel abandoned when referred from our practice to a mental health professional. clearly communicating that they are not being "turfed" but instead are being offered specialist care, similar to being offered cardiology referral if a heart defect was found and reassuring the patient that the mental health professional is one more member of a team that will still center around the patient and primary care provider, can enhance the likelihood of obtaining care. increasingly evidence suggests collocating mental health services as part of the medical practice has improved outcomes. in some rural areas advanced planning will be required to increase opportunities for referral and access to mental health services. clinicians in such areas may want to reach out to the nearest va center and establish a collaborative relationship with ptsd and other services in anticipation of patients returning from the persian gulf. motor vehicle accidents (mva). large-scale studies following male and female gulf war i veterans over several periods of time after return from the middle east demonstrated a significantly higher risk of death from accidents, especially motor vehicle accidents (mva) during the initial years home. [ ] [ ] [ ] , of note, many were not wearing seatbelts. however, by the sixth year post war, the relative risk of mortality due to mva had fallen significantly. these results are consistent with a mortality study of vietnam war veterans. they, too, experienced excess mortality from mva, which was most pronounced in the first years after serving in vietnam. after the fifth year, the mortality rate from mva for vietnam veterans paralleled non-vietnam controls. given mva are a leading cause of death among adolescents and clearly a worrisome cause of death among newly returning war veterans, it is important for clinicians to alert troop patients about this risk and the cofactors that are likely to be at play-alcohol and other substance abuse, exhaustion, work, stress, or coping related, medication effect. it is well described that adolescent males who drive with passengers are more likely to be involved in an mva; returning troops who are adolescents or young adult males are not immune to this reality and should be counseled about the trend in mortality associated with returning war veterans and mva. opening up such dialogue may also make discussing seatbelt use and substance abuse more likely. there has also been an increase in traumatic death among gulf war i veterans. , , , , a population-based survey of , gulf war veterans revealed that, since the war, these veterans have been involved in serious accidents, injuries, and illnesses, more than non-gulf veterans. high-risk activities post war may be part of the etiology. ptsd has also been shown to contribute to excess number of deaths due to trauma. substance abuse. roughly one-third of the u.s. population meets criteria for problem drinking , , , ; it is not unreasonable to expect this proportion to be higher among individuals with varying degrees of behavioral issues or facing horrific challenges as significant life stressors. an example of a population at risk is the young men and women facing impeding deployment to a combat zone or those who are already participating in the war. fortunately, most reactions are generally mild and transient, as healthy coping mechanisms emerge to the stressor. however, in others fear and uncertainty precipitate unhealthy actions. maladaptive behaviors manifest in a variety of actions-substance abuse, abusive behaviors to others-sexual or pugilistic, and a host of psychiatric morbidities. therefore, the hcp who has patients potentially being deployed should anticipate the psychosocial as well as medical needs including a predeployment substance abuse screening. , clearly, in the context of primary care, patients should be screened for risk behaviors regardless of their military or occupational status given the prevalence of substance abuse; nevertheless, those about to enter a war zone present an obvious population in need for guidance. rapid recognition of this potentially life-changing stressor and the need for the hcp to provide resources to develop safer coping mechanisms than alcohol or other drug abuse is essential. screening for substance abuse requires a three-stage strategy that should focus on behavior pre-deployment, during deployment, and return from deployment. , in terms of reservists and national guard troops, there is the potential for "slipping through the cracks" if we as clinicians do not follow the same playbook, given active military may receive their care from military clinical facilities and nonactive duty from civilian health care. nevertheless, each stage warrants brief, focused screening. the goal for returning troops is to ensure they are able to cope with daily life and reconnect with family, friends, work, and society. in addition to ptsd and other mental illnesses, battlefield wounds is the deleterious impact of substance abuse on the critical domains of daily living. there are a variety of screening tools available. , [ ] [ ] [ ] it is important to validate the patient's concerns, that yes, a war zone is a dangerous place, and acknowledge that an impending deployment elicits a wide range of emotions from fear to excitement. asking the patient what best characterizes their reaction is a nonthreatening way to open the dialogue. it can be adapted to the returning troop as well. a statement such as, "how are you (have you) handling your concerns/anxiety/fear?" or "some people find that drinking more alcohol, smoking a few more cigarettes, drinking more coffee, or doing drugs like pot help relieves the stresswhich of these has been your approach?" if such questions have resulted in insights about substance abuse, then a more formal screen with either the quantity-frequency questions (table ) or the traditional cage screening should be administered (table ) . , [ ] [ ] [ ] [ ] of note, combining the quantity-frequency and cage questions with the patient interview can reliably predict to % of individuals with alcohol abuse or dependency. this approach can also be adapted to illicit drug use. the caveat, part i . "on average, how many days a week do you drink alcohol?" . "on a typical day when you drink, how many drinks do you have?" . multiply the days of drinking a week times the number of drinks ϭ score. scoring: any score exceeding for men or for women suggests an at-risk behavior. part ii . "what is the maximum number of drinks you had on any given day since learning about your deployment (or during deployment)?" ϭ score. scoring: any score exceeding for men or for women suggests a potential alcohol problem. c ---"have you ever felt that you should cut down on your drinking?" a ---"have people annoyed you by criticizing your drinking?" g ---"have you ever felt guilty about your drinking?" e ---"have you ever had a drink first thing in the morning (an eye-opener) to steady your nerves or get rid of a hangover?" individuals who answer "yes" to of the cage questions over the past year are likely to be alcohol dependent. individuals who answer "yes" to or of the cage questions may likely have alcohol abuse. however, is that no predetermined cutoff scores have been validated when adapting tables and for the wide range of illicit drugs, including narcotics, marijuana, ecstasy, cocaine, and designer drugs. nevertheless, it is critical and good medical practice to explore these risks with the prethrough post-deployment patient. realize once the patient arrives in the theater of operation, combat stress can amplify preexisting, under-, or untreated substance abuse or mental health issues, underscoring the importance of addressing this with your military (active, reserve, or national guard) patient. there is a sizable "black market" in iraq and the middle eastdiazepam and alcohol, among other substances that are used to selfmedicate-are readily available. herbal products, over-the-counter medications (some of which are controlled substances in the u.s.), even steroids, are available, some of which may not be made according to food and drug administration or good manufacturing standards and thus the military patient should be counseled about the risks of such products. clinicians should be alert to behavioral changes consistent with withdrawal; some of these can be misinterpreted as associated with other morbidities. sleep difficulties, agitation, anxiety, and autonomic hyperactivity can indicate withdrawal, not just combat stress disorder. the correct diagnosis is critical and warrants appropriate, timely evaluation. patients returning to the u.s. after deployment in a combat zone may have significant substance abuse, perhaps even new onset abuse, as well as stress-related behavioral issues, psychiatric illness, and/or traumatic brain injury-all of which share similar signs and symptoms, but presenting widely different diagnostic, therapeutic, and prognostic implications. the fact that ptsd, substance abuse, and combat-related neurological trauma can coexist in a returning pgw ii patient poses a diagnostic challenge and thus hcp should be alert to these issues, providing counsel, reassurance, diagnostic and treatment resources, education, and ongoing follow-up to the servicemember patient. sexual abuse. military sexual trauma (mst) refers to both sexual harassment and sexual assault occurring in military settings. men or women can be victims or perpetrators, although most often women are the victims and men are the perpetrators. va statistics from october through december report females and males seeking medical care stated they were sexually assaulted or harassed. a somewhat unique aspect of mst is that it occurs in a setting where the victim lives and works. civilians do not often live and work in the same environment, unlike the military, which ultimately has its own legal rules (uniform code of military justice) and social norms. as such, the victim often must live and work closely with their perpetrators, which can lead to an ongoing feeling of victimization, feelings of helplessness, and exacerbating the trauma. victims may also rely on their perpetrators, who may be supervisors with enormous influence on careers. an unprecedented number of women are serving in pgw ii compared to prior wars. overall, more than , female servicemembers have been deployed to the middle east, including iraq and afghanistan, compared with who served in vietnam and , in pgw i. although typically limited to combat-support roles, as the battlefield lines are blurred and combat occurs in the streets, roadside bombs, ambushes, guerilla warfare have all virtually eliminated the safety categories and distinction between combat and support roles. ironically driving a truck in iraq is considered combat-support, yet with ied and roadside bombs, this activity is turning out to be one of the most dangerous jobs in pgw ii. camp victory was attacked by mortars, resulting in several deaths including two servicewomen. as such, women are in harm's way with their male counterparts. the impact of combat on women, especially in terms of psychiatric illness such as ptsd, remains to be fully characterized. most data on ptsd and women are derived from civilian research and usually related to sexual trauma, including rape. , a dod report revealed nearly one-third of a nationwide sample of female veterans who sought health care through a va said they experienced rape or attempted rape during their military service. of that group, % reported that they were raped multiple times and % reported being gang-raped. a small va study following pgw i suggested that rates of sexual harassment and assault rise during wartime. from to nearly , women veterans reported being victims of sexual assault or harassment, sometimes from fellow servicemembers. , , compared to the civilian population, men and women in the military have been shown to have higher rates of sexual and physical abuse in their backgrounds than the general population and women entering the military are likely to have more traumas accumulated than their male counterparts. although a small percentage of male veterans revealed being sexually abused/assaulted, the overwhelming majority are women. as such, women experience what has been referred to as a "double whammy" in pgw ii: military sexual trauma and combat exposure. what impact this will have ultimately on the psychiatric health of returning women from the gulf remains to be seen. while sexual trauma presents diagnostic and treatment challenges among civilian patients, the additional impact of military life and the pervasive sense among many military women that reporting a sexual crime is seldom worthwhile can enhance feelings of vulnerability, loss of control, and fear and exacerbate the effect of other traumas. since many of the perpetrators of the sexual abuse are supervisors, reporting such traumas can place the victim in a challenging position-career-wise, among colleagues, and just the normal pain attendant with reliving the event during the vetting process of a formal complaint. also, unlike the typical male bonding that occurs among wartime combatants, small studies suggest this is not the case among female troops during deployment. such isolation can contribute to the deleterious impact of a wartime experience and is worth remembering when treating female military patients-current or retired, as the signs and symptoms of untreated mental illness resulting from such events can persist and go unaddressed or be considered associated with other issues. interestingly, such isolation does not appear to occur among reserve and medical units or when commanders establish a zero tolerance for such sexism. female veterans who use va health care and report a history of mst also report a range of negative outcomes that include poorer health (mental and physical), readjustment problems following discharge (finding work, homelessness, substance abuse), and unresolved mental health issues. studies of sexual assault among civilians identify ptsd as a frequent outcome. interestingly, rates of ptsd associated with mst seem higher than those associated with combat exposure. major depressive disorder is another common reaction following mst. a large-scale study revealed, not surprisingly, that rape survivors compared to nonvictims were times more likely to use major drugs and times more likely to use cocaine. anger, shame, guilt, and self-blame are all associated with mst and sexual trauma in general. moreover, difficulties with trust, social avoidance, and sexual dysfunction may also result-the impact not only seen in the victim but perhaps with loved ones, significant others, life-partners, or spouses. it is important to screen all patients but especially military (active, reserve, national guard, or veteran) for a history of sexual harassment (verbal or physical) and assault. mandated by the va, it is good clinical practice for civilian providers as well. when screening for sexual trauma, avoid terms that may trigger negative responses, are stigmatizing, and may assume an interpretation different from that of the patient. , , these include "rape" and "sexual harassment." instead ask questions in a supportive way and with more open-ended, nonthreatening phrases. examples include "while you were in the military, did you ever experience any unwanted physical or sexual attention, verbal remarks, touching, or pressure for sexual favors?" "did anyone ever use force or the threat of force to have sex or physical contact with you against your will?" remind the patient this conversation is privileged; you care about her/him and are a trusted resource. patients who may have to undergo forensic rape examinations are often less traumatized if education is provided, realizing the examination can present powerful triggers. resnick and schnicke prepared a -minute educational video that has been shown to reduce post exam stress compared to patients who did not view the program. data are scant in terms of validated measures specifically designed to assess mst. most checklist measures currently available include a least a question about sexual assault but do not usually assess sexual harassment. several self-report measures and structured interviews do exist and are designed to assess sexual harassment and sexual assault. one such tool is the sexual experience questionnaire by fitzgerald, the most widely used measure of sexual harassment. interview guidance can be obtained from the national women's study interview developed by resnick and schnicke. clearly the most important issue is to engage in the dialogue and elicit information that can lead to appropriate intervention. while there are treatments available that can reduce the psychological impact of sexual harassment and sexual trauma, improving the victim's quality of life, there are little outcomes-based data on the treatment of mst. nevertheless, given the results of treatment outcomes with civilians, these can be used to guide treatment of veteran populations until such a time that best practices can be identified for military victims of sexual trauma. , , , key interventions start with addressing immediate health and safety concerns, normalizing posttrauma reactions, validating the patient, supporting their existing positive adaptive coping strategies, and helping the patient develop additional coping skills. addressing the cognitive and affective reactions such as fear, self-blame, anger, and other issues is important. referral to appropriate mental health expertise but in the context of a collaborative team approach is essential. it is important to recognize the feelings of vulnerability; thus referral without explanation can lead to feelings of abandonment. reassuring the patient that you are going to be working with her or him even while the trauma specialist is on board underscores you are bringing on an additional member of the health care team, and that the patient is not being sent away. another valuable preparation for community clinicians is to assess and become familiar with the level of local resources available to your patients who may be victims of sexual abuse or mst in advance of returning pgw patients, helping to address gaps in your region, and working with professionals in the field to increase options for care. new threats to our troops have emerged given the evolving nature of battlefield medicine. more severe, even horrific wounds-traumatic amputations, burns, head injuries-are now survivable but at what impact to the survivor and his/her family? , , , , , , , , , , long-term care, the mental and well as physical component of rehabilitation, and readjustment to the u.s. all require hcp to be engaged and aid the civilian troops navigate the often dizzying array of required health care often amid red tape and limited resources. psychological morbidities-ptsd, depression, anxiety, substance abuse, and tbi-are significant problems for troops serving in and returning from pgw as well as for some of those preparing for deployment. , , given many of the troops-male and female-are not full-time active military, it is likely they receive medical care from civilian hcp. reports confirm there is a gap between services needed and available-access, cost, quality, and quantity all need to be addressed from a federal, state and local, military, and civilian perspective. [ ] [ ] [ ] , the role of the civilian hcp cannot be stressed enough! the rates of sexual abuse and mst are on the rise as the number of women in the military, especially in combat zones, increases. female troops are increasingly in harm's way as the distinction between combat and combat support roles blurs amidst a guerilla war. whether mst, tbi, or the fog of war-the complexities of treating female troops represent a unique challenge unseen in prior wars. whether male or female, the need for mental health services in addition to addressing the physical ailments associated with war will likely exceed current capacity. , , primary care clinicians and civilian specialists will be called upon to fill the voids and must be attuned to the special needs of our servicemen and servicewomen. the united states is no longer isolated from a dangerous world or protected by its geography. , - , , , oceans and borders can be readily crossed, making the united states as vulnerable as other nations to acts of terrorism. geoglobal and societal factors have combined to create conditions that facilitate the emergence and spread of previously unknown clinical entities such as severe acute respiratory syndrome (sars), emerging pathogens not common to the united states but endemic to other regions, such as west nile virus, and relatively harmless viruses evolving into highly lethal pathogens such as the hpai h n strain of avian influenza as well as the intentional release of biological weapons. , , , over the last few years we have seen the appearance of monkeypox in the united states as the result of animal importation, and plague patients diagnosed in new york (contracted it in the southwest). war, increased globalization, climate changes, encroachment of previously untouched natural habitats, worldwide food distribution, human population growth, overcrowding, and travel all favor the spread of infectious diseases-especially ones not commonly seen in the u.s. , , , , , tens of thousands of our servicemen and servicewomen will be returning from the persian gulf-many of whom may have been exposed to undetected chemicals or bioweapons, or be infected with diseases endemic to the region. certain "desert illnesses" as well as brucellosis, mosquito-borne diseases, can present with central nervous system, behavioral, and mental status changes. will we diagnose them correctly or will their return be marked by another "persian gulf syndrome?" this syndrome in the early postwar years became synonymous for ptsd. in reality, it represented a variety of etiologies ranging from chemical exposure, desert illnesses, as well as ptsd. therefore the threat of uncommon illness is but the reality of our future practices. the physician should remain alert for such exigencies. if the intentional use of anthrax in taught us anything, it was that an astute physician could save lives. equally, physicians who do not know the common signs of serious, perhaps deadly, emerging illnesses will lose lives. emerging infectious diseases can pose a significant diagnostic challenge and threat to our communities. whether increasing our knowledge and vigilance against emerging threats for our troops or communities, even in a profession fraught with numerous competing demands, the benefit of being able to diagnose rapidly and accurately the index case of an emerging pathogen or helping a servicemember return to health and society is worth the effort. the optimism of the "antibiotic era" and our so-called victory over pathogens should be tempered by the realization that . million annual deaths are the direct result of tb, aids, and malaria, according to the who. this represents approximately one-fourth of the deaths worldwide per year-the result of three infectious diseases. multi-drug-resistant tb and extremely drug-resistant tb are on the increase and pose a significant threat worldwide, including the u.s., where in certain regions and among certain risk groups it remains a significant health problem. , , , , recognition of the potential for troops to import an illness endemic to the middle east and a basic familiarity of the clinical syndromes associated with emerging pathogens-whether those previously unknown, pathogens spread to new areas by global forces, or biological weapons-and subsequently implementing containment and treatment measures will largely rest upon the clinical acumen of the physician. , , , maintaining an index of suspicion for relatively uncommon illnesses-this includes the common presentations of heretofore nonendemic (to the u.s.) infections, staying abreast of trends in travelrelated illness, and emerging patterns of disease, especially in the middle east, using easily obtained sources such as the who internet site may enhance the likelihood of recognizing an uncommon illness. while the incidence of imported infectious disease presenting to hcf is not well defined, , it is well known that significant numbers of patients present to medical facilities upon return from traveling with a variety of complaints, including respiratory infections. studies suggest clinicians do a poor job of obtaining a travel history, including a general lack of awareness by physicians concerning the potential for nonendemic disease in the population that they attend. , in one such study evaluating whether a travel history was recorded in patients, a travel history was recorded in only % of all patients presenting to this emergency department, although among total number of patients presenting to the emergency department, . % actually had the potential for a travel-related illness. , while many of the illnesses that troops are likely to import are not contagious, we should take small comfort in that it only takes one missed case of a contagion to cause an outbreak! physicians and hcp should consider the physical, rehabilitative, and mental health issues within the broader context of a patient who has been in a war zone and now must reenter and adjust to society, job, and family. addressing these domains as part of the overall therapeutic and clinical management plan is critical. moreover, these domains, including financial pressures, will impact recovery, not unlike our civilian patients. however, unlike noncombatant civilians, our civilian troop patients may have faced dramatic, draconian, and devastating experiences unfathomable to their neighbors and thus requiring appropriate medical service. being sensitive to the self-image and pride of these patients, prearranging or collocating psychosocial services, and allowing for seamless care has been shown to improve outcomes. integrating psychiatry and primary care, often referred to as co-location, is effective for improving access to mental health services and for increasing treatment engagement. hcp may be treating the noncombatant family member as well. psychological morbidities can affect loved ones not deployed and, thus, these patients should be screened and counseled. financial worries can cause significant stress and, in a nonthreatening manner, compassionate concern and gentle inquiry should be provided. physicians are often in a position to provide guidance as community leaders and may aid in "networking" on behalf of a financially challenged patient. it is likely some of our patients serving in pgw will experience some form of injury from mst/sexual abuse, ptsd or other psychiatric illness, physical wounds, or a combination thereof. like most patients, they may feel a total lack of control. empowering patients and involving them as active participants in their medical care, education, and choices is an important therapeutic approach. more than , u.s. troops have been deployed to the gulf region. secretary of va principi stated that "we have learned every battlefield poses unique dangers. there are bullet wounds and shrapnel wounds, but there are those things that may not manifest themselves for years. we have to make sure that our system is capable of providing care for them." he is right! it cannot just be the va. it takes a village or a community! as physicians and hcp, we enjoy many privileges in a free nation. we have the benefit of working in far safer conditions than our servicemen and women in iraq, afghanistan, and other dangerous locations worldwide. freedom is not free and we have the opportunity to use our professional skills, community position, and network of colleagues to provide for a special population that placed itself in harm's way for us. deploying to or returning from war presents a spectrum of emotions, risks, injuries, and therapeutic challenges. troops must reenter society after experiencing the horrors of war, the loss of friends, injuries, and deprivation not encountered in the u.s., or they are preparing to enter such a challenging environment, leaving friends, family, safety, and the comforts of home. unlike previous large-scale wars such as wwii or korea, except for families and friends of troops, most u.s. citizens are not engaged in, impacted by, or involved with the war on a daily basis. civilian hcp are in a unique position to help prepare the young men and women who serve as civilian military (reservists/national guard) and active military who may be our patients, for deployment, provide comfort in the knowledge that we will keep a watchful eye on their loved ones-also our patients, in their absence, and be prepared to care for them upon their return to the u.s. builds and remodels homes for severely wounded troops. phone: - - troops. for more information, review their internet site: http://www. homesforourtroops.org/site/pageserver?pagenameϭabouthfot provides helmet upgrade kits to troops in iraq and afghanistan (and about to be deployed); shock-absorbing pads enhance protection against ied and decrease risk of tbi. phone: - - - from to cst or visit their internet site at: http://www.operation-helmet.org/index.html post this information for patients. if a patient is in need of immediate crisis counseling, please contact the va's suicide hotline at - - -talk; counselors are available / to help. an advocacy and humanitarian organization to ensure that our country meets the needs of servicemembers and veterans who have served in oef and oif. veteran's for america focuses on psychological traumas and traumatic brain injuries. resources also for women veterans. internet site: http://www.veteransforamerica.org/military-women/ the central resource for women veterans in the commonwealth of massachusetts. the veterans administration also has resources for women. http://www.mass.gov/?pageidϭveteranstopic&lϭ &sidϭeveterans&l ϭ home&l ϭwomenϩveterans the following may be able to assist veterans and their families: the department of defense (dod) has opened the military severely injured joint support operations (msijso) center ( / ) to help severely injured service members find jobs and answer their or family member questions. toll free - - - . the dod and www.military.com have partnered to create an online career center that can assist severely injured service members with benefits, resources, and employment opportunities. in each of the va medical centers, there is an elk committee at work to help veterans in need, including those who are homeless. bpo elks, usa. n. lakeview avenue, chicago, il . dav develops financial resources for the assistance, care, and support as well as rehabilitation of disabled veterans and their dependents. alexandria pike, cold spring, ky . ph: - - - . a resource and technical assistance center for community-based service providers and agencies that provide emergency and supportive housing, food, health services, job training placement assistance, legal aid, and case management. ph: - - - ( - -vet-help) nahhh is a network of Ͼ organizations throughout the u.s. providing family-centered lodging and support services to families and their loved ones confronted with medical emergencies. ph: - - - . of note, some states (connecticut, for example) establish funds to provide emergency financial assistance. internet site: www.va.gov the intrepid fallen heroes fund provides support toward the severely injured. in january , the fund completed construction of a $ million world-class state-of-the-art physical rehabilitation center at brooke army medical center in san antonio, texas. the "center for the intrepid" serves military personnel who have been catastrophically disabled in operations in iraq and afghanistan, and veterans severely injured in other operations and in the normal performance of their duties. the , square foot center provides ample space and facilities for the rehabilitation needs of the patients and their caregivers. internet site: http://www.fallenheroesfund.org/ in harm's way: infections in deployed american military forces old world leishmaniasis: an emerging infection among deployed us military and civilian workers impact of illness and non-combat injury during operations iraqi freedom and enduring freedom defense intelligence agency, armed forces medical intelligence agency. medical threat assessment-northern iraq q fever and the us military va research and development. united states department of veterans affairs burden of medical illness in women with depression and post-traumatic stress disorder can we prevent a second 'gulf war syndrome'? population-based healthcare for chronic idiopathic pain and fatigue after war combat duty in iraq and afghanistan, mental health problems and barriers to care bringing the war back home casualties of war-military care for the wounded from iraq and afghanistan military sexual trauma: issues in caring for veterans. iraq war clinician guide, dept. of veterans affairs. the national center for ptsd manuals treating the traumatized amputee tympanic membrane perforation as a marker of concussive brain injury in iraq analysis of battlefield head and neck inquires in iraq and afghanistan with 'invisible injuries,' thousands of brain-damaged troops returning home traumatic brain injury in the war zone report faults hospital for marine's death. the tampa tribune, friday rehabilitation and the long-term outcomes of persons with trauma-related amputations does the presence of a specialized rehabilitation unit in a veterans affairs facility impact referral for rehabilitative care after a lower extremity amputation? acute psycho-social intervention strategies with medical and psychiatric evacuees of protecting military convoys in iraq; an examination of battle injuries sustained by a mechanized battalion during operation iraqi freedom ii the experience of the us marine corps' surgical shock trauma platoon with operative combat casualties during a month period of operation iraqi freedom screening for brain injury is set for illinois veterans treatment of medical casualty evacuees caring for the wounded in iraq-a photo essay the san diego union-tribune. / / va preparing for health issues from iraq war vets wait longer for care than va allows combat duty in iraq and afghanistan, mental health problems and barriers to care are veterans seeking veterans affairs' primary care as healthy as those seeking department of defense primary care? a look at gulf war veteran's symptoms and functional status the neurological consequences of explosives casualties treated at the hospital in the madrid experimental pressure induced rupture of the tympanic membrane in man military tbi during the iraq and afghanistan wars operation helmet; data on helmets and brain injury blast injuries toxicology of blast overpressure medical management of explosives explosive and traumatic events q fever meningoencephalitis in a soldier returning from the persian gulf war brucellosis in a soldier who recently returned from iraq cutaneous leishmaniasis in soldiers from fort campbell, kentucky returning from operation iraqi freedom highlights diagnostic and therapeutic options centers for disease control and prevention. two cases of visceral leishmaniasis in u.s. military personnel-afghanistan an outbreak of malaria in us army rangers returning from afghanistan acute eosinophilic pneumonia among us military personnel deployed in or near iraq q fever and the us military acinetobacter baumannii infections among patients at military medical facilities treating injured us service members centers for disease control and prevention. outbreak of acute gastroenteritis associated with norwalk like viruses among british military personnel-afghanistan gastroenteritis outbreak in british troops sequelae of traveler's diarrhea: focus on postinfectious irritable bowel syndrome deployment related conditions of special surveillance interest, us armed forces world health organization (who) institute of medicine committee on the gulf war and health diagnostic and therapeutic pitfalls associated with primaquine tolerant plasmodium vivax persistence of leishmania parasites in scars after clinical cure of american cutaneous leishmaniasis: is there a sterile cure? opthalmomiasis caused by the sheet bot fly oestrus ovis in northern iraq q fever in members of the united states armed forces returning from iraq old world leishmaniasis: an emerging infection among deployed us military and civilian workers defense intelligence agency, armed forces medical intelligence agency. final report: analysis of iraqi military blood samples q fever in oif deployed soldiers: an emerging disease of military importance diagnosis of q fever avian influenza: the next pandemic atypical q fever in us soldiers treatment of cutaneous leishmaniasis by curettage military of the united states www.defenselink.mil surge seen in number of homeless veterans. erik eckholm. the ny times the impact of deployment on the military family post traumatic stress disorder (ptsd) mental health online. www. mentalhealthchannel chapter vii: ptsd in iraq war veterans: implications for primary care topics specific to the psychiatric treatment of military personnel posttraumatic stress disorder and depression in battle injured soldiers iraq war clinician guide, dept. of veterans affairs. the national center for ptsd substance abuse in the deployment environment in: iraq war clinician guide, dept of veterans affairs va intranet) . national institute for mental health information on ptsd increased ptsd risk with combat-related injury: a matched comparison study of injured and uninjured soldiers experiencing the same combat events veterans' mental health in the wake of war adolescent health and risk behaviors: the role of the primary care physician train the trainers guide integrating comprehensive adolescent preventive services into routine medical care; rationale and approaches mental health problems, use of mental health services and attrition from military service after returning from deployment to iraq or afghanistan post traumatic stress disorder and depression in health care providers returning from deployment to iraq and afghanistan gulf war injections are toxic cocktail when combined, researchers say. cnn presidential advisory committee on gulf war veterans' illnesses. presidential advisory committee on gulf war veterans' illnesses: final report national institutes of health technology assessment workshop panel. the persian gulf experience and health national academy of sciences. health consequences of service during the persian gulf war: recommendations for research and information systems the iowa persian gulf study group. self-reported illness and health status among gulf war veterans illness among united states veterans of the gulf war: a population-based survey of , veterans chronic multisymptom illness affecting air force veterans of the gulf war health of uk servicemen who served in persian gulf war the centers for disease control vietnam experience study. post service mortality among vietnam veterans present at the conference on federally sponsored gulf war veterans' illnesses research chronic q fever: ninety-two cases from france including cases without endocarditis endocarditis after acute q fever in patients with previously undiagnosed valvulopathies q fever outbreak during the czech army deployment in bosnia self-reported description of diarrhea among military populations in operations iraqi freedom and enduring freedom update: cutaneous leishmaniasis in us military personnel-southwest/central asia cutaneous leishmaniasis: clinical aspect biological warfare-an emerging threat bioterrorism and weapons of mass destruction : physicians as first responders. the do new and re-emerging infectious diseases: epidemics in waiting coxiella burnetii infection psychiatry and the military: an update veterans affairs. internet site: www.va.gov playing numbers game with our dead posttraumatic stress disorder and the risk of traumatic deaths among vietnam veterans mortality among us veterans of the persian gulf war: year follow-up arm center for substance abuse programs with links to world wide asap locations federal research strategy needs reexamination. united states general accounting office (gao) epilogue: social and historical perspectives on the vietnam veteran avian influenza: critical considerations for the primary care physician epidemiology of travel-related hospitalization knowledge, attitudes and practices in travel-related infectious diseases: the european airport survey update: chlorine use as a weapon- pulmonary agents-(phosgene, chlorine, vinyl chloride, vinylidine chloride) healthcare for the whole person; reconnecting the mind and body study makes case of reintegrating behavioral health, primary care mind and body primary mental healthcare: new model for integrated services building new bridges in primary care new rule will change the psychologist-physician relationship. monitor psychiatry multidrug resistant tuberculosis: a menace that threatens to destabilize tuberculosis control visceral infection caused by leishmania tropica in veterans of operation desert storm diffusely disseminated cutaneous leishmania major infection in a child with acquired immunodeficiency syndrome rapid diagnosis of leishmaniasis by fluorogenic polymerase chain reaction comparative study of the efficacy of combined cryotherapy and intralesional meglumine antimoniate (glucantime) vs. cryotherapy and intralesional meglumine antimoniate alone for the treatment of cutaneous leishmaniasis a randomized controlled trial to test the efficacy of thermotherapy against leishmania tropica in kabul blood donation eligibility guidelines usamriid's medical management of biological casualties handbook preparing for an era of weapons of mass destruction (wmd)-are we there yet? why we should all be concerned women veterans' network of the department of veterans' services the central resource for women veterans in the commonwealth of massachusetts. the veterans administration also has resources for women us low risk drinking guidelines: an examination of four alternatives validation of the screening strategy in the niaaa. physicians' guide to helping patients with alcohol problems cognitive processing therapy for rape victims: a treatment manual treating the trauma of rape: cognitive-behavioral therapy for ptsd america's secret war: victims of sexual assault while serving in the military world health organization (who) the author thanks lt. deena disraelly (usn, ret) for tremendous assistance, both for military service and for the preparation of this manuscript. her insights into the health care issues of returning troops were invaluable. there were several active and retired military who shared their personal experiences but on condition of anonymity; my gratitude for their service and candor. the author also thanks jamie walker, an amazing editor and colleague; her guidance, enthusiasm, and skills shared on this and previous manuscripts are greatly appreciated. thank you to dr. caren teitelbaum, yale university school of medicine, department of psychiatry, for sharing her knowledge and insightful suggestions. key: cord- -lghjiw p authors: chaix, b.; delamon, g.; guillemasse, a.; brouard, b.; bibault, j.-e. title: psychological distress during the covid- pandemic in france: a national assessment of at-risk populations date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: lghjiw p introduction more than . billion people in the world are currently in lockdowns to limit the spread of the novel coronavirus disease (covid- ). psychological distress (pd) and post-traumatic stress disorder have been reported after traumatic events, but the specific effect of pandemics is not well known. the aim of this study was to assess pd in france, a country where covid- had such a dramatic impact that it required a country-wide lockdown. patients and methods we recruited patients in groups of chatbot users followed for breast cancer, asthma, depression and migraine. we used the psychological distress index (pdi), a validated scale to measure pd during traumatic events, and correlated pd risk with patients characteristics in order to better identify the one who were the most at-risk. results the study included participants. . % ( ) were female with a mean age of . years (sd= , ), . % ( ) were male with a mean age of . years (sd= , ). in total, . % ( ) of the respondents had psychological distress (pdi [≥] ). an anova analysis showed that sex (p= . ), unemployment (p= . x - ) and depression (p= . x - ) were significantly associated with a higher pdi score. patients using their smartphone or computer more than one hour a day also had a higher pdi score (p= . ). conclusion prevalence of pd in at-risk patients is high. these patients are also at increased risk to develop post-traumatic stress disorder. specific steps should be implemented to monitor and prevent pd through dedicated mental health policies if we want to limit the public health impact of covid- in time. the novel coronavirus disease (covid- ) pandemic called for unprecedented policies by governments around the world to counter its spread. most european countries have implemented social distancing and shelter in place measures. these measures are comparable to generalized quarantine and prevent the spread of the virus by restricting the movement and social interactions of people who are potentially exposed ( ) . as of may, rd, . billion people are in lockdowns ( ) . in france, these measures have been in force since march . several studies have reported the negative effects of quarantine on stress or depression ( ) ( ) ( ) . peritraumatic distress (pd) is defined as the emotional and physiological distress experienced during and/or immediately after a traumatic event. it is associated with a higher risk and severity of post-traumatic stress disorder (ptsd) ( , ) . the peritraumatic distress inventory (pdi) was created to assess the emotional and physiological experience of individuals during a traumatic event ( ) . studies have shown that pdi has a good internal consistency, stability, and validity. pdi items can be grouped into factors that better reflect and predict pd and ptsd: negative emotions (items , , , , , , and ) and perceived life threat and bodily arousal (items , , , , , and ) ( ) . it has also been shown that a pdi score equal or over was predicting full or partial ptsd six-weeks post-injury ( ) . the main objective of this study was to assess the effect of the covid- crisis on psychological distress in at-risk patients. the secondary objectives were to describe the patients characteristics that can be used to predict the risk of pd and ptsd. in order to do so, we built an e-cohort consisting of users of medical chatbots designed to support patients with ( ) asthma, ( ) breast cancer, ( ) depression and ( ) migraine. a chatbot is a software leveraging artificial intelligence to provide a natural language conversation with a user. they can be use to monitor patients during treatment or to collect patient-reported outcomes ( ) . vik chatbots, developed by wefight, have shown their interest in patient support and adherence to treatment ( ) . they are also able to provide medical information to breast cancer patients with a level of quality comparable to physicians, as shown in the phase randomized controlled trial incase (nct ) ( ) . the "vik asthme" chatbot is dedicated to information and management of asthma-related symptoms, the "vik breast" chatbot is specialized in the management of breast cancer patients, the "vik depression" chatbot accompanies patients with symptoms of depression and the "vik migraine" chatbot is helping patients with chronic migraine. people with asthma are populations at increased risk of severe viral respiratory infections that can also induce exacerbations. the sars-cov can induce asthma exacerbations which are a source of additional stress for asthma patients. initial data shows that asthma patients do not appear to be over-represented in patients with covid- ( , ) . in order to mitigate the lack of pathology control and treatment adherence during travel restrictions, the french government has implemented solutions to facilitate the renewal of treatment in the long term ( ) . in addition, , hospitalizations are attributable to asthma every year in france ( ) . this pandemic also represents a significant concern to cancer patients, who are at high risk of complications due to several predisposing factors ( ) ( ) ( ) . in patients with breast cancer, management must be tailored and cannot be delayed. european countries have increased the use of telehealth systems to reduce the number of hospital visits. in italy, these changes in care lead to many questions for patients, which can generate severe stress or anxiety ( ) . the first studies conducted in china following the coronavirus pandemic have shown the impact on the mental health of healthcare workers, with an increased risk of depression and anxiety ( ) . patients already diagnosed with depressive disorder could be at a high risk of distress during the covid- pandemic. finally, migraine is a pathology with a high prevalence: it is estimated to be between % and % in adults aged to ( ) with a sex ratio of women to man ( ) . despite its high prevalence, migraine remains an under-diagnosed and under-treated condition in the general population. migraine can have a significant impact on the patient's quality of life ( ) . migraines can worsen in times of stress. this period of pandemic can generate a new source of stress and aggravate the pathology. the study was conducted in france between march and april . the participants were users of the different vik chatbots. they were contacted online to participate in a survey assessing their level of stress during the covid- crisis. the inclusion criteria were to be of legal age and to have breast cancer, asthma, migraine or depression. the non-inclusion criteria concerned users who were unable to formulate their non-opposition, who had insulted the chatbot or who had dialogues that made no sense. a self-report questionnaire, the peritraumatic distress index (pdi), was used. peritraumatic distress is defined as the emotional and physiological distress experienced during and/or immediately after a traumatic event ( , ) . it is the standard tool designed to assess psychological distress in times of crisis . it consists of questions rated from (not at all true) to (extremely true). it explores the frequency of anxiety, depression, specific phobias, cognitive changes, avoidance and compulsive behaviors, physical symptoms and loss of social interaction in the past week. the total score, ranging from to , is the sum of all items. a score equal of over indicates significant distress. the french validation of the pdi has a good internal cohesion, with a cronbach's alpha of . ( ) . the pdi questionnaire was presented to the participants by text messages. users were asked to click on a button corresponding to the score they wished to give their status. there was no actual conversation per question, nor was there a need for natural language processing for each question. classical demographic information (age, sex, city, professional profile), level of knowledge and use of internet tools and the presence or absence of symptoms related to covid- were also assessed. participants were not paid. the collected data were anonymized and then hosted by wefight on a server that meets the requirements for storing health data. consent was collected online before the start of the study. this study was registered in the clinicaltrials.gov database (nct ) and was approved by an ethics committee (cpp sud méditerranée iv) independently selected by the french ministry of health. in accordance with french and european laws on information technology and liberties (commission nationale informatique et libertés, registration n° , general regulations for data protection), users had the right to access the data to verify its accuracy and, if necessary, to correct, complete and update it. they also had a right to object to their use and a right to delete such data. the general conditions for the use of the data were presented and explained very clearly. they had to be accepted before accessing the questionnaire. the description of the populations included was carried out by the classic elements of the calculation of mean, standard deviation, median and quartiles for quantitative variables, numbers and percentages and % confidence intervals for qualitative variables. the population density was defined by french government's depp (direction of evaluation, prospection and performance) ( ) . anova was performed to detect patients' attributes with a significant effect on pdi. in addition, a binomial logistic regression analysis was carried out to determine the patients' features associated with a pdi> , because this subpopulation is at a higher risk of partial or full ptsd six weeks after the traumatic event. pdi items were grouped into two factors that have been shown to better reflect and predict pd and ptsd: negative emotions (items , , , , , , and ) and perceived life threat and bodily arousal (items , , , , , and ). for both groups an anova was performed. the pearson correlation coefficient was calculated between the average pdi and the number of infected people in each french region and was tested to be equal to . the study included participants. we excluded of them because they were not eligible (incomplete questionnaires and age requirements). the total sample size was . overall, . % ( ) were female with a mean age of . years (sd= , ), . % ( ) were male with a mean age of . years (sd= , ) and . % ( ) were "other" with a mean age of . years (sd= , ) ( table ). in total, . % ( ) of participants were using a smartphone or computer less than an hour a day, . % ( ) for more than hour but less than hours a day and . % ( ) more than hours a day. they were . % ( ) who had been using the internet for more than years. during the survey period, all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . https://doi.org/ . / . . . doi: medrxiv preprint patients using their smartphone or computer more than one hour a day also had a higher pdi score (p= . ). there was no significant difference between groups (p> . ; figure ). ). the negative emotions factor was significantly associated with depression (p= . x - ), age higher than y.o. (p= . ), being a woman (p= . ), living in a low population density area (p= . ), being unemployed (p= . x - ) and using a smartphone or computer more than hours a day (p= . ). the life threat and bodily arousal factor was significantly associated with depression (p= . x - ), age younger than y.o. (p= . ), being a woman (p= . ), living in a low population density area (p= . ) and being unemployed (p= . ). the first case of covid- was diagnosed in december in wuhan, china and has since brought unprecedented efforts from governments all over the world to limit its spread. these steps have included social distancing and global shutdowns. their precise consequences on mental health are still unknown. it is currently considered that the risk for mental health is outweighed by the need to prevent infections. the available literature on the mental health consequences of pandemics are more focused on the sequelae of the infection, however other catastrophic events, such as the world trade center terrorist attacks, are followed by increase in depression and ptsd cases, substance abuse, domestic violence and child abuse ( ) . in that regard, the sars epidemic also induced an increase in pd and ptsd in patients and clinicians ( ) . covid- could also have the same effect, specifically because of the strong mitigation strategies that have been enforced all over the world, on a scale never seen before, but also because of the major economic disruptions it has induced ( ) . the aim of our study was to quantify psychological distress and the risk of post-traumatic stress disorder on a national scale in a country that has been hard-hit by covid- , france. all rights reserved. no reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted may , . . using a chatbot-administered standardized and validated tool specifically designed to rate pd, the psychological distress index ( ) . we showed that, in groups of patients at-risk to develop pd and ptsd, the prevalence of psychological distress was high ( . %, n= ). these patients are also at high risk to develop partial of full ptsd six-week after the evaluation, as shown by bunnel et al. ( ) . within those groups of patients, women, unemployed (p= . x - ) and depressed (p= . x - ) patients had significantly higher pdi score. interestingly, patients using their smartphone or computer more than one hour a day also had a higher pdi score (p= . ). this could also highlight the potential negative psychological impact of information and/or social networks in the context of such an event. our study is the first to assess pd in patients during a pandemic on a national scale. there are limitations that should be considered when interpreting our results: first, a majority of participants were women ( . %). this is due in part to the fact that one of the groups explored consisted in breast cancer patients, but it could also show that men are less likely to participate in this kind of online self-reported survey. this fact could potentially bias the results and specifically the value of the features we found to be associated with a pdi over (predictive of ptsd). another limitation is due to the sampling technique itself, relying on groups of patients already using the chatbots, excluding patients not using them. this study still holds interesting results because of the large cohort of respondents, the adequate geographical spread across france and the sampling time frame that corresponds to the pandemic peak in france. other studies have been conducted to measure the impact of covid- among the general population. in italy, rossi et al conducted a web-based survey on , . they found high rates of negative mental health outcomes three weeks into the covid- lockdown: % of the participants declared they had symptoms of ptsd, . % of depression and . % of anxiety. like in our study, the majority of respondents were women ( . %). overall, policy makers are rightfully concerned by the potential negative effects on public health of covid- , beyond the pandemics itself. in the uk, psychological first aid guidance has been issued by mental health uk ( ) . in france, several psychological support hotlines have been created for healthcare professionals ( ) and the general public ( ) . the precise mental health sequelae of the pandemic are still unknown but should not be neglected. in the coming weeks, months and years, we need to thoroughly investigate these consequences to be able to correctly address them. specific efforts should be made to lower the risk of pd, depression, suicide, substance abuse and domestic violence, otherwise the long-term consequences of the covid- pandemic could be even more dire, should they remain unexplored, unaddressed, and ultimately forgotten. covid- has a significant impact on psychological distress in patients with breast cancer, asthma, depression and migraine: % of participants have a pdi equal or over . this population is also at increased risk of partial or full post-traumatic stress disorder. specifically, women, unemployed and depressed patients are at an even higher risk. patients using their smartphone or computer more than one hour a day are also at higher risk to develop pd. this measures call for systematic evaluation of the consequences of the covid- pandemic in countries where lockdowns were enforced ( . billion people as of may, rd ). study concept (bc, jeb), drafting of the manuscript and supervision (bc, jeb, gd), acquisition of data (gd, ag), statistical analysis (ag), interpretation of data (bc, jeb), critical revision of the manuscript for important intellectual content (all authors). gd, ag and bb are employed by wefight. bc and jeb own shares of wefight. quarantine and isolation | quarantine | cdc infographic: what share of the world population is already on covid- lockdown? survey of stress reactions among health care workers involved with the sars outbreak the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk posttraumatic stress disorder in parents and youth after health-related disasters. disaster medicine and public health preparedness comprehensive guide to post-traumatic stress disorders peritraumatic distress and the course of posttraumatic stress disorder symptoms: a meta-analysis the peritraumatic distress inventory: a proposed measure of ptsd criterion a the peritraumatic distress inventory: factor structure and predictive validity in traumatically injured patients admitted through a level i trauma center prediction of trauma-related disorders: a proposed cutoff score for the peritraumatic distress inventory healthcare ex machina: are conversational agents ready for prime time in oncology when chatbots meet patients: one-year prospective study of conversations between patients with breast cancer and a chatbot. jmir cancer a chatbot versus physicians to provide information for patients with breast cancer: blind, randomized controlled noninferiority trial clinical characteristics of patients infected with sars-cov- in wuhan, china novel coronavirus ( -ncov) outbreak: a new challenge l'asthme en france en : prévalence et contrôle des symptômes epidemiology, diagnosis, treatment, and prevention of influenza infection in oncology patients cancer patients in sars-cov- infection: a nationwide analysis in china sars-cov- transmission in patients with cancer at a tertiary care hospital in wuhan, china reorganisation of medical oncology departments during the novel coronavirus disease- pandemic: a nationwide italian survey multiple risk factors of depression and anxiety in medical staffs: a cross-sectional study at the outbreak of sars-cov- in china social science research network; mars professional recommendations and references: economic evaluation service prevalence of headache in europe: a review for the eurolight project global, regional, and national incidence, prevalence, and years lived with disability for diseases and injuries for countries, - : a systematic analysis for the global burden of disease study . the lancet une typologie des communes pour décrire le système éducatif post-traumatic stress disorder following disasters: a systematic review stress and psychological distress among sars survivors year after the outbreak mental health and the covid- pandemic covid- and your mental health ministère des solidarités et de la santé covid- ) : numéros utiles | service-public key: cord- -fl yrpzs authors: sayde, george; stefanescu, andrei; conrad, erich; nielsen, nathan; hammer, rachel title: implementing an intensive care unit (icu) diary program at a large academic medical center: results from a randomized control trial evaluating psychological morbidity associated with critical illness date: - - journal: gen hosp psychiatry doi: . /j.genhosppsych. . . sha: doc_id: cord_uid: fl yrpzs background: psychological morbidity in both patients and family members related to the intensive care unit (icu) experience is an often overlooked, and potentially persistent, healthcare problem recognized by the society of critical care medicine as post-intensive care syndrome (pics). icu diaries are an intervention increasingly under study with potential to mitigate icu-related psychological morbidity, including icu-related post-traumatic stress disorder (ptsd), depression and anxiety. as we encounter a growing number of icu survivors, in particular in the wake of the coronavirus pandemic, clinicians must be equipped to understand the severity and prevalence of significant psychiatric complications of critical illness. methods: we compared the efficacy of the icu diary, prospectively written by third parties during the patient's intensive care course, versus education alone in reducing acute ptsd symptoms after discharge. patients with an icu stay greater than h, who were intubated and mechanically ventilated over h, were recruited and randomized to either receive a diary at bedside with psychoeducation or psychoeducation alone. intervention patients received their icu diary within the first week of admission into the intensive care unit. psychometric testing with ies-r, phq- , hads and gad- was conducted at weeks , , and after icu discharge. change from baseline in these scores, obtained within one week of icu admission, was assessed using wilcoxon rank sum tests. results: from september , to september , , our team screened patients from the surgical and medical icus at a single large academic urban hospital. patients were enrolled and randomized, of which patients completed post-discharge follow-up (n = ) in the diary intervention group and (n = ) in the education-only control group. the control group had a significantly greater decrease in ptsd, hyperarousal, and depression symptoms at week compared to the intervention group. there were no significant differences in other measures, or at other follow-up intervals. both study groups exhibited clinically significant ptsd symptoms at all timepoints after icu discharge. follow-up phone interviews with patients revealed that while many were interested in getting follow-up for their symptoms, there were many barriers to accessing appropriate therapy and clinical attention. conclusions: results from psychometric testing demonstrate no benefit of icu diaries versus bedside education-alone in reducing ptsd symptoms related to the intensive care stay. however, our study finds an important gap in care – patients at high risk for pics are infrequently connected to appropriate follow-up care. perhaps icu diaries would prove beneficial if utilized to support the work within a program providing wrap-around services and close psychiatric follow up for pics patients. this study demonstrates the high prevalence of icu-related ptsd in our cohort of survivors, the high barrier to accessing care for appropriate treatment of pics, and the consequence of that barrier—prolonged psychological morbidity. trial registration: nct grant identification: gh- - (arnold p. gold foundation) j o u r n a l p r e -p r o o f patients enduring critical illness carry an increased risk for developing new-onset posttraumatic stress features related to their course in the intensive care unit (icu). this is largely due to the near-death nature of their medical conditions and complicated hospital courses, which often involve acute stress, delirium, and delusional memories. the prevalence of post-traumatic stress disorder (ptsd) in icu survivors is estimated at - % during the first month, and - % during the next - months [ , ]. icu-related psychological sequela, such as ptsd, depression, and anxiety, comprise clinically important components of post-intensive care syndrome (pics). both post-icu ptsd and depression are associated with a significant decrease in patient quality of life after discharge compared to the general population [ , ] . we are thus faced with the challenge of identifying modifiable risk factors in order to prevent the long-term complications of critical care. risk factors related to the development of ptsd in the icu setting include delusional memory formation, poor functional status, use of physical restraints, use of sedation, pre-existing psychiatric history, younger age (less than years), female gender, sepsis, and treatment with benzodiazepines and neuromuscular blockers [ , [ ] [ ] [ ] [ ] . early identification of high-risk patients and subsequent interventions in the forms of social support, administration of self-help manuals, and post-discharge psychiatric consultations have all shown to have a protective effect on the incidence of icu-related ptsd [ , ] . particular genetic polymorphisms regulating corticotropinreleasing hormone are also associated with significantly fewer post-icu depressive and posttraumatic stress symptoms [ ] . in addition, the use of an icu diary, where everyday events can be prospectively recorded by family members and healthcare workers, has been shown in some studies to reduce j o u r n a l p r e -p r o o f new-onset ptsd, anxiety, and depressive symptoms and promote psychological wellbeing in both patients and their families [ , , ] . early interventions, in general, may have the most impact on psychological and cognitive sequela following the icu course. thus, early counseling and planned follow-up with mental health providers appears to be critical for at-risk patients. previous research has shown that patients exhibiting the most severe ptsd symptoms have no factual recall of their icu stay and experience vivid delusional memories of their hospital course, such as memories of staff members trying to kill them [ ] . the icu diary's proposed benefit is based on the idea that -one of the strongest and most consistent predictors of subsequent psychological dysfunction is the memory of what may or may not have happened during the course of critical illness‖ [ ] . the early work of jones, et al. demonstrated benefit of the icu diary as intervention to improve icu-related ptsd outcomes [ , ] ; however, subsequent larger multi-centered studies with randomized control trial (rct) methodology in france have not replicated the early reported benefit [ ] . subjective reports of the secondary benefits of icu diaries have been recognized, especially among caregivers of patients with pics. diaries provide families with a sense of control by allowing them to keep track of general events and to log support and well wishes for their loved one when otherwise unable to communicate. for patients who survive their hospital stay, the diary provides a basic chronology of events and a symbol of the support they received during their icu stay [ ] . prior studies [ , ] involving icu diaries have mostly been implemented in europe, where hospital systems routinely offer diaries to critically ill patients. these trials largely differentiated study groups based on time-to-receiving diaries post-icu discharge, as opposed to randomizing patients from the onset to diary versus no-diary groups. our study examines the j o u r n a l p r e -p r o o f effect of the diary protocol in a new setting where the culture of icu diaries had not previously been implemented. this paper describes our rct at a large, public, level one trauma center in the gulf south to assess the efficacy of a diary versus bedside ptsd education-only on reducing symptoms of new-onset ptsd in patients after their icu course. from september to september , we screened patients at high risk for icurelated ptsd from both the surgical and medical intensive care units of university medical center new orleans, which holds icu beds. inclusion criteria required that patients had an icu stay greater than hours, were intubated more than hours, and did not have pre-existing ptsd, dementia, intracranial injury, or other debilitating neurocognitive conditions (supplemental content, error! reference source not found.). after screening, patients were enrolled and underwent randomization. all patients (and available family members) in our study received ptsd education and referrals at the bedside within one week of admission to the intensive care unit (supplemental content, . ). patients provided informed consent if able to do so on their own behalf. if not able, a legally authorized representative/surrogate decision-maker provided voluntary written consent for participation into the study for the purpose of initiating the diary intervention while the patient was unconscious. surrogates were made aware that their consent for the patient could be overridden by the patient when re-consented by our team upon regaining consciousness. study participants (and respective family members) who received the icu diary were educated on its purpose by a member of our team. this study was approved by our university and hospital j o u r n a l p r e -p r o o f institutional review boards prior to its implementation. our clinical trial registry is found at https://clinicaltrials.gov/ct /show/nct (with study number nct ). for the diaries, we used blank journals, into which we encouraged family and icu healthcare workers write daily events in everyday language. we instructed participants that entries detail daily activities, subjective or hoped for response to treatment, and personal notes of encouragement. diaries remained in the patient's possession after discharge. our study team did not examine or photocopy contents of the personal diaries. patients were visited every two to three days until hospital discharge by a member of our study team, who answered questions and encouraged use of the diary during the intensive care course. we reminded users of the diaries that they were contributing to a public document and cautioned against including personal or sensitive medical information (e.g.: hiv status, details of treatment, substance use history, and other diagnostic information). nursing staff also received educational sessions regarding use of the diaries along with written guidelines of best practices. all family members and healthcare staff involved in diary writing received written instructions adapted from prior studies [ , , ] for consistency (supplemental content, enrolled patients were randomized to either a diary group (intervention group) or an education-only group (control group) (figure ) . randomization was conducted in a : ratio via a computer-generated algorithm. there was some cross-over between groups during the course of the study due to popularity of the idea of using an icu diary among family members. we conducted both an intention-to-treat (itt) analysis maintaining the initial randomization and an as-treated analysis that included the crossover participants originally randomized to the control group in the intervention group. we will present the itt results and discuss key differences between the itt results and as-treated results where differences arose. questionnaire (phq- ), hospital anxiety and depression scale (hads), and generalized anxiety disorder -item (gad- ) within one week of icu admission (baseline) and again at the following time points after icu discharge: week , week , and week . the ies-r assesses the presence and intensity of new-onset ptsd symptoms (range, - ; higher scores indicate more severe symptoms), related to a recent inciting event, and we chose to use this for consistency with prior studies [ , ] . the ies-r also includes sub-scores that reflect the severity of hyperarousal, intrusion, and avoidance symptoms. the phq- identifies the presence and severity of depressive symptoms (range, - ; higher scores correspond to more severe symptoms). the question regarding suicidality on the phq- was omitted. the hads screens for anxiety and depression symptoms in the acute hospital setting (range, - ; higher scores indicate more severe symptoms). the gad- assesses the presence and severity of anxiety symptoms (range, - ; higher scores indicate more severe symptoms). in addition, patient demographic data was collected at baseline: age, sex, race, past medical and psychiatric conditions, reasons for icu admission, hospital diagnosis, and length of icu stay in days. our primary outcome was change in total ies-r score from baseline at week . secondary outcomes included: changes in the other measures and ies-r sub-scores at week , changes in all measures at week , and length of stay (los). moreover, the prevalence of clinically significant ptsd, defined by ies-r total score greater than [ , , ] , was calculated for both groups at all time points. the recruitment target was n = which accounted for a % withdrawal and loss rate, % study power, p-value of . , and -point clinically significant reduction in post-traumatic stress symptoms via the ies-r [ , ] . wilcoxon rank sum tests were used to test group j o u r n a l p r e -p r o o f differences in continuous variables, fisher's exact tests were used for categorical variables, and log rank tests were used for time-to-event variables. all data analyses were conducted using sas . . the screening and enrollment procedures and randomization scheme are summarized in table ) . patients were withdrawn from our study before baseline evaluation, most often due to mortality. reasons for withdrawal included: death, new-onset strokes, hospital elopement, and loss to follow-up after discharge. all patients were withdrawn within one week of enrollment into the study, and complete baseline data was unable to be obtained on these subjects. six participants randomized to the control group were subsequently found to have started diaries on their own, effectively crossing over into the intervention group. five patients randomized to the intervention group never successfully started a diary, thus crossing over into the control group. the results presented below reflect the initial randomization, and key differences with the astreated analysis will be discussed. j o u r n a l p r e -p r o o f changes in ies-r and sub-scores at and weeks can be seen in table . the use of a diary during the icu course was associated with a smaller reduction in ptsd symptoms, as measured by the ies-r, compared to the control group (p = . ). participants in the control group also experienced significantly greater improvements in ies-r hyperarousal sub-scores compared to the intervention group at week (p = . ). changes in other sub-scores and scores at week did not differ significantly between groups. when crossovers were accounted for in an as-treated analysis, there was no longer a significant difference in change from baseline total ies-r score at week between groups. however, the change from baseline in hyperarousal sub-score remained significantly better in the control group than the intervention group (p = . ). changes from baseline in gad- , phq- , and hads-total score and anxiety and depression sub-scores at weeks and are summarized in table . we found a statistically significant reduction in depressive symptoms (as measured by the phq- ) in the control group, compared to the intervention group, at week (p= . ). this difference was not observed in an as-treated analysis, however. our study finds no other significant difference between groups with respect to these secondary measures. length of icu stay did not significantly differ between diary and control groups (table ) . however, the diary group trended towards greater length of stay (supplemental content, error! reference source not found.). the diary intervention group was found to have clinically our analysis indicates that further investigation is warranted before arriving at conclusions regarding the efficacy of diaries in treating icu-related ptsd symptoms. we found no significant benefit attributable to the intervention, consistent with the results of a cochrane review [ ] and a multicenter randomized control trial [ ] studying the use of diaries across icus in france. in fact, our study may indicate harm associated with the use of diaries, which appears to be a new finding. in our sample, the difference in changes of ies-r scores seems to be driven by an effect in the hyperarousal subscore. this may be due to the particular sample we had, especially given its small size. it may also signal that those with significant hyperarousal have a more severe form of icu-related ptsd which may prove to be more persistent and possibly treatment-resistant. both study groups trended towards worsening, clinically relevant ptsd symptoms by weeks after icu discharge. our data demonstrates no benefit to icu-related ptsd with use of an icu diary, but it does suggest that pics is a clinically significant phenomenon that merits attention and improved access to care. our study has several important limitations. we experienced a significant participant withdrawal rate ( . %) within one week of patient enrollment, largely due to loss to follow-up and icu-related morbidity and mortality, which is not uncommon for this study population. initiating practice habits regarding voluntary clinician use of a diary in a hospital without a prior institutional culture of diary stymied staff involvement, and momentum to participate in a novel therapy without direct incentive was difficult to generate. we saw inconsistent family investment at the bedside in utilizing the diary, inconsistent participation among clinicians, and little use of the diary among patients after discharge. for instance, patients who were initially randomized to the intervention group never successfully started a diary, due to lack of family presence and failure to recruit healthcare team involvement. icu diaries are a non-invasive and low-cost intervention, and when adopted by critical care settings, are widely considered to be a way of humanizing an otherwise chaotic, impersonal and sterilized critical care environment. icu diaries are more common in europe where some hospital systems routinely offer diaries to critically ill patients [ , ] . our study endeavored to implement the diaries intervention within a hospital system that was previously not enculturated with the practice of administering icu diaries, and despite efforts at training nurses and clinicians, some diaries received very little attention from staff. if there was no family at bedside for a patient, the intervention for that individual may have been no better than control, which may have contributed to the lack of significant difference we saw between the two groups in the majority of our secondary outcomes. other limitations include our small sample size, which likely explain some of our unexpected results, as small studies are at higher risk of selecting non-representative samples. in addition, the outcomes we measured do not represent all aspects of wellness. it is likely that diaries have benefit in other ways that we did not capture, particularly as patients and families responded positively to them. due to loss to follow-up and our specific study design, we were not able to study the long-term effects that may be associated with the diaries. for instance, j o u r n a l p r e -p r o o f diaries may be effective tools in outpatient therapy long term, leading to faster recovery, rather than preventing ptsd symptoms. our study would not be able to capture this. moreover, we did not look at measures in family members. after an icu experience, family members comprise such an important support system for patients, and the critical illness course can have negative mental health effects on them as well [ ] . the icu diary may have been beneficial for family members and caregivers with regard to certain psychometric outcomes, as shown by jones et al. [ ], and our study did not account for this. many patients and family members in our study population were hesitant towards interacting with mental health providers, largely due to misconceptions about the role and intentions of psychiatrists. this was mostly observed by our study team in the icu rooms during the initial process of consenting patients into our study. multiple patients elicited negative associations, such as forced medications and experimentation, related to the field of mental health. this posed a challenge towards recruitment into our study, along with attempts at bedside education on icu-related psychological complications. in part, these sentiments likely derive from longstanding mistrust towards healthcare providers (due to historical injustices in the medical field in the southern united states and beyond) and the stigmatization of mental illness [ ] . we suspect that underlying mistrust with the mental health care system also affected the willingness of our study participants to present for aftercare. moreover, nearly all of our participants were unaware of their risk for pics that might manifest following an intensive care unit stay when consenting for the study. all of our participants received education on pics. many of our patients who were interviewed after icu discharge required prompting to connect their post-traumatic stress symptoms (e.g., nightmares, j o u r n a l p r e -p r o o f flashbacks, delusional memories) to a mental health condition attributable to their icu course, and many did not recall having been educated about the syndrome while in the icu. this highlights the importance of following up with patients who survive the icu to re-educate about psychological morbidity, which is currently not a routine practice at our institution but perhaps should be. despite follow-ups by phone, only % of our icu survivors in the study presented for mental health follow-up appointments, which is striking given that almost % were reporting impairing symptoms at weeks after discharge. the onus to direct patients toward resources and follow-up care for icu-related psychiatric sequela should not be on the patient and the patient's family alone, but should ideally be absorbed by a system designed to prevent and treat pics. few level one trauma centers in the united states have dedicated pics clinics and case managers, but the awareness of pics as an ongoing disabling syndrome appears to be shifting more research and funding resources toward improving care for those who survive critical illness. as we encounter a growing number of icu survivors, in particular in the wake of the coronavirus pandemic, clinicians must be equipped to understand the severity and prevalence of significant long-term psychiatric complications of critical illnessin an effort to mitigate icurelated symptoms and improve the quality of life of icu survivors [ ] . our icu diary intervention promoted a culture of compassion, collaboration, and humanism among healthcare workers and their critically ill patients and changed the conversation around what can be done, aside from medical care, to improve the psychological j o u r n a l p r e -p r o o f health of those who endure and survive the icu. despite finding no significant improvement in symptoms with use of the diary, our intervention increased awareness of the psychological support available to icu survivors and family members. the intervention also offered a way for staff in a busy teaching hospital to concretize positive sentiments felt toward patients and offer lasting messages of hope. our data demonstrates no benefit in using an icu diary versus bedside education-alone in reducing ptsd symptoms related to the intensive care stay. while our findings with regard to psychometric testing are largely consistent with the available literature [ , ] as a whole, our icu diary intervention for the critically ill proved to be worthwhile to patients and families, and subjectively aided in the recovery process per the feedback of participants and family members. the prevalence of post-intensive care ptsd was staggering in our population. while some patients were connected with pics resources and treatment, this remains an area for improvement: how best to connect patients suffering from symptoms of icu-related ptsd to services? consultant-liaison psychiatrists have a potential role to bridge services in hospitals with icu patients, helping to identify patients at risk for icu-related ptsd, educating patients and families regarding psychological morbidity of icu survival, and building networks of outpatient pics providers for referral. future research with icu diaries may demonstrate benefit in hospital systems with established pics clinics facile in making therapeutic clinical use of these totems from the icu experience. we suspect the true benefit of icu diaries is not in simply making them in the first place but in using them for progressive exposure therapy in the outpatient setting. it remains unclear how diaries may attend to the prevalent and predictive symptoms of delusional traumatic memories, and whether the diaries have the power to replace delusion with factual narrative. further research is required to assess the clinical utility of the icu diary in patients who survive the icu. what is clear from our work is that the psychological needs and pics symptoms of the icu survivor post-discharge are chronic and prevalent and merit improved efforts at prevention, education, treatment, and access to care. j o u r n a l p r e -p r o o f j o u r n a l p r e -p r o o f on behalf of my coauthors, i would like to thank you for the opportunity to revise and resubmit our manuscript ghp-d- - , entitled -implementing an intensive care unit (icu) diary program at a large academic medical center: results from a randomized control trial evaluating psychological morbidity associated with critical illness.‖ we greatly appreciate the thoughtful feedback and suggestions for improvement. we carefully considered and responded to each comment. the recommendations made by the reviewers were successfully incorporated into our revised manuscript. we have clarified elements of our study methods, especially with regard to the early introduction of the icu diary. our discussion and conclusions expand on some of our study's limitations and elaborate on further implications of our findings, as suggested by the reviewers. we highlight the utility of psycho-education, family support and presence at the bedside, and the call for comprehensive post-intensive care services. we have included a response to reviewers in which we address each comment voiced. our responses are highlighted in blue, and prefaced by -author response.‖ corresponding changes are highlighted in the manuscript in the revised file. thank you again for your consideration of our revised manuscript. posttraumatic stress disorder in critical illness survivors: a metaanalysis stress 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survivors intensive care diaries and relatives' symptoms of posttraumatic stress disorder after critical illness: a pilot study evaluation of the effect of prospective patient diaries on emotional well-being in intensive care unit survivors: a randomized controlled trial memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care the spectrum of psychocognitive morbidity in the critically ill: a review of the literature and call for improvement precipitants of post-traumatic stress disorder following intensive care: a hypothesis generating study of diversity in care effect of an icu diary on posttraumatic stress disorder symptoms among patients receiving mechanical ventilation: a randomized clinical trial patients' and relatives' opinions and feelings about diaries kept by nurses in an intensive care unit: pilot study developing a framework for implementing intensive care unit diaries: a focused review of the literature psychometric properties of the ies-r in traumatized substance dependent individuals with and without ptsd postintensive care unit psychological burden in patients with chronic obstructive pulmonary disease and informal caregivers: a multicenter study impact of event scale: a measure of subjective stress the impact of event scale-revised: psychometric properties in a sample of motor vehicle accident survivors diaries for recovery from critical illness family response to critical illness: postintensive care syndrome-family why ethnic minority groups are underrepresented in clinical trials: a review of the literature j o u r n a l p r e -p r o o f key: cord- -e i buow authors: mak, ivan wing chit; chu, chung ming; pan, pey chyou; yiu, michael gar chung; ho, suzanne c.; chan, veronica lee title: risk factors for chronic post-traumatic stress disorder (ptsd) in sars survivors date: - - journal: gen hosp psychiatry doi: . /j.genhosppsych. . . sha: doc_id: cord_uid: e i buow background: post-traumatic stress disorder (ptsd) is one of the most prevalent long-term psychiatric diagnoses among survivors of severe acute respiratory syndrome (sars). objectives: the objective of this study was to identify the predictors of chronic ptsd in sars survivors. design: ptsd at months after the sars outbreak was assessed by the structured clinical interview for the dsm-iv. survivors' demographic data, medical information and psychosocial variables were collected for risk factor analysis. results: multivariate logistic regression analysis showed that female gender as well as the presence of chronic medical illnesses diagnosed before the onset of sars and avascular necrosis were independent predictors of ptsd at months post-sars. associated factors included higher-chance external locus of control, higher functional disability and higher average pain intensity. conclusion: the study of ptsd at months post-sars showed that the predictive value of acute medical variables may fade out. our findings do not support some prior hypotheses that the use of high dose corticosteroids is protective against the development of ptsd. on the contrary, the adversity both before and after the sars outbreak may be more important in hindering recovery from ptsd. the risk factor analysis can not only improve the detection of hidden psychiatric complications but also provide insight for the possible model of care delivery for the sars survivors. with the complex interaction of the biopsychosocial challenges of sars, an integrated multidisciplinary clinic setting may be a superior approach in the long-term management of complicated ptsd cases. infectious diseases have become one of the major global public health threats in the st century. these diseases appear to be spreading more rapidly and emerging more quickly than ever before [ ] . severe acute respiratory syndrome (sars) was the first massive infectious disease outbreak in this century, but it is not expected to be the last. thus, the knowledge and experience gained from sars should be regarded as a dress rehearsal for the catastrophe that could emerge from an influenza pandemic or similar emergent infectious disease [ ] . the sars epidemic of spread rapidly to over countries with more than reported cases, resulting in deaths worldwide [ ] . in hong kong (hk), sars affected up to individuals and caused deaths. patients were confronted with a novel and deadly infectious disease, a need for compulsory isolation treatments and fears of cross-infection to their family and friends. there was also a risk of the subsequent development of avascular necrosis (avn) of the bones, which was found to be associated with the culminative steroid dosage prescribed for acute control of sars illness [ ] [ ] [ ] . the sars epidemic has been described as a bio-disaster [ ] with a psychological impact comparable to other major disasters. being infected with sars can be a traumatic experience [ ] . a study of the long-term psychiatric morbidities among sars survivors by mak et al. [ ] revealed that ptsd was the most prevalent long-term psychiatric condition. the cumulative proportion of patients with ptsd is . %, while . % continue to meet ptsd criteria at months post-sars. therefore, ptsd deserves special attention even though it is not the only psychological response to sars. sars and its associated psychiatric problems may cause stigmatisation [ ] . risk factor analysis can improve the detection of hidden psychiatric complications. previous reported predictors of acute psychiatric complications include sociodemographic variables [e.g., being a health care worker (hcw)] [ ] [ ] [ ] ; illness-related variables [e.g., the severity of disease and the administration of high-dose corticosteroids [ ] , lowest level of arterial oxygen saturation (sao ) during hospitalisation] [ ] ; and psychosocial variables including social support, cognitive appraisal and coping style [ , ] . there are various methodological problems with these studies, including high attrition rates, the use of convenience sampling methods and the use of selfadministered questionnaires as the primary measuring instrument. the predictors for long-term psychiatric complications have yet to be investigated. the present study was aimed at identifying the risk factors for post-traumatic stress disorder among sars survivors at months post-sars. the research design and detailed methodology have been previously reported [ ] . the following is a brief summary of the study. this is a retrospective cohort study designed to investigate psychiatric complications among sars survivors treated in united christian hospital (uch) months after the sars outbreak. phase i of the study defined the pattern of long-term psychiatric complications [ ] . phase ii of this study focused on the diagnosis of ptsd and the identification of its associated risk factors. the study was reviewed and approved by the hong kong hospital authority research ethics committee. criteria for inclusion were as follows: a history of sars infection according to world health organization (who) criteria [ , ] , hospitalisation at uch for the index sars infection, chinese race and age ≥ years at the time of the sars infection. patients with severe communication problems (e.g., deafness, dementia, mental retardation) were excluded from the study. patients who also received treatment for sars infection in other hospitals and were transferred back to uch for follow-up were also excluded due to possible differences in hospital management and the likelihood that these patients represented a biased group with fewer complications. a total of adult patients were admitted to uch for treatment of suspected or confirmed sars infection. all of them were offered subsequent follow-ups at uch according to the government policy. of these patients, failed to fulfill who criteria for sars infection, had also received sars infection treatment in other hospitals, were of filipino ethnicity, and had a history of a cerebrovascular accident with severe dysphasia and communication problems. of the remaining eligible subjects, refused to participate and returned to his home country. the cohort consisted of subjects, representing a response rate of . %. the subjects were relatively young (mean age= . years, s.d.= . ), predominantly female ( . %) and relatively well educated ( % had received education to the level of secondary school or above). more than two thirds ( . %) were either cohabiting or married at the time of the sars outbreak. however, five subjects' spouses died of sars, and one subject divorced after the sars outbreak. twenty-seven ( %) subjects were hcw. among them, nursing staff constituted . % (n= ), followed by health care assistants ( . %, n= ) and doctors ( . %, n= ). in order to maximise the response rate, the interviews for the recruited cases were conducted on the same day of their scheduled medical follow-ups between september and march (i.e., around months post-sars on average). the chinese version of the structured clinical interview for dsm-iv (scid) was administered. self-administered questionnaires were used to collect the socio-demographic data, pre-sars traumatic event information and cross-sectional biopsychosocial factors. finally, the acute medical variables and the pre-sars medical or psychiatric variables were extracted from the computerised database created during the sars outbreak. the scid was used to diagnose ptsd and other axis i disorders, including depressive disorder and other anxiety disorders. the patient edition of the scid was translated into a bilingual chinese/english version for use with chinese (cantonese)-speaking subjects with satisfactory reliability and validity [ , ] . all subjects were assessed by a psychiatrist (i.m.) who has received standard training in the use of this instrument. the variables were grouped into two blocks: ( ) potential predictive factors and ( ) association factors. the potential predictive factors involved pre-sars demographic factors or objective, sars-related clinical data that preceded the outcome of interest ( months post-sars ptsd). the association factors included variables gathered during the interview months post-sars. the predictive factors could be further categorised into four groups: sociodemographic characteristics, medical and psychiatric background, sars-related acute medical variables and subsequent complications. the sociodemographic characteristics included age, gender, marital status, and residential status, amoy gardens residency (amoy gardens is a private housing complex where the largest local sars outbreak occurred), educational level, income, employment, occupation, employment as a hcw, and religious background. the medical and psychiatric background included pre-sars chronic medical illness, distressing pain, psychiatric disorders, traumatic events, and a family history of psychiatric illness. the sars-related acute medical variables included days of hospitalisation, intensive care unit admission, intubation, desaturation during the course of sars infection, initial and peak viral load from nasopharyngeal specimens, total steroid dosage and whether or not a family member(s) died from sars. sars-related complications were indicated by the development of avn as detected by magnetic resonance imaging. the association factor block was grouped into physical, social and psychological factors. physical factors involved subjective, distressing pain after sars as determined by a maximum and average pain scale in the month before the interview ( -point scale). functional impairment was measured by the functional impairment checklist score (fic), which is a self-reported instrument designed as a functional assessment tool for sars survivors. it consists of the fic symptoms score, which focuses on physical impairment, and the fic disability score, which indicates limitations on daily life [ ] . social factors included the perceived inadequacy of social support during sars (six-point likert scale), involvement in litigation and compensation and whether or not the subjects were on social allowance. psychological factors involved the subjective perception of danger during sars infection, the subjective usefulness of religious or spiritual support in coping with sars and the subjective feeling of being stigmatised during the worst period of sars illness, all of which were measured by a sixpoint likert scale. the appraisal of locus of control was assessed by the multidimensional health locus of control scale (mhlc) [ ] . the scale consists of three independent subscales: the "internal health locus of control," "chanceexternal locus of control" or "powerful others-external locus of control" subscales. the scale was translated into chinese with acceptable internal consistency [ ] . the chinese ways of coping questionnaire (cwcq) [ ] was used to assess coping style. the questionnaire covers a broad range of cognitive and behavioral coping activities based on the ways of coping questionnaire [ ] . it includes four subscales: "rational problem solving," "seeking support and ventilation," "resigned distancing" and "passive wishful thinking." all statistical analyses were performed using spss . (chicago, spss). the chi-square test, fisher's exact test (for categorical variables), t test (for continuous variables) and mann-whitney u test (for highly skewed data) were used to identify the potential predictive and association factors for ptsd at months post-sars. multiple logistic regression analysis (stepwise forward) was performed by including variables found as significant at the level of pb. by univariate analysis. the variables were grouped into predictor and association factor blocks as described above. finally, the statistically significant association factors were examined after controlling for the factors that were found to be significant in the predictive factor blocks. hierarchical regression analysis was also used to examine whether an addition of the association factors to the predictor variables would change the odds ratio of predictor variables significantly, as the association factors could be potential mediating factors on the causal pathway between the predictor variables and the psychiatric outcome of interest. there were sars survivors in hk at the time of our study. no statistically significant differences concerning the mean age, gender distribution or the proportion of hcws were found between our sample and the sars survivor population in hk [ ] . only one subject had experienced a pre-sars trauma with nature fulfilling the definition of dsm-iv criteria [ ] . no subject was diagnosed as having pre-sars ptsd. a total of . % of the subjects had ptsd at some time point after the sars outbreak and all of these subjects identified the sars outbreak as the index trauma. twenty-three out of subjects ( . %) still suffered from ptsd at months post-sars. in the univariate analysis, variables significantly associated with current ptsd in the predictor block included female gender (p=. ), being a hcw(p=. ), pre-sars chronic medical illness (p=. ) and having avn as a complication (p=. ) ( table ) . for the association factors block ( table ) , reports of higher average pain in the past month (pb. ), higher functional impairment checklist scores (pb. ), higher perceived inadequacy of social support (p=. ), higher subjective perception of danger during the sars outbreak (p=. ) and higher subjective perception of being stigmatised during the sars outbreak (p=. ) were associated with ptsd. for coping strategies and the health locus of control measures, the current ptsd group tended to report more frequent use of the avoidant coping mechanism [e.g., resigned distancing (p=. ) and passive wishful thinking (p=. )] with less use of active coping mechanisms, such as seeking support and ventilation (p=. ). the chance subscale score of the multi-dimensional health locus of control scale for the current ptsd group was also significantly higher than for the group without a current ptsd diagnosis (p=. ). . . . logistic regression of predictor and association factor block multivariate logistic regression analysis showed that being of the female gender (p=. ), the presence of chronic medical illness before sars (p=. ) and having avn as a physical complication (p=. ) were predictors of ptsd at months post-sars (table ) . higher "functional impairment checklist disability score" (pb. ), "chance external locus of control of mhlc scales" (pb. ) and "average pain intensity in the past month" (p=. ) were found to be associated with ptsd at months post-sars (table ). in order to deal with the extensive comorbidity in subjects with ptsd, the status of "current depressive disorder" and "current anxiety disorders other than ptsd, including panic disorder, agoraphobia, generalised anxiety disorder and social phobia" as measured by scid were controlled by adding these diagnostic variables into the existing logistic regression model. all of the previously significant variables in the predictor and association factors blocks remained significant after adding these variables, thus indicating that the identified variables were specifically related to the outcome of current ptsd, independent of other psychiatric diagnostic categories. the variables of litigation and compensation were recorded and taken into consideration in the data analysis. no statistically significant association between litigation and compensation and psychiatric morbidities was found. the factors also did not affect the final logistic regression model when these variables were controlled. after combining the significant factors of the two blocks into one model (tables and ), all association factors (table ) were still statistically significant while the predictors (table ) become insignificant. this may be because the association factors of table may be the mediating factors of the causal pathway between the potential predictors and ptsd. in order to further examine whether the effect of the predictive factors in table on ptsd were mediated by the association factors shown in table , sequential regression was employed. the adjusted odds ratios did not change significantly from the simpler models with the exception of the adjusted odds ratio for avn, which became considerably smaller (from . to . ) when "functional impairment checklist-disability score" was included. this result would suggest that functional impairment is a possible explanation for the higher rates of ptsd among those with avn. the study of the association factors of current ptsd was compatible with the suggested theories of ptsd involving both biological and psychological mechanisms [ ] . although the study of the association factors does not permit us to infer any causal relationship, the findings may shed light on future research for understanding the mediating factors or mechanisms in the causation of chronic trauma-related response. the finding that perceived pain severity was an association factor of ptsd at months post-sars is consistent with previous disaster studies [ , ] . another significant association factor of current ptsd was the functional impairment checklist disability score. it was shown that the disability score was a stronger prediction for chronic ptsd compared with the symptoms score, which measures subjective lung function and fatigability. the interaction between ptsd and biological factors involving pain and functional impairment is complex. on one hand, patients with ptsd may have elevated anxiety, impaired coping strategies and attentional bias to pain and functional deficit. all of these factors may exacerbate pain and cause functional impairment. on the other hand, pain and functional impairment may perpetuate ptsd by serving as a continual reminder of the traumatic event, maintaining arousal, and preventing the return to a normal life. in addition, somatisation in the form of pain may be one potential pathway for trauma to express itself psychologically [ ] . our findings were consistent with the evidence that the optimisation of pain control may reduce the risk of subsequent development of ptsd and be effective for the secondary prevention of ptsd [ ] . in addition to physical factors, this study also showed that the perceived control of health may be an important factor, a finding that is consistent with previous sars studies [ , ] . the clinical course, outcome and treatment methods after contacting this novel virus could have been a threatening, unpredictable and helpless experience to the patients and even to the medical staff. the experience of sars infection may have threatened the subject's view of the self, the world and the future. there is evidence that diminished perceived control is associated with more severe pain and functional disability [ ] . however, appraisal is a dynamic process, and it may change when new dramatic health or illness-related experiences like sars occur. whether certain appraisal styles exacerbate the effects of stressor and whether the predominant use of each style is related to the stress process are complex issues [ ] . a prospective study may help to explain the relationship between the appraisal style and the subsequent psychological response. early intervention to enhance self efficacy in coping with these stressful events may be a potential secondary prevention strategy, a hypothesis that requires further exploration. this study was the first to document the relationship between avn and ptsd in sars patients. because avn is a delayed complication of sars treatment, it cannot be taken into account in acute-stage studies. by further comparing subjects who have recovered from ptsd with those experiencing chronic ptsd, it was shown that avn was an important factor in slowing recovery from ptsd. a hierarchical regression analysis demonstrated that residual functional disability might also be a possible mechanism hindering recovery from ptsd. this result is consistent with the findings from studies on other traumas where long-term health problems and loss of function might play an important role in maintaining ptsd [ , ] . avn is believed to result from the impairment of circulation to bone and is associated with steroid use [ , ] . the femoral head is the most commonly affected area, but other bone areas may be involved as well. avn might affect recovery from ptsd through the following mechanisms. first, avn has the potential to cause pain and functional impairment, which are associated with chronic ptsd as previously discussed. second, the discovery of avn occurred between six and nine months post-sars, when patients started to expect improvement of physical function. the delayed and unexpected onset causes a heavy blow to the subject's locus of control system. the unclear likelihood of avn later progressing to bone collapse may further defeat the subject's belief system of self-efficacy. thus, avn demonstrates that the interaction of biopsychosocial consequences might hinder recovery from ptsd. this study also illustrates that unexpected, long-lasting physical complications of sars might affect recovery from ptsd. the careful detection of psychiatric symptoms is needed when any further physical complication is newly identified. the presence of pre-sars chronic medical illness was found to be a factor associated with long-term ptsd. previous research has revealed that, during the development of a chronic illness, the patients' perceptions of personal control are affected [ , ] . the experience of sars infection in subjects with pre-sars chronic physical illnesses might further affect their perceived self-efficacy. the poor physical and psychological conditions might weaken their innate ability to recover from ptsd. it is important to note that the association between the acute medical variables and the acute post-traumatic stress and anxiety symptoms in acute-phase studies were no longer significant in the current study [ ] [ ] [ ] [ ] . while there is evidence that steroid administration may decrease the rate of ptsd [ ] , the cumulative steroid dosage was not found to be protective in reducing chronic ptsd in the current study. the beneficial effect of steroids, if any, may have been negated by the subsequent complications of avn. in contrast to the association between initial viral load and poor acute physical outcome [ ] , there is no obvious relationship between the initial viral load and long-term ptsd. however, further immunological correlations should be addressed in future studies. this study illustrates how the predisposing experience affects the course of the traumatic event of a medical illness. the relative contributions of the acute stressors seem to diminish progressively [ ] . female gender was found to be an independent risk factor for chronic ptsd in this study. this finding is well documented in numerous trauma-related studies [ ] [ ] [ ] . it carries important implications in the health care system, where the majority of the nursing staff and health care assistants are female. being a hcw is regarded as one of the most consistent predictors for psychiatric morbidity both in the acute and convalescent phase [ , , ] . in this study, although being a hcw was found to be significantly associated with ptsd outcome by univariate analysis, it became statistically insignificant after controlling for gender. in fact, a very large proportion of the hcws in this sample were female (n= / ). this finding suggests that the association between being a hcw and ptsd may be partly explained by the fact that the front-line hcws who contracted sars were primarily female. clinicians who are responsible for the follow-up of sars patients should be alerted to the possible long-term psychiatric sequelae, especially ptsd. this evaluation requires a tactful enquiry of symptoms due to subjects' fear of stigmatisation. clinicians can consider the risk factors identified in this study (e.g., having chronic medical illness, having significant pain and functional disability) as indicators for a high risk of hidden psychiatric consequences. however, clinicians should not be overly dependent on the acute medical variables in predicting long-term psychiatric conditions. adversity, both before and after the disaster, combined with particular interactions between biopsychosocial factors, can markedly hinder recovery from psychiatric consequences. we have shown that avn, an unexpected and delayed treatment complication, was associated with persistent psychiatric morbidity. clinicians should thus be alert to the psychological impact of any other unexpected physical complications, especially if they have a strong biological and psychological impact. the association factors for ptsd included subjective pain perception, functional impairment and the locus of control appraisal. these findings highlight the potential treatment direction for optimization of pain management, physical rehabilitation and cognitive work in promoting self-efficacy. because of the need to attend multiple clinics, the stigmatisation of attending specialist psychiatric clinics and the complex interaction of the biopsychosocial challenges of sars, an integrated multidisciplinary clinic setting with regular case conferences may be a superior approach in the long-term management of complicated cases. the findings of this study should be interpreted with consideration of the following methodological limitations. the retrospective design may cause bias for assessment of different psychiatric correlates with ptsd. discrimination and stigmatisation were important phenomena in the sars population. patients may therefore under-report their psychopathology to avoid the phenomenon of "double stigmatisation." on the other hand, litigation and compensation processes might cause an overexaggeration of the reported psychiatric symptoms. in order to minimise these potential confounding effects, the principal investigator was not involved in the clinical care or medical board assessment of the subjects before the completion of this research. we also stressed that the investigation was used solely for research and that it would not be used for other purposes. the variables of litigation and compensation did not affect the final logistic regression model when these variables had been controlled. the treatment effect of biological and psychosocial interventions was not evaluated. no general population or other chronic illness control groups were included for comparison. finally, the relatively small sample size may limit the power of this study to detect risk factors with moderate strength. further studies with multicentre involvement are required to increase the power of the study and to study the course of psychiatric morbidity. despite its limitations, this study has an exploratory role in revealing the risk factors of chronic ptsd among sars survivors. the results show that, in addition to gender differences and pre-sars chronic medical illnesses, subsequent physical complications like avn are associated with the chronic course of ptsd. the important roles of pain, appraisal and the locus of control may be the future focus for understanding the risk mechanisms and potential treatments of ptsd. although our findings were based on a cohort of sars survivors in a general hospital in hk, we hope that the findings can help in exploring the management of comparable infectious disease outbreaks. in case of an unfortunate future massive outbreak, a prospective study with an early baseline and longitudinal assessment should be adopted to study the effects of psychosocial correlates with ptsd. school of public health and primary care, the chinese university of hong kong for their advice with statistical analysis. last but not least, credit should also go to all the patients who participated in this study and unconditionally shared their experiences after the sars infection. the world health report : a safer future: global public health security in the st century was sars a mental health catastrophe? summary of probable 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of mental health problems after disaster the course of ptsd, major depression, substance abuse and somatization after a natural disaster post-traumatic stress disorder and somatization symptoms: a prospective study rationale for a posttraumatic stress spectrum disorder morphine use after combat injury in iraq and post-traumatic stress disorder post-traumatic stress disorder symptoms, pain and perceived life control: association with psychosocial and physical functioning psychosocial sequelae of the newcastle earthquake: ii. exposure and morbidity profiles during the first years post-disaster psychological predictors of chronic posttraumatic stress disorder after motor vehicle accidents the relationship between self-efficacy and selfreported physical functioning in chronic obstructive pulmonary disease and chronic heart failure moderators of the relation between perceived control and adjustment to chronic illness can posttraumatic stress disorder be prevented with glucocorticoids? initial viral load and the outcomes of sars the aetiology of post-traumatic morbidity: predisposing,precipitatingandperpetuatingfactors posttraumatic stress disorder in the national comorbidity survey sex differences in posttraumatic stress disorder gender differences in long-term posttraumatic stress disorder outcomes after major trauma: women are at higher risk of adverse outcomes than men psychological intervention with sufferers from severe acute respiratory syndrome (sars): lessons learnt from empirical findings severe acute respiratory syndrome (sars) in hong kong in : stress and psychological impact among frontline healthcare workers the authors would like to thank prof. y. k. wing, dr. sammy k.w. cheng and dr irene kam for their advice on this study. we would also like to express our appreciation to professor william goggins and professor joseph lau of the key: cord- - wwqxkjl authors: ma, ke; wang, xin; feng, shiyao; xushan, xia; zhang, hongxiu; rahaman, abdul; dong, zhenfei; lu, yanting; li, xiuyang; zhou, xiaoyu; zhao, haijun; wang, yuan; wang, shijun; baloch, zulqarnain title: from the perspective of traditional chinese medicine: treatment of mental disorders in covid- survivors date: - - journal: biomed pharmacother doi: . /j.biopha. . sha: doc_id: cord_uid: wwqxkjl purpose: the aim of this study is to explore the possible benefits of traditional chinese medicine on the pathogenesis of psychological and mental health of covid- survivors. methods: a literature search was conducted to confirm the effects of covid- on psychological and mental health of survivors. in addition to this, on the basis of signs and symptoms, tcm were used on treat mental disorder as per suggested clinical and animal experimental data plus relevant records in classical chinese medicine books written by zhang zhongiing during han dynasty. a series of treatment plans were prescribed for covid- survivors with psychological and mental disorders. results: according to previous extensive studies focusing on effects on mental health of survivors, high incidence was observed in severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers) survivors. during investigations of mental health of covid- patients and survivors, it is observed that they also had symptoms of mental disorders and immune dysfunction. furthermore, it was also proposed that depression, anxiety and post-traumatic stress disorder (ptsd) were most common mental disorders requiring special attention after the recovery from covid- . the symptoms of covid- were analyzed, and the tcm syndrome of the depression, anxiety and ptsd after recovered from covid was interpreted as internal heat and yin deficiency. these three mental disorders pertains the category of “lily disease”, “hysteria” and “deficient dysphoria” in tcm. conclusion: lily bulb, rhizoma anemarrhena decoction and ganmai dazao decoction were used to treat depression. suanzaoren decoction, huanglian ejiao decoction and zhizi chi decoction were suggested for anxiety. moreover, lily bulb, rehmannia decoction and guilu erxian decoction were the formula for ptsd. coronavirus disease (covid- ) , which broke out in wuhan on december , , was an emerging, rapidly developing epidemic and a public health emergency of international concern (pheic) that affected people around the world [ , ] . according to latest investigations, fever, cough and fatigue are the main symptoms of patients with mild covid- while patients with severe covid- might present with respiratory distress syndrome, shock and sepsis [ ] . both post-traumatic stress disorder (ptsd) and acute stress disorder (asd) refer to the stress response that occurs after the person suffered a fatal and catastrophic traumatic event that is beyond the individual's capacity [ , ] . the understanding about covid- has been insufficient yet, and there is no effective treatment plan for it at this stage as vaccines are still testing or trial phases [ ] . most current practice to address covid- , isolation and addressing symptomatic treatment is the only option at this stage, isolation and treatment measures would lead to a battery of emotional and behavioral reactions. past evidence suggests that mental disturbance in covid- cases is closely j o u r n a l p r e -p r o o f linked to symptoms coming in survivors after large infectious diseases. research proved that severe acute respiratory syndrome (sars) and middle east respiratory syndrome (mers) survivors had a higher prevalence of ptsd [ , ] . besides this, individuals with ptsd often suffered from depression and anxiety as well [ ] . the research found that percent of those who fully met the ptsd diagnosis had anxiety disorder and . % had depression [ ] . according to the investigation results of ju el, nearly % of covid- patients in isolation ward suffered from asd, along with anxiety, depression, insomnia and other mental and psychological symptoms [ ] . moreover, a clinical survey of patients with covid- showed that the anxiety score was ( . ± . ), the incidence rate was . % (including cases of mild anxiety, cases of moderate anxiety and cases of severe anxiety), the depression score was ( . ± . ), and the incidence rate was . % (including cases of mild depression, cases of moderate depression and case of severe depression) among them [ ] . therefore, patients recovering from covid- are more likely to suffer from ptsd, anxiety and depression. unfortunately，there are many limitations to treat mental disorders. serotonin reuptake inhibitors (ssris) and norepinephrine reuptake inhibitors (snris) are commonly used as antidepressants drugs for the treatment of pstd. however, their clinical application was very limited (more or less %), and this treatment regime comes with possible side effects such as headache, dizziness and increased muscle tension [ ] . although benzodiazepines had a significant anti-anxiety effects, but because of respiratory inhibition effects of these drugs are not suitable for patients with pulmonary damage related to covid [ ] . on the other sides, tcm therapy has the advantages of multi-pathway and multi-target, and is comparatively safer option. in addition to this, chinese herbs treat symptoms and deal with causes of disease, and it can remedy the remaining symptoms of covid- at the time of treating j o u r n a l p r e -p r o o f mental disorders. in this review, we were trying to find the pathogenic factors of mental disorders in covid- survivors from the perspective of both western medicine and traditional chinese medicine theory, and trying to put forward the corresponding tcm treatment plan ( figure ). based on the researches, all of sudden and life-threatening events, people would experience the corresponding psychological stress reaction and emotions such as anxiety, fear and loneliness. a small number of people could even suffer into mental distress [ ] . studies demonstrated that the prevalence of all kinds of mental illness within months after the outbreak of sars was . %, and a quarter of the patients had ptsd, while . % underwent depression disorder [ , ] . besides this, a four-year follow-up of sars survivors showed that more than % claimed to be suffering from mental illness, and . % reported chronic fatigue problem [ ] . in addition to this, many patients and medical workers went through severe emotional stress during the outbreak period of mers [ ] . when the epidemic was controlled, many medical workers and recovered patients would be bothered with anxiety, depression and even ptsd [ ] . covid- is a respiratory infection caused by corona virus that similar to sars and mers. an investigation on the basic reproduction number of sars-cov- transmission proved that the r ( . , . ) of sars-cov- was higher than the r ( . , . ) of sars-cov, but lower than the r ( . , . ) of mers-cov, indicating that sars-cov- was a medium-high infectious disease [ ] . on january , , the world health organization declared the outbreak of covid- in wuhan, central china as a public health emergency of international concern (pheic) [ ] . so far, there is no treatment of covid- available and the number of infections continuously increasing. until thursday, j o u r n a l p r e -p r o o f may , , more than . million people had been infected [ ] , i.e. more than the total number of people infected with sars and mers. therefore, due to the fear of disease, physical discomfort, drug side effects and social isolation, covid- patients might be suffering from loneliness, anger, anxiety, depression, insomnia and ptsd in the period of treatment and isolation [ ] . the investigation suggested that the medical workers infected with covid had varying extent of depression, anxiety and sleep disorders [ ] . a recent study on covid- patients confirmed that the prevalence of significant post-traumatic stress symptoms among the recovered patients was . % [ ] . furthermore, studies demonstrated that patients with covid- showed higher level of depression, anxiety, and ptsd than people without covid- [ ] .therefore, the mental health of covid- survivors needed to be noticed. wang el. [ ] analyzed cases of hospitalized covid- patients, and they observed that the number of neutrophils cell were increased in patients. that might be related to cytokine storm during the invasion of virus. recent clinical studies had been done to [ , ] summarize the clinical characteristics of covid- patients. it's also proposed that compared with healthy people, covid- patients' lymphocyte count was significantly less. besides this, their inflammatory factors such as interleukin- β (il- β), interleukin- (il- ), interleukin- (il- ), interleukin- (il- ) and the tumor necrosis factor alpha (tnf-α) were markedly high. these levels of cytokines were sharper in critically ill patients with pneumonia [ ] . therefore, patients with covid- showed signs of immune dysfunction and elevated levels of inflammatory cytokines. meanwhile, several researches had provided obvious evidences which indicates that immune system activation, pro-inflammatory cytokines were concern with psychiatric symptoms [ ] . consequently, patients with j o u r n a l p r e -p r o o f covid- could have a higher propensity to be attacked by mental disorders than normal people. there was evidence to support the cross-correlation between cytokine levels and depression risk in many diseases [ ] . along with this, depression may be related to infectious diseases which had been supported by the conclusion of relevant studies [ ] . in addition, a meta-analysis which brought into studies demonstrated that levels of pro-inflammatory cytokines, especially il- β, il- , and tnf-α, were associated with depressive symptoms [ ] . an excessive dose of interleukin- beta had been affirmed to be associated with neuro-inflammatory degenerative diseases and mental disorders [ ] . shim el. stated that lateral ventricular il- β could induce anxiety-like behavior in rats [ ] . moreover, systematic reviews had also found that higher levels of interleukin , interleukin beta, and tnf-α were interrelated with ptsd [ ] . as a result, it is necessary to pay close attention to their mental health during and after the treatment. traditional chinese medicine doctors named highly infectious and easily prevalent disease as "yi disease", which meant epidemic, and considered its etiology as "yi qi" [ ] . thus, in accordance with tcm theory, covid- pertained to the category of "yi disease" [ ] . referring to the theory of tcm, "yi qi" entered the human body from the mouth and nose, while the mouth connected the spleen as well as the whole digestive system, and the nose linked the lung as well as the total respiratory system [ ] . while, covid- in the infected patients would first affect the lung and spleen, leading to abnormal function of lung and spleen, and triggering a series of digestive and respiratory symptoms [ ] . the above statements were consistent with the clinical reports that patients with covid- had not only respiratory symptoms, but also metabolic disorder symptoms such as diarrhea and vomiting [ ] . the harmonious and consistent unity of body and emotion was the stand j o u r n a l p r e -p r o o f point of tcm. therefore, the emotions of patient were concerned with the function of five organs (heart, liver, spleen, lungs and kidneys) [ ] . seven main emotions in tcm (anger, joy, worry, thinking, sadness, fear, shock) were regulated by the state of function of the five organs, meaning that the five organs control the generation and change of seven emotions. when the status of five organs changed, the moods changed accordingly [ ] . the lung controlled worry and sadness, while the spleen controlled thinking [ ] . as a result, once lung and spleen was invaded by "yi qi", the moods controlled by them would also be abnormal. then, the patients would be bothered with sadness, or they could be tired of over thinking. consequently, there was a tendency that the covid- survivors suffered from psychological disorders. additionally, there was a view in the tcm theory that the diseases with sign of fever could cause the loss of yin fluid in human body [ ] . yin fluid referred to body fluid and blood [ ] . during the development of covid- , "yi qi" could cause internal heat in body resulting in the symptom of fever that consumed yin fluid. as a result, the balance of yin and yang was broken and the deficiency of yin led to the relative excess of yang. yin was supposed to be cold while yang was considered hot. then the relative excess of yang could make the internal body hotter than normal, which contributed to the internal heat and yin deficiency syndrome. anxious and grim [ ] . tcm, which provided a record of "lily disease" caused by internal heat and yin deficiency in heart and lung. the main symptoms were willingness to eat, loss of appetite, daily in a bad mental, less words, fatigue but unable to sleep, unable to walk. they concluded that a series of symptoms could appears including psychological abnormalities; paresthesia and eating behavior abnormalities [ ] . these symptoms were very similar to those of depression [ ] . another classic book of tcm typhoid fever theory recorded an opinion that after fever, internal heat had not been cleaned, which contributed to "deficient dysphoria disease", an internal heat disease due to deficiency of yin. the symptoms of "deficient dysphoria " such as insomnia, restlessness were consistent with the clinical manifestations of anxiety [ ] . "lily disease" can be characterized by wandering mind and confusing the illusion and reality, which was similar to ptsd patients' traumatic memory forced into mind to reproduce the event scene in the form of flashbacks or nightmares, compelling them repeatedly to experience the emotion and feeling of that time. on the basis of concept and clinical manifestations of ptsd, guo also considered ptsd as a kind of "lily disease", and proposed ptsd of heart-lung yin deficiency syndrome type [ ] . therefore, as explained in tcm, anemarrhenae was cold in tcm theory, and it would turn the efficacy of decoction colder [ ] . by adding anemarrhena asphodeloides bge., the heat-clearing function of the decoction could be strengthened, making it more suitable for those who were already diagnosed as internal heat and yin deficiency syndrome with more heat. ganmai dazao decoction was indicated for "hysteria disease", whose symptoms were sadness, crying, mood disorders, and abnormal behavior, decoction combined with flupentixol and melitracen tablets in the treatment of menopausal depression and found that the total clinical effective rate of the combined group was significantly higher than that of the single group [ ] . furthermore, lily bulb and rehmannia decoction was able to alleviate the symptoms of depression patients with yin deficiency and internal heat syndrome remarkably and long-term administration was not harmful [ ] . in j o u r n a l p r e -p r o o f addition, the investigation used lily bulb and rehmannia decoction combined with fluoxetine for weeks, confirmed that it was able to reduce the anxiety somatization factor and sleep factor, and the efficacy was more obvious than single modern depression intervention medicine [ ] . yan el. adopted ganmai dazao decoction combined with lily bulb and rhizoma anemarrhena decoction to treat depression. compared with conventional modern medicine, the decoctions were safer and the incidence of adverse reactions was less [ ] . patients with initial severe depression, which mechanism may be related to the regulation of monoamines and amino acid neurotransmitters, the regulation of immune inflammation, and the reduction of the level of inflammatory factors [ ] . in addition to this, some animal experiments had been carried out to explore the antidepressant pharmacological mechanism of above decoctions. after lily bulb and rehmannia decoction intervention, the content of monoamine such as neurotransmitters norepinephrine (ne), -hydroxytryptamine ( -ht) and dopamine (da) were greatly increased in the hippocampus of cums rats, and the activity of monoamine oxidase was significantly reduced [ ] . bi el. treated depressed rats with ganmai dazao decoction, and the results showed that it could significantly improve the depressed behavioral characteristics of rats, and significantly increase the activity and content of neurotransmitters -ht and ne in the brain of rats [ ] . study confirmed that ganmai dazao decoction could significantly improve the depression-like behavior of cums rats by regulating hpa axis elevation and protecting hippocampus injury [ ] . the intervention of lily bulb and j o u r n a l p r e -p r o o f increase the content of monoamine neurotransmitters in the brain of depression animal model [ ] . besides this, research proposed that lily bulb and rhizoma anemarrhena decoction could alleviate the loss of pleasure and despair in depressed rats, and promote the remodeling of neurons. the mechanism behind this was related to inhibiting the hyperfunction of hpa axis and up-regulating the expression of bdnf mrna in hippocampus of depressed rats [ ] . previous evidence showed that antidepressant mechanism of lily bulb and rhizoma anemarrhena decoction was also related to up-regulation of monoamine transmitters in serum and cerebral cortex [ ] . furthermore, there are some experiments about active compounds of these decoctions. evidence from guo el. confirmed that lily saponins, as the main component of lilii bulbus, could relieve depression symptoms, whose effect might be related to the increased level of monoamine neurotransmitters in brain and the hyperfunction inhibition of hpa axis [ ] . research suggested that lily saponins treated depression with irritable bowel syndrome by synergistically regulating the content of brain-gut peptide and the function of -ht nervous system in blood, stomach and intestine [ ] . further, in the alcohol extract of rehmannia glutinosa linosch is one of the main effective components with higher content of it. study proved that catalpol had more remarkable antidepressant effect by involving monoamine nervous system than other ingredients in rehmannia glutinosa linosch [ ] . reduced the contents of tnf-α, il- β and il- in mouse brain tissue for anti-inflammatory treatment of depression [ ] . therefore, these three tcm decoctions can be applied to the treatment of depression. suanzaoren decoction，huang lian e jiao decoction, zhizi chi decoction, were used for anxiety of internal heat and yin deficiency syndrome ( table ) . they were recorded in typhoid fever theory, and were classic decoctions for meng el. [ ] randomly divided patients with generalized anxiety disorder into the observation group and the control group with cases each, the observation group was treated with modified suanzaoren decoction, and the positive control group was treated with estazolam, the results proved that the total effective rates of the observation group and the control group were . % and . % respectively, suggesting that modified suanzaoren decoction was more appropriate than modern medicine in the treatment of generalized anxiety disorder. zhang el. [ ] analyzed the clinical effect of modified suanzaoren decoction on cancer patients who met the ccmd- anxiety diagnosis standard, the total effective rate of clinical effect was higher than that of the control group and no adverse reactions were found. it indicating that modified suanzaoren decoction can significantly improve the mild and moderate anxiety of cancer patients. it was proved that the ant-anxiety effect of suanzaoren decoction might be related to the increase of no concentration in blood and the decrease of il- β, tnf-α in serum [ ] . zhang el. [ ] selected patients with generalized anxiety, and randomly divided them into treatment group ( cases) treated with huanglian e jiao and decoction, and control group ( cases) that treated with lorazepam. the total effective rate of the treatment group was . % and that of the control group was . % at the fourth week of treatment. and the treatment effect of the decoction was more lasting and the adverse reactions were less than that of lorazepam. huanglian e jiao decoction had a better curative effect and fewer adverse reactions than fluvoxamine in the treatment of anxiety that pertained to yin deficiency and fire hyperactivity syndrome [ ] . liu el. reported cases of anxiety treated with zhizi chi decoction, and the total effective rate was % [ ] . in addition, study confirmed that suanzaoren decoction combined with zhizi chi decoction was more effective than diazepam in the treatment of anxiety disorder, and the relapse rate after cessation of the medication was lower [ ] . liu el. applied suanzaoren decoction combined with zhizi chi decoction to the treatment of cases of anxiety insomnia, and consequently the symptoms of anxiety and insomnia were significantly improved [ ] . meanwhile, there are some reports about the therapeutic mechanism and effective compounds of the above decoction. researches considered that the anti-anxiety effects of suanzaoren decoction and huanglian e jiao decoction were both related to the increase of γ-gabaa level [ , ] . besides, suanzaoren decoction also decreased the release of ne in hippocampus and inhibited the synthesis of -ht [ ] . sanjoinine a isolated from zizyphi spinosi semen had been proved to be concerned the gaba ergic transmission [ ] . decoction [ ] . in addition, study confirmed that berberine which was the main component of coptidis rhizoma in huanglian e jiao decoction could regulate the expression of monoamine neurotransmitters and their metabolites and -ht receptors to resist anxiety [ ] . baicalin and wogonin isolated from scutellariae radix both perform anti-anxiety effects mediated by γ-gabaa [ , ] . moreover, a research mentioned that geniposides, as the main component of gardeniae fructus water extract, was one of the anti-anxiety components of gardeniae fructus [ ] . complementarily, mixed anxiety-depression disorder (mad) was also a common comorbid psychiatric disorder that frequently-observed with ptsd [ ] . thus, covid- survivors may suffer from mad. the above three kinds of decoctions have been proved to be effective in treating depression [ ] . in conclusion covid- survivors with anxiety could be treated with the above three decoctions, and patients with insomnia and mad could also take the decoctions. lily bulb and rehmannia decoction and guilu erxian decoction were the decoctions for ptsd of internal heat and yin deficiency syndrome ( table ) . most of the researches on the treatment of ptsd with chinese herbal medicine were done on animal but the less clinical studies were reported. research suggested that patients with ptsd of yin deficiency of heart and lung syndrome were suitable to be treated with lily bulb and rehmannia decoction. as they showed lung dryness symptoms such as lung heat cough, which are also a common symptom in the convalescence of covid- . it was suggested to add tuber raidix ophiopogonis (ophiopogon japonicas), liquorice root radix glycyrrhizae (licorice) in the decoction [ ] . meanwhile, if patients had insomnia, they can add ziziphus spinosa hu and radix pseudostellariae (heterophylly falsesatarwort root) [ ] . furthermore, the investigation confirmed that lily bulb and rehmannia decoction could up regulate -ht level in hippocampus and deal with the symptoms of ptsd [ ] . the results demonstrated that lily bulb and rehmannia decoction down regulated the expression of glucocorticoid receptor (gr) in hippocampus, up regulated the expression of glucocorticoid receptor (mr), and improve the symptoms of ptsd in rats [ ] . guilu erxian decoction was composed of antler gum, tortoise plate gum, ginseng and wolfberry fruit which nourished yin. li el. demonstrated that guilu erxian decoction may play an anti-ptsd role by regulating synaptic plasticity, anti-apoptosis, anti-inflammation and promoting fear memory extinction through network pharmacology [ ] . moreover, researches had confirmed that the therapeutic mechanism of was to regulating the function of the hpa axis, the expression of gr and -ht receptors in the hippocampus to improve the emotional and behavioral abnormalities in ptsd rats [ , ] . besides this, study confirmed that lycium barbarum polysaccharide in guilu erxian decoction can reduce the level of cortisol in serum to improve the symptoms of ptsd [ ] . previous evidence showed that ginsenoside rg can regulate the function of hpa axis to treat ptsd [ ] .consequently，ptsd patients could be treated with the two decoctions. all funding source just support in conduct of experiments. we strictly disclosed 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glue on behavior and expression of gr and -ht receptor in hippocampus of rats with posttraumatic stress disorder protective effects of lycium barbarum polysaccharide on depression rats with post-traumatic stress disorder the anxiolytic-like effects of ginsenoside rg on an animal model of ptsd nourishing yin of heart and calming mind key: cord- - kcygis authors: restauri, nicole; sheridanmd, alison d. title: burnout and ptsd in the covid- pandemic: intersection, impact and interventions date: - - journal: j am coll radiol doi: . /j.jacr. . . sha: doc_id: cord_uid: kcygis summary sentence individual physicians and hospital administration should take proactive steps to minimize the compounding effects of high baseline burnout and the acute stressors of the covid- pandemic in order to promote wellness among health-care providers. the covid - pandemic has posed unprecedented challenges to the healthcare system worldwide while revealing major deficiencies in this country's epidemic preparedness. individuals have been required to drastically modify their lifestyle in an effort to "flatten the curve" and engage in social distancing in order to allow an overwhelmed healthcare system time to respond to the novel coronavirus. in healthcare, this circumstance is so profound that the covid- pandemic has required an adoption of the language of war. there is talk of physician redeployment to the frontline and sophisticated statistics track daily causalities while military style temporary hospitals are constructed. the cable news network (cnn) has compared the epidemic's impact on our civilization to that of wwii ( ) . in their personal lives, radiologists are required to adapt to the myriad challenges imposed by the pandemic while also managing the stresses related to caring for patients with covid- and working in a healthcare system with limited resources while evaluating constantly evolving knowledge surrounding containment and management of the covid- illness. this pandemic has exacerbated stressors in a healthcare system in which physician burnout, a response to workplace stress, is already epidemic ( ) . individual physicians and hospital administration should take proactive steps to minimize the compounding effects of high baseline physician burnout with the acute stressors of the covid- pandemic. although post traumatic stress disorder (ptsd) is commonly associated with active military conflict, the context and definition of what constitutes a traumatic event is, in fact, much broader and is relevant to the covid- pandemic and it's impact on radiologists. this paper presents a conceptual paradigm for understanding the relationship between burnout, acute stress disorder and ptsd while providing an evidence based review and recommendations for systems based interventions that may reduce provider suffering and stress ensuring a stable, healthy radiology workforce. mental health providers define "trauma" as a stressful occurrence that is outside the range of the usual human experience and that would be markedly distressing to almost anyone ( ) . this type of stressor, according to the dsm iv, involves a perceived intense threat to life, physical integrity, intense fear, helplessness or horror ( ) . by this definition, the covid- pandemic and the collective and personal threats and fear that it has produced, meets the definition of a traumatic event. exposure to such traumatic events can lead to the development of acute stress disorder (asd) and finally ptsd if symptoms persist. similarly, burnout is a syndrome driven by increased exposure to workplace stressors that results in emotional exhaustion, depersonalization and a decreased sense of personal accomplishment ( ). in a , a study by shanefelt et al, a survey using the maslach burnout inventory, found the rate of radiologist burnout to be % ( ) . in this regard, the covid- pandemic presents a sort of perfect storm regarding the intersection of chronic workplace stress resulting in a epidemic physician burnout rates with the acute traumatic stress imposed by the pandemic. exploring the intersection of these two phenomena is necessary in order to inform interventions. symptoms related to ptsd fall into three categories that include: reliving the event, a sense of emotional numbness/depersonalization, and symptoms of increased arousal (difficulty sleeping, feeling irritated or easily angered, difficulty concentrating). the diagnosis of ptsd occurs when a person has experienced symptoms for at least month following a traumatic event, although symptoms may be delayed by several years. ( ) . in the initial month following exposure to a traumatic event, the diagnosis applied is acute stress disorder (asd) and includes symptoms of intrusion, dissociation, negative mood, avoidance, and arousal. the prevalence of asd is - % following a traumatic event ( ) . importantly, intervention in this early phase can reduce the progression to ptsd ( ) . increased exposure to stress and trauma in multiple life domains, including acutely increased workplace stress resulting from the pandemic, when combined with underlying baseline burnout; may result in rising rates of ptsd among physicians. additionally, as there is significant overlap in drivers of both ptsd and burnout, as well as consequences and comorbidities, the intersection of these entities may have a compounding effect (table ) . for example, lack of control over one's schedule is a known driver of burnout that may acutely worsen for individual radiologists as hospital administration responds to changes in imaging volume and economic consequences by redefining work hours, staffing and clinical responsibilities. many radiologists also face the threat of redeployment to understaffed fields of medicine taxed by the pandemic providing an example of the way in which another known driver of burnoutimbalance between skillset and work demands-may be exacerbated by the pandemic. theoretically, and in a worse case scenario, if these workplace stressors were combined with the added loss of control and sense of displacement that may arise if a radiologist were exposed to or contracted covid- and chose to quarantine away from home and family, the mental health consequences could be devastating. large-scale disasters are associated with significant increases in mental health disorders in both the immediate aftermath of the trauma and over longer periods of time with increased rates of ptsd, depression and substance abuse disorders reported ( ) . similarly, burnout is associated with higher rates of substance abuse, depression and suicide ( ) . those studies that specifically before addressing appropriate systems based responses to such stressors, it is important to also consider the role that racism may play with regard to increased ptsd susceptibility among minority healthcare providers in response to the covid- colleges (aamc) found that . % of physicians in the united states self-identified as ethnic asian ( ) . many minority groups experience higher rates of ptsd when compared with white populations and one theory for this vulnerability focuses on the traumatic nature of racism ( ) . on may , , the united nations secretary general warned against xenophobia and anti-asian sentiment, stating, "the pandemic continues to unleash a tsunami of hate and xenophobia, scapegoating and scare-mongering" and advised governments to "act now to strengthen the immunity of our societies against the virus of hate" ( ) . there is, unfortunately, an abundance of historical precedent for minority discrimination related to epidemics and pandemics. examples include violent pogroms against the jewish community during the black death ( - ) and, in recent history, discrimination in response to hiv/aids pandemic ( ) . historians cite "the newness and mysteriousness of a disease" as a predisposing factor for igniting racial violence and minority scapegoating and these elements certainly apply to the current state of the covid- pandemic underscoring the potential of this pandemic to incite racism ( ) . it is critical that radiology leadership maintain a zero tolerance policy regarding workplace discrimination while also committing to support strong diversity training programs and efforts that focus on humanism and tolerance. the impact of ptsd among healthcare workers on patient care has not been widely studied in radiologists. however, there is evidence that among those with symptoms of ptsd, burnout is also highly prevalent and a recent meta-analysis identified physician burnout as significantly and positively correlated with increased medical error ( , ) . physician burnout is costly, and not only in terms of the risk of medical error. the syndrome of burnout is associated with increased risk of physician suicide as well as substance abuse and may contribute to healthcare infrastructure instability by fostering increased turnover, early retirement and decrease in percent of professional effort; consequences certainly undesirable in the setting of a pandemic requiring increased healthcare resources and reserves ( , ) . previous conceptual models related to mitigating physician burnout focus on individual as well as systems based interventions and suggest that responsibility for maintaining a healthy physician work force lies, not only with individual physicians, but with hospital administration and department leadership ( ) . therefore both individual strategies and systems based interventions should be adopted in these challenging times ( ) . recent recommendations to improve individual radiologists well-being in the setting of the covid- pandemic have suggested "micropractices", or strategies requiring just a few seconds that are readily available to individual physicians in order to manage stress. these practices focus on managing the emotional aspects of stress and fear and leverage positive psychology, mindfulness practices and embodiment to combat the fight or flight response as well as emotional exhaustion and depersonalization ( ) . similar interventions, including mindfulness and gratitude practices, have been successful in the setting of ptsd ( , , ) . the american college of radiology (acr) radiology well-being program has compiled an on-line collection of resources to promote radiologist wellness during the covid- pandemic and site contains direct links to resources focusing on the arts, mindfulness, fitness and sleep ( ) . an additional important and potentially overlooked well-being practice involves limiting ones exposure to media coverage of the pandemic. one study found that those individuals with repeated related medial exposure following the boston marathon bombing reported experiencing higher levels of acute stress than those present during the actual event ( ) . while individual action steps are certainly required to promote resilience and well-being during this time of crisis, an appropriate and informed response from the healthcare system and radiology leadership will also be required. interestingly, the incidence of ptsd in healthcare workers following the sars pandemic positively correlated with the perceived risk of exposure and was negatively associated with provider identification with their work as altruistic ( ) . these are important factors that may be considered in informing the allocation of department resources and efforts to minimize physician burnout and ptsd. a frame work of suggested interventions to prevent burnout and treat ptsd in the radiology workforce are outlined below and in table and figure . in addition to promoting those individual based interventions discussed above, radiology leadership should direct departmental resources toward creating a physically safe work environment and support the development of an infrastructure that allows radiologists and staff to work from home. this specific strategy is in line with many public health policies promoting containment and individual well-being such as the "safer at home" policy, advocated by the government of the state of colorado ( ) . the capacity to work from home is an advantage of the digital era and may have a positive impact on radiologist mental as well as physical health. for example, a workplace centered at home mitigates several previously outlined sources of physician anxieties related to the pandemic, including concerns about bringing the virus home to family, stress regarding the impact that contracting the virus may have on family resources, while helping those who may be vulnerable, such as single parents or households where both parents work, cope with child-care requirements ( ) . additionally, maintaining a healthy radiologist workforce in the setting of a pandemic requires the type of social distancing that can only be maximized with home quarantine. therefore, developing an infrastructure whereby radiologists may care for patients directly from home is an asset that will support radiologist personal and family needs in myriad unforeseen ways in the era of covid- and should be a key component of future pandemic preparedness. creating a work environment and culture where mental illness is not stigmatized may be challenging, but it is a critical step in establishing policies and practices whereby physicians are enabled to cura te ipsum, "heal themselves" ( ) developing psycho-educational seminars on the symptoms of ptsd and burnout with direction to the appropriate resources may be an essential first-step for those who are affected but might not recognize the illness or symptoms in themselves. additional efforts that may contribute to a culture where burnout and mental illness is not stigmatized may involve coordinating expert panel discussions on stress and ptsd, allowing dedicated time away from work to attend to mental health appointments and, in unprecedented times, considering non-traditional methods of physician engagement. for example, the field of narrative medicine leverages the arts and humanities as well as reflective writing exercises that allow healthcare providers the time and space necessary to access emotions and process experiences in a structured manner ( ) . this contemplative environment facilitates cognitive reframing and self-compassion while helping to solidify professional identity and reinforce a sense of altruism at work, a factor previously shown to be protective from ptsd following a pandemic ( ) . and this should be a conversation with both value and time given to the voice of those with "boots on the ground" knowledge. in order to optimize high performing teams in the workplace, a culture of psychological safety is a pre-requisite and key components of psychological safety include trusting that one will not be punished for making a mistake or speaking one's mind ( ) . finally, responding to the covid- pandemic may be a time to recognize diverse personnel as a resource in the department. radiology leadership may ask to hear from voices of those that may have worked through prior natural disasters, such as hurricane katrina or the world trade center terrorist attacks, when creating policy and procedure. these perspectives may add elements of both wisdom and hope to those of us navigating the complex uncharted territory of this pandemic. as much as social distancing is being leveraged as a critical method of covid- disease containment, both individual and system based practices will be required to reduce workplace stress and burnout and minimize the acute stress response and risk of subsequent ptsd. the mental health consequences for physicians related to this pandemic may be significant given the common drivers of burnout and ptsd and the high rate of underlying burnout among radiologists ( ) . as the covid- pandemic has highlighted, the healthcare system in the united states is marred by imperfections. taking good care of the physical as well as mental wellbeing of physicians on the frontline of the covid- pandemic should not be among them. support an infrastructure that allows radiologists and staff to work from home decrease exposure and mitigate concerns about contracting the virus and promotes schedule flexibility increase education treatment about burnout, asd, and ptsd, via expert panel discussions and access to mental health increase awareness and early intervention, reduce stigma employ non-traditional methods of physician engagement (eg narrative medicine) facilitates cognitive reframing and self-compassion, reinforce a sense of altruism in work clear communication from leadership increase sense of safety and stability, increase team work engage radiologists in scheduling increase engagement and prevent burnout, promotes schedule flexibility virus confronts leader's with one of modern history's gravest challenges association between physician burnout and patient safety, professionalism, and patient satisfaction: a systematic review and meta-analysis post traumatic stress disorder: the management of ptsd in adults and children in primary and secondary care controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis burnout among u.s. medical students, residents, and early career physicians relative to the general u.s. population uptodate: acute stress disorder in adults: epidemiology, pathogenesis, clinical manifestations, course, and diagnosis the mental health consequences of covid- and physical distancing: the need for prevention and early intervention the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk center for disease control and prevention (cdc): severe acute respiratory syndrome(sars). sars basic fact sheet case of coronavirus (covid- ) in the u understanding and addressing sources of anxiety among health care professionals during the covid- pandemic association of american medical colleges: diversity in facts and figures assessing racial trauma within a dsm- framework: the uconn racial/ethnic stress & trauma survey national action plans needed to counter intolerance pandemics: waves of disease, waves of hate from the plague of athens to aids the prevalence and impact of post -traumatic stress disorder and burnout syndrome in nurses executive leadership and physician well-being: nine organizational strategies to promote enagement and reduce burnout coronavirus disease (covid- ) and beyond: micropractices for burnout prevention and emotional wellness fessell gratitude and ptsd symptoms among israeli youth exposed to missile attacks: examining the mediation of positive and negative affect and life satisfaction a meta-analytic investigation of the impact of mindfulness-based interventions on post traumatic stress the american college of radiology (acr) radiology well-being program: combatting the covid- pandemic: a collection of well-being resources for radiologists boston marathon bombings, media, and acute sress physician heal thyself: meaning and origin narrative medicine: a model for empathy, reflection, profession and trust high performing teams need psychological safety. here's how to create it figure : a system based model for minimizing physician workplace stress and promoting policies that simultaneously minimize burnout and acute stress disorder (asd) while decreasing the risk of subsequent post-traumatic stress disorder key: cord- - cz jtt authors: ismael, f.; bizario, j. c. s.; battagin, t.; zaramella, b.; leal, f. e.; torales, j.; ventriglio, a.; marziali, m. e.; martins, s. s.; castaldelli-maia, j. m. title: post-infection depression, anxiety and ptsd: a retrospective cohort study with mild covid- patients date: - - journal: nan doi: . / . . . sha: doc_id: cord_uid: cz jtt background: it remains unclear whether covid- is associated with psychiatric symptoms during or after the acute illness phase. being affected by the disease exposes the individual to an uncertain prognosis and a state of quarantine. these factors can predispose individuals to the development of mental symptoms during or after the acute phase of the disease. there is a need for prospective studies assessing mental health symptoms in covid- patients in the post-infection period. methods: in this retrospective cohort study, nasopharyngeal swabs for covid- tests were collected at patients homes under the supervision of trained healthcare personnel. patients who tested positive for covid- and were classified as mild cases (n= ) at treatment intake were further assessed for the presence of mental health disorders (on average, . days after the intake). we investigated the association between the number of covid- symptoms at intake and depression, anxiety and ptsd, adjusting for previous mental health status, time between baseline and outcome, and other confounders. multivariate logistic regression and generalized linear models were employed for categorical and continuous outcomes, respectively. findings: depression, anxiety and ptsd were reported by . % (n= ), . % (n= ), and . % (n= ) of the sample. reporting an increased number of covid-related symptoms was associated with depression (aor= . ; %ci= . - . ), anxiety (aor= . ; %ci= . - . ), and ptsd (aor= . ; %ci= . - . ). sensitivity analyses supported findings for both continuous and categorical measures. interpretation: exposure to an increased number of covid- symptoms may predispose individuals to depression, anxiety and ptsd after the acute phase of the disease. these patients should be monitored for the development of mental health disorders after covid- treatment discharge. early interventions, such as brief interventions of psychoeducation on coping strategies, could benefit these individuals. the covid- pandemic has affected more than million individuals worldwide (kim et al., ) . despite the efforts to limit viral spread, cases are increasing worldwide and deaths are continually occurring (aljabali et al., ) . this pandemic is generating further mental issues such as insomnia, anxiety, depression, stress, anger, and fear (torales et al., ) . those directly or indirectly affected by the virus could be more disturbed by these symptoms (torales et al., ; vindegaard & benros, ) . word cloud studies indicate that uncertainties about lack of covid- tests and medical supplies are common (lwin et al., ) . there is still much uncertainty about the best treatment to be administered to individuals affected by the disease (lwin et al., ) . though highly transmissible, most cases present with mild symptoms (aljabali et al., ) . however, having been affected by the disease exposes the individual to an uncertain prognosis and a need to quarantine to mitigate viral spread (fernández et al., ) . these factors can predispose individuals to the development of mental symptoms during or after the acute phase of the disease. it is unclear whether covid- can produce psychiatric symptoms during or after the acute illness phase (vindegaard & benros, ; sinanović et al., ) . in general, survivors of critical illnesses have a high level of mental symptoms after the condition improves. depression, anxiety and post-traumatic stress disorder (ptsd) are among the most reported events in patients with these conditions (sparks, ) . patients infected with sars-cov- had a high rate of depressive symptoms during follow-up after the acute phase of the disease (cheng et al., ; wu et al., ; lee et al., ) . these symptoms lasted for an extended period, being reported up to a year after the improvement in sars-cov- symptoms (lee et al., ) . anxiety symptoms were also reported during the post-sars-cov- follow-up (cheng et al., ; wu et al., ) . some studies in asia investigated depression and/or anxiety in patients admitted in hospitals due to covid- (guo et al., ; hu et al., ; nguyen et al., , zhang et al., . in a case-control design, guo et al. ( ) investigated the mental status and inflammatory markers of covid- hospitalized mild patients, matching them with controls that were covid- negative. hu et al. ( ) carried out a cross-sectional survey with covid- inpatients in two isolation wards of a covid- designated hospital. zhang et al. ( ) evaluated the prevalence and severity of depression and anxiety within patients recently recovered from covid- infection, who were under quarantine. in vietnam, nguyen et al. ( ) carried out a cross-sectional study with individuals infected by covid- attending outpatient departments of nine hospitals and health centers across the country. all these studies found increased levels of both anxiety and depression ( . - . % and . - . %, respectively). there was no follow-up study to investigate prospective symptoms of depression and anxiety in covid- patients. the ongoing covid- pandemic has disrupted the lives of many across the globe, resulting in an increased burden of physical and mental health consequences. through this analysis, we investigated the association between covid- symptoms and post-infection depression, anxiety and post-traumatic stress disorder (ptsd) among a sample of patients diagnosed with mild covid- in brazil. there is a need for prospective studies assessing mental health symptoms in covid- patients, evaluating the post-infection period in other regions of the world. the present study was approved by the local ethics committee (comissão de Ética para análise de projeto de pesquisa -cappesq, protocol no. . . . , approved on july th , ). this was a retrospective cohort study. all people who tested positive for covid- and classified as mild cases at treatment intake (baseline: april th to july th ) were considered for the presence of mental health disorders in a follow-up assessment (outcome: july th to early august th ). we investigated the association between the number of covid- symptoms at intake and depression, anxiety and ptsd in the follow-up assessment, adjusting for previous mental health status, and the time between the baseline and outcome, among other possible confounders. sensitivity analyses were carried out where we excluded: (i) individuals with a short time between baseline and outcome assessment (≧ days), because these individuals could be in the late active phase of the covid- disease, and (ii) those who progressed to a more severe case of covid- . residents of the municipality ≥ years of age with suspected covid- symptoms were encouraged to contact the dedicated corona são caetano platform via the website (access at https://coronasaocaetano.org/) or by phone (baseline: april th to july th ). they were invited to complete an initial screening questionnaire that included socio-demographic data; information on symptoms type, onset and duration; and recent contacts. people meeting the suspected covid- case definition (i.e., having at least two of the following symptoms: fever, cough, sore throat, coryza, or change in/loss of smell (anosmia); or one of these symptoms plus at least two other symptoms consistent with covid- ) were further evaluated, whilst people not meeting these criteria were reassured, advised to stay at home and contact the service again if they were to develop new symptoms or the worsening of current ones. patients were then asked by a medical student to complete a risk assessment. there were no refusals. all pregnant women, and patients meeting pre-defined triage criteria for severe disease, were advised to attend a hospital service -either an emergency department or outpatient service, depending on availability. all other patients were offered a home visit for self-collection of a nasopharyngeal swab (nps -both nostrils and throat), which were collected at the patients' homes under the supervision of trained healthcare personnel. more details can be found in leal et al. ( ) . due to shortages of some reagents, two rt-pcr platforms were used at different times during the study: altona realstar® sars-cov- rt-pcr kit . (hamburg, germany) and the mico biomed rt-qpcr kit (seongnam, south korea) . for serology, we tested μl of serum or plasma (equivalent in performance) using a qualitative rapid chromatographic immunoassay (wondfo biotech co., guangzhou, china), that jointly detects anti-sars cov- igg/igm. the assay has been found to have a sensitivity of . % and specificity of . % in a u.s. study. in our local validation, after two weeks of symptoms, the sensitivity in rt-pcr confirmed cases (n= ) was . %, and specificity in biobank samples (n= ) from was %. patients testing rt-pcr negative were followed up by the primary health care program of their residential area. they were advised to contact the platform for additional consultation if they developed new symptoms. all patients testing sars-cov- rt-pcr positive (n= , ) were invited to participate in the retrospective cohort study (n = ), in which we assessed depression and anxiety (outcome: july th to early august th ). we had a response rate of . %. table s presents differences a comparison between those that agreed to participate (n= ) and those that did not (n= ). people that agreed to participate in the study were younger and reported more headaches, anosmia and dysgeusia, and less tachypnea and joint pain than those that refused to be part of the study. more importantly, no significant difference was found regarding the total number of covid- symptoms, which was our main exposure measure. patients testing positive for sars-cov- via rt-pcr were followed up to days (a maximum of phone calls) from completion of their initial questionnaire. they were contacted every hours by a medical student (supervised by a medical doctor) who completed another risk assessment and recorded any ongoing or new symptoms. following the covid- clinical assessment protocol of são caetano do sul (leal et al., ), the following covid- symptoms were assessed during these contacts: dyspnea; tachypnea; persistent fever (≥ hours); mental health disturbance (e.g., changes in consciousness, thought, perception); fever (at any timepoint); cough; sore throat; nasal congestion; coryza; headache; fatigue; asthenia; lack of appetite; myalgia; joint pain; diarrhea; nausea; vomit; anosmia; and dysgeusia. the total number of symptoms during the treatment was the primary exposure investigated in the present study. the gad- scale is an instrument for assessing, diagnosing and monitoring anxiety. it was created by spitzer et al. ( ) . it was validated by kroenke et al. ( ) , according to the criteria of the diagnostic and statistical manual of mental disorders -fourth edition (dsm-iv), for the assessment of signs and symptoms of anxiety disorder, and also to classify severity levels. this study uses the brazilian portuguese validated version (moreno et al., ) . gad- consists of seven items, on a four-point scale: (not at all), (several days), (more than half the days), and (nearly every day). the total score ranges from to , assessing the frequency of signs and symptoms of anxiety over a two-week period. no missingness was observed in any of the question items. a cutoff ≥ was used for the categorical diagnosis of anxiety (muñoz-navarro et al., ) . in our sample, we found a cronbach's alpha of . (table s ). the phq- scale is an adaptation of the prime-md (sptizer et al., ) . it is a brief instrument for assessing, diagnosing and monitoring depression. it was validated by spitzer et al. ( ) and by kroenke et al. ( ) . the present study uses a version which has been translated and validated to brazilian portuguese (de lima osório et al., ). phq- was created based on the dsv-iv criteria for major depressive disorder, for the assessment of its signs and symptoms, and also to classify severity levels. it consists of nine items, arranged on a frequency four-point scale: (not at all), (several days), (more than half the days), and (nearly every day). its score ranges from to , assessing the frequency of signs and symptoms of anxiety over two weeks. no missingness was observed in any of the question items. a cutoff ≥ was used for the categorical diagnosis of depression (levis et al., ) . in our sample, we found a cronbach's alpha of . (table s ) . weathers et al. ( ) developed the pcl-c scale, which was translated, adapted and validated to brazilian portuguese (berger et al., ; lima et al., ) to assess the consequences of different types of traumatic experiences. it is based on the dsm-iii diagnostic criteria for ptsd. the patient must report the levels of last-month disturbance by items, using a severity scale ranging from (not at all), (a little bit), (moderately, (quite a bit), and (extremely). no missingness was observed in any of the question items. a cutoff ≥ for the categorical diagnosis of ptsd (archer et al., ) . in our sample, we found a cronbach's alpha of . (table s ). lifetime diagnosis of psychiatric disorder (yes vs. no), current psychiatric treatment (yes vs. no), age (continuous: - years), gender (male vs. female), education (up to high school vs. more than high school), civil status (married vs. single, which included previously married), income level (as defined by the brazilian institute of geography and statistics: up to three times the typical salary for a minimum wage job vs. more), current health treatment for any acute or chronic medical condition (yes vs. no) and time between the treatment intake and mental assessment (continuous: - days), were assessed as potential confounders. stata software version . was used to run the analysis. initially, we performed a comparison between those who attended the mental health follow-up assessment and were included in the present study (n= ) and those who did not, using logistic regression models. this comparison was performed to identify any potential baseline difference between the groups, which could generate bias to our outcome analysis (e.g., higher number of covid- -related symptoms among those not included). our final analytical sample included participants. we first conducted a descriptive analysis of the covid- treatment intake profile, sociodemographic measures, and the health profile of included patients. secondly, we described the mean and prevalences of anxiety, depression and ptsd in these patients. we then created scatterplot figures for continuous outcomes across time. multivariate logistic regression models for categorical outcomes (binarized scales) were carried out. these models were adjusted for all aforementioned confounders listed in section . . . two distinct models were carried out, one which included lifetime psychiatric diagnosis, and the other included current psychiatric treatment, due to significant correlation between these two variables determined via pairwise testing (p< . ). we subsequently ran sensitivity analyses, where we excluded: (i) individuals with a short time between baseline and outcome assessment, as individuals could be in the late active phase of the covid- disease (≧ days), (ii) those who progressed to a more severe covid- case, and (iii) those with a previous psychiatric diagnosis. in a final sensitivity analysis, we ran multivariate generalized linear models (glm) for the continuous outcomes. based on a previous study (gustavsson et al., ) , gamma-family glm with log link were the models of choice, because of a log-normal distribution of the continuous outcomes of depression, anxiety and ptsd in our sample (figures s , s , and s ). table shows descriptive analysis of our sample (n= ). the majority were female ( . %), married ( . %), and had up to high-school education ( . %) and three minimum salaries per month of income ( . %). around one in every five individuals have had a psychiatric disorder during lifetime ( . %). only about half of these individuals have been undergoing psychiatric treatment ( . %). current health treatment was reported by . % of the sample. regarding covid- symptomatic profile, patients had a mean of . covid- -related symptoms. the most common symptoms were anosmia ( . %), dysgeusia ( . %), cough ( . %), headache ( . %), and fatigue ( . %), being reported by more than % of the sample. table presents depressive, anxiety and post-traumatic stress symptoms and disorders in the sample. depression, anxiety and ptsd were reported by . % (n = ), . % (n = ), and . % (n = ) of the sample. among these patients, . % (n = ), . % (n = ), and . % (n = ), had a previous psychiatric diagnosis during lifetime. on average, we assessed patient mental health almost two months after the treatment intake (mean = . days, %ci = . - . ), with the vast being assessed after the acute phase of the disease ( . %, n = ). few patients ( . %, n = ) were referred for in-person consultation. figures a, b, and c present scatterplots of mean scores of depression, anxiety, and ptsd (y-axis) by the time of the mental health assessment (x-axis). there were wide ranges of scores for all disorders, more concentrated in the lower severity levels during the entire period (from week to almost four months). for all disorders, a similar pattern of distribution was found through the time of the mental health assessment. table presents the results of the logistic regression models of the exposure (previous total number of symptoms of covid- ) for the outcomes (categorical diagnosis of depression, anxiety disorder and ptsd). the exposure was significantly associated with all the outcomes, after adjustment for all confounders. in the sensitivity analysis (table ) , these results remained significant after the exclusion of (i) individuals with a short time between baseline and outcome assessment (≥ days), as individuals could be in the late active phase of the covid- disease, (ii) those who progressed to a more severe covid- case, and (iii) those with a previous psychiatric diagnosis. in the final sensitivity analysis (glm for continuous outcomes), we found a significant relationship between number of covid- symptoms and all the outcomes, with the exception of ptsd when adjusting for lifetime psychiatric disorder (p = . ). the present study aimed to investigate the post-infection levels of mental health disorders among individuals with mild covid- disease. we aimed to investigate whether covid- infection symptomatology could be associated with mental health disorders. we found that an increased number of covid-related symptoms were associated with depression, anxiety, and ptsd. sensitivity analyses supported those findings for the categorical clinical diagnosis of such disorders. more importantly, our findings adjusted for confounders that could increase the vulnerability of mental health disorders. these results shed light on a significant subpopulation at risk for mental disorders. this has been the largest study . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . evaluating mental health symptoms in patients who had covid- disease to date, and the only study assessing mental health status of patients with prior covid- infections. four studies in asia investigated depression and/or anxiety in covid- patients using the same scales used in the present study (guo et al., ; hu et al., ; nguyen et al., , zhang et al., . prevalence of depression and anxiety varied between . - . %.and . - . %, respectively (guo et al., ; hu et al., ; nguyen et al., , zhang et al., . all of these studies were conducted in asia (three in china and one in vietnam). the prevalence of depression in our study ( . %) is included within this interval, but anxiety prevalence was greater ( . %) than previously reported values ( . - . %). our results were more similar to those found by zhang et al. ( ), who sampled home-quarantined covid- patients. the lowest depression and anxiety prevalences were found in the guo et al. ( ) (lin et al., ) . previous estimates of ptsd levels within brazil were . % (de castro longo et al., ) demonstrating that the prevalence of ptsd within individuals presenting with mild covid- is increased in comparison to past estimates. our results support the hypothesis that the prevalence of depression, anxiety and ptsd were elevated in people with increased number of covid- symptoms at baseline. these findings echo warnings from the previous sars outbreak, wherein survivors of sars infections experienced increased psychological distress, persisting one year or more subsequent to the outbreak (lee et al., ) . similar findings were observed following the occurrence of the middle east respiratory syndrome coronavirus (mers-cov) in , indicating that survivors experienced mental health consequences following the outbreak (park et al., ) . mental health supports should be strengthened, and healthcare systems must prepare for an influx of individuals experiencing psychological distress as a result of the covid- pandemic. following the ptsd model, these individuals should be referred to early interventions. brief interventions of psychoeducation on coping strategies have been effective in promoting mental health among individuals who experienced traumatic life events (oosterbaan et al., ) . internet-based psychological intervention for acute covid- patients has also been described, and could be an interesting early-intervention tool for those who experience psychological distress during this phase (wei et al., ) . it is unclear whether covid- can produce psychiatric symptoms during or after the acute illness phase (vindegaard & benros, ) . neuropsychiatric issues, such as: headaches, paresthesia, myalgia, impaired consciousness, confusion or delirium, and cerebrovascular diseases have been reported among individuals with covid- (sinanović et al., ) . however, the symptoms assessed in the present study (i.e., depressive, anxiety and ptsd) are substantially different from neuropsychiatric symptoms observed among some individuals . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . in the acute phase of covid- . in addition, we found no differences of level of mental health symptomatology depending on the time of assessment after the acute phase of the disease. thus, it seems improbable that depressive, anxiety and ptsd symptoms could be a direct effect of the sars-cov- . rather, it is likely that the increased prevalence of mental health disorders post-covid- is resultant from the psychosocial context of the pandemic (dubey et al., ). people who have been infected with covid- have likely experienced long periods of quarantine, and some have reported fear of transmitting the virus to members of their social and familial networks (iglesia-sanchez et al., ) . this, in combination with uncertainties surrounding treatment and clinical course (guo et al., ) , could be working synergistically to worsen mental health symptoms. future studies should explore neurobiological effects of sars-coronavirus- and mental health impacts. assessing people for depression, anxiety, and ptsd at different timepoints should be noted as an important limitation of the present study. however, we adjusted all the logistic regression and glm models to the time of assessment and also conducted sensitivity analyses, excluding those who could potentially be assessed during the acute phase of covid- and testing whether the continuous or categorical version. we were also not able to assess other important behavioral disorders (i.e., substance use and sleep disorders). however, we were able to assess the most prevalent disorders following traumatic experiences in almost a thousand covid- patients, with an acceptable response rate. the patients included in the present study were slightly different from those who did not attend the invitation. despite being the latter being older, no significant difference was found for the total number of covid- symptoms, which was our exposure measure. exposure to increased levels of covid- symptomatology may predispose individuals to depression, anxiety and ptsd after the acute phase of the disease, independently of previous psychiatric diagnosis. these patients should be monitored for the development of mental health disorders after covid- treatment discharge. early mental health intervention such as psychotherapy and supportive groups could play an important role in preventing incident mental health problems in these people. it is probable that the increased prevalence of mental health disorders post-covid- is due to the social and psychological context of the disease. however, further studies should investigate the possible neurobiological mechanisms linking covid- and mental health conditions. is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . - pandemic. brain, behavior, and immunity, , - . https://doi.org/ . /j.bbi. . . . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . d e s c r i p t i v e a n a l y s i s o f p a t i e n t s c l a s s i f i e d a s h a v i n g m i l d c o v i d - a t t r e a t m e n t i n t a k e , s ã o c a e t a n o d . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint t a b l e . d e p r e s s i v e , a n x i e t y a n d p o s t -t r a u m a t i c s t r e s s s y m p t o m s a n d d i s o r d e r s a m o n g p a t i e n t s w h o h a d p r e v i o u s l y m i l d c o v i d - , s ã o c a e t a n o d o s u l , . m e a n % c i c u t t o f f n % d e p r e s s i v e s y m p t o m s / d e p r e s s i o n ( p h q . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . figures a- b- c . scatterplots of mean scores of depression, anxiety, and ptsd (y-axis) by the time of the mental health assessment (x-axis). . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . https://doi.org/ . t a b l e . r e s u l t s o f t h e m u l t i v a r i a t e l o g i s t i c r e g r e s s i o n m o d e l s a m o n g p a t i e n t s w h o h a d p r e v i o u s l y m i l d c o v i d - , s ã o c a e t a n o d o s u l , . e x p o s u r e : t o t a l n u m b e r o f c o v i d - s y m p t o m s c a t e g o r i c a . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. the copyright holder for this preprint this version posted august , . . t a b l e . r e s u l t s o f t h e s e n s i t i v i t y a n a l y s i s a m o n g p a t i e n t s w h o h a d p r e v i o u s l y m i l d c o v i d - , s ã o c a e t a n o d o s u l , . e x p o s u r e : t o t a l n u m b e r o f c o v i d - s y m p t o m s c a t e g o r i c a . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . figures s -s -s . distribution of the continuous outcomes of depression, anxiety and ptsd in our sample. . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . https://doi.org/ . / . . . doi: medrxiv preprint t a b l e s . l o g i s t i c r e g r e s s i o n m o d e l s f o r f o l l o w -u p v e r s u s m i s s i n g a m o n g t h o s e c l a s s i f i e d a s h a v i n g m i l d c o v i d - p a t i e n t s a t t r e a t m e n t i n t a k e , s ã o c a e t a n o d o s u l , . cc-by-nc-nd . international license it is made available under a is the author/funder, who has granted medrxiv a license to display the preprint in perpetuity. (which was not certified by peer review) the copyright holder for this preprint this version posted august , . . https://doi.org/ . global sentiments surrounding the covid- pandemic on twitter: analysis of twitter trends. jmir public health and surveillance factor structure, reliability, and item parameters of the brazilian-portuguese version of the gad- questionnaire screening for generalized anxiety disorder in spanish primary care centers with the gad- people with suspected covid- symptoms were more likely depressed and had lower health-related quality of life: the potential benefit of health literacy do early interventions prevent ptsd? a systematic review and meta-analysis of the safety and efficacy of early interventions after sexual assault posttraumatic stress disorder and depression of survivors months after the outbreak of middle east respiratory syndrome in south korea covid- pandemia: neuropsychiatric comorbidity and consequences journal of trauma nursing : the official journal of the society of trauma nurses validation and utility of a self-report version of prime-md: the phq primary care study. primary care evaluation of mental disorders. patient health questionnaire a brief measure for assessing generalized anxiety disorder: the gad- utility of a new procedure for diagnosing mental disorders in primary care. the prime-md study key: cord- -f yglaz authors: forte, giuseppe; favieri, francesca; tambelli, renata; casagrande, maria title: the enemy which sealed the world: effects of covid- diffusion on the psychological state of the italian population date: - - journal: j clin med doi: . /jcm sha: doc_id: cord_uid: f yglaz background: starting from the first months of , worldwide population has been facing the covid- pandemic. many nations, including italy, took extreme actions to reduce the diffusion of the virus, profoundly changing lifestyles. the italians have been faced with both the fear of contracting the infection and the consequences of enforcing social distancing. this study was aimed to understand the psychological impact of the covid- outbreak and the psychopathological outcomes related to the first phase of this emergency. methods: the study included respondents. an online survey collected information on socio-demographic variables, history of direct or indirect contact with covid- , and additional information concerning the covid- emergency. moreover, psychopathological symptoms such as anxiety, mood alterations and post-traumatic symptomatology were assessed. results: the results revealed that respectively . %, . % and . % of respondents reported levels of general psychopathological symptomatology, anxiety, and ptsd symptoms over the cut-off scores. furthermore, a significant worsening of mood has emerged. being a female or under the age of years, having had direct contact with people infected by the covid- , and experiencing uncertainty about the risk of contagion represent risk factors for psychological distress. conclusions: our findings indicate that the first weeks of the covid- pandemic appear to impact not only on physical health but also on psychological well-being. although these results need to be considered with caution being based on self-reported data collected at the beginning of this emergency, they should be used as a starting point for further studies aimed to develop interventions to minimize both the brief and long-term psychological consequences of the covid- pandemic. in december , an outbreak of pneumonia associated with a new coronavirus (i.e., severe acute respiratory syndrome due to coronavirus (sars-cov- )) was reported in wuhan, china. in the following weeks, the infection attracted worldwide attention for its rapid and exponential diffusion across different countries around the world. on february , who named it coronavirus disease (covid- ) [ ] . at the beginning of april , covid- has infected more than one and a half million people, causing over , deaths in countries [ ] . this viral infection spread quickly, becoming unstoppable, and forcing the who to declare it a pandemic [ ] . although the containment measures a web-based cross-sectional survey, implemented using the kobo toolbox platform and broadcasted through mainstream social-media (such as facebook, twitter, instagram, telegram), was used to collect data among the italian speaking population. in our opinion, this procedure represents the best data collection strategy in the present phase of forced social distancing, and it leads to reaching the largest number of people. the survey was carried out from march to march . a brief presentation informed the participants about the aims of the study, and electronic informed consent was requested from each participant before starting the investigation. the survey took approximately min to complete. when the participants' responses to the survey lasted less than min or more than min, data were excluded to ensure a standard quality of questionnaires. participation was entirely voluntary and free of charge. to guarantee anonymity, no personal data, which could allow the identification of participants, was collected. for the current research, being at least years old was the only inclusion criterion employed. after a short demographic questionnaire, the participants answered questions that assessed knowledge and perceptions related to the spread of covid- and the government measures adopted to contain it. finally, italian versions of standardized questionnaires were administered to assess psychological dimensions. this study was conducted in accordance with the declaration of helsinki and was approved by the ethics committee of the department of dynamic and clinical psychology of the "sapienza" university of rome (protocol number: ). participants could withdraw from the study at any time without providing any justification, and the data were not saved. only the questionnaire data that had a complete set of answers were considered. ninety-eight per cent of the total respondents ( out of people) who started the questionnaires completed the entire survey, and the related data were considered for statistical analyses. the main demographic characteristics of the sample are shown in table . the authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the helsinki declaration of , as revised in . the first session of this questionnaire required information about gender, age, education and occupation, city, and region of origin. the second section aimed to evaluate personal knowledge about covid- diffusion, individual perception of the situation, and lifestyle changes related to government restrictions. the scl- [ ] (italian version: ) is a -items questionnaire aimed to assess psychological distress and symptomatology. the items are rated on a five-point likert scale, ranging from 'not at all' ( ) to 'extremely' ( ). ten primary symptom dimensions are measured: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, anger-hostility, phobic anxiety, paranoid ideation, psychoticism, and sleep disturbance. a global severity index provides measures of overall psychological distress. higher scores in each dimension indicate greater distress and psychopathological symptomatology. a cut-off score of . was selected to define higher psychopathological symptomatology, in line with previous studies on the general italian population [ , ] . the internal consistency in the participants of the present study was α = . . the stai measures state and trait anxiety [ ] (italian version: ). the questionnaire includes items. twenty items refer to state anxiety (stai-s) and evaluate how participants feel about anxiety "right now, at this moment"; items refer to trait anxiety (stai-t) and assess how people "generally feel" about anxiety. the items are rated on a four-point likert scale, ranging from (not at all) to (very much so). in both the state and trait anxiety scales, higher scores indicate greater anxiety levels. a cut-off point of was used to define higher state anxiety, according to kvaal et al. [ ] . although this study was interested in assessing state anxiety, trait anxiety was also measured to check whether the anxious state could be explained by a high anxious trait of the italian population. the internal consistency of stai in the sample of this study was adequate (α = . ). fifteen mood aspects (insecurity, helplessness, sadness, fear, anger, frustration, stress, anxiety, depression, boredom, serenity, happiness, preoccupation, tranquility, energy) both positive and negative were assessed to examine the emotional impact of the current situation. in these evaluations, the participant was required to refer to two different periods. the first was december, preceding the outbreak of the contagion (december ); the second period referred to the last week. the mood scales required a response on a -point likert scale [ ] , from (not at all) to (very much). the use of mood scales has mainly been adopted to analyse the self-reported conditions of individual mood [ ] [ ] [ ] . the items on the mood scales presented high internal consistency (α = . ). the ies-r is a self-report measure designed to assess ptsd symptomatology according to the diagnostic and statistical manual of mental disorders-fourth version (dsm-iv) criteria for ptsd. the questionnaire requires the indication of the magnitude of distress on specific dimensions (e.g., recurring dreams, feelings of anger and irritability) related to specific life events (i.e., the current covid- emergency) referring to the last seven days [ ] (italian version: ). the three subscales measure avoidance (the tendency to avoid thoughts or reminders about the incident), intrusion (difficulty in staying asleep, dissociative experiences similar to flashbacks), and hyperarousal (irritated feeling, angry, difficulty in sleep onset). the ies-r requires a response on a -point likert-scale, from (not at all) to (extremely). the score on an ies-r subscale is the mean of the scores of the items of that cluster. the ies-r also gives an overall score (ies-r total that is the sum of the scores of the three subscales). the cut-off of was adopted to indicate a high risk of ptsd symptomatology [ , ] . in the present sample, the ies-r presented high internal consistency (α = . ). descriptive analyses were conducted to describe demographic characteristics, and covid- related aspects in the italian population, considering the different italian territorial areas. student's t-test was performed to compare our data on anxiety, general psychological symptomatology, and ptsd symptomatology with data from the general italian population, reported by previous studies. specifically, our data on anxiety were compared with those reported by corno et al. [ ] , scl- outcomes were compared with the data given by holi et al. [ ] , and ptsd indices were compared with the results of ashbaugh et al. [ ] . analyses of variance (anovas) were performed to explore the potential difference in the impact of covid- in the italian territorial areas. the differences between north italy, central italy, and south italy were reported for state and trait anxiety, psychopathological symptomatology (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, anger-hostility, phobic anxiety, paranoid ideation, psychoticism, and sleep disturbance), and ptsd symptomatology (ies-r). furthermore, within-subjects anova designs were adopted to compare the respondents' self-reporting mood before and during the covid- emergency. logistic regressions were performed to explore the influence of demographic factors and experiences which were covid- related in determining risk for state anxiety (stai), psychopathological symptoms (scl- ), and ptsd symptomatology (ies-r). all data were analyzed using statistical package for social sciences (spss) version . and statistica . (statsoft.inc., tulsa, ok, usa). p-values of less than . were considered statistically significant. to better control the results for the multiple comparison analyses, the bonferroni correction was adopted; in these cases, an adjusted p-value of less than . was considered statistically significant. the characteristics of the respondents are shown in table . two thousand two hundred ninety-one individuals completed the questionnaires, ( . %) were males, and ( . %) were females; the mean age of the participants was . years (sd: . years; age range: - ). the most represented age range was - years ( . %). most of the participants ( ; . %) received a high school education and were students ( ; . %) or employees ( ; . %). the respondents' current locations were sorted considering territorial area: north ( . %), central ( . %), and south ( . %) of italy. most of the participants live in urban areas ( ; . %) with a number of inhabitants between , and , . among all respondents, only ( . %) were infected by the covid- , and ( . %) were sure that they had had close contacts with individuals suspected of covid- infection (see table ). of the overall sample, respondents ( . %) and ( . %) respectively knew people dead and patients in intensive care units (icu) because of covid- infection. comparisons of state and trait anxiety, psychopathological symptomatology, and post-traumatic symptomatology during the covid- epidemic were made with data from the general population. the comparisons of psychological outcomes during the covid- epidemic in the italian population with data from the general population are presented in table . considering scl- indices, depression (t = . ; p < . ), anxiety (t = . ; p < . ), anger-hostility (t = . ; p < . ), phobic anxiety (t = . ; p < . ), psychoticism (t = . ; p < . ), and global severity index (t = . ; p < . ) significantly differ from holy's data [ ] , indicating greater psychopathological symptomatology in our sample. considering stai indices, state anxiety appears to be higher in our sample compared to data reported by corno et al. [ ] in an italian sample that considered the levels of anxiety separately in both males and females (males: t = . ; p < . ; females: t = . ; p < . ), while no significant differences were present considering trait anxiety. finally, ptsd related symptomatology assessed by the ies-r resulted higher in our sample compared to the data reported by ashbaugh et al. [ ] (t = . ; p < . ) (see table ). table reports the differences in psychological outcomes, considering the three territorial areas of italy. considering psychopathological symptomatology assessed by the scl- , significant differences were reported only in the sleep disturbance subscale (f , = . ; p < . ; pη = . ). people from north italy reported higher sleep disturbances compared to people from south italy (p < . ). however, no other significant differences were observed (see table ). anovas on stai subscales did not highlight significant differences between individuals from north, central, and south italy. finally, considering ptsd, no significant differences were reported in ies-r subscales (see table ). the results on the difference in subjective mood before and during the covid- epidemic are shown in table and figure . the analyses confirmed for all dimensions a perceived worsening of mood by the respondents. figure shows the prevalence of psychopathological symptomatology, state of anxiety, and ptsd, stratified by gender, age, territorial areas, knowledge of people affected by covid- , and loneliness in social distancing experience. table ). sudden outbreak events always pose huge challenges to the countries where they occur, impacting not only on physical health but also on social and mental well-being. from this perspective, the covid- pandemic will have long-term consequences, influencing international and national public health policies. this study is part of a series of works aimed at investigating the characteristics and the psychological effects of the covid- pandemic and the restrictive measures adopted by the italian government during the early and more severe stages of the covid- outbreak [ , ] . since the outbreak of the covid- epidemic, the italian government imposed a lockdown in north italy, expanding it nationwide following the exponential diffusion of the pandemic from the northern territorial areas to both the central and south areas. these severe limitations included the request for both people infected by the virus and healthy citizens to isolate themselves at home, prohibiting all other than indispensable activities, and making it mandatory to wear surgical masks to enter public places. our data were collected near the infection peak (between the end of march and the beginning of april ) [ ] , and they provide an accurate snapshot of italians' perception of this emergency. this study delivers further information to add to the findings reported on the chinese population that was the first to be severely affected by ] , indicating that the effects of this pandemic on the psychopathological conditions are similar in the italian and chinese populations. in both countries younger age, student status, female gender and direct contact with covid- infection are associated with a greater psychological impact of the emergency, involving many psychopathological dimensions (e.g., anxiety, distress, sleep disturbance) [ ] [ ] [ ] [ ] [ ] ] . one of the aims of the study was to analyse the psychological impact of the covid- outbreak in the different italian territorial areas. north italy was the first area in italy infected by the covid- and in which social distancing was imposed. it continues to have the highest prevalence of contagion and deaths, with a heavy burden on the public health system. accordingly, we expected an impact of these conditions on the psychological well-being and mental health of its inhabitants. however, although respondents from north italy reported more sleep disturbances and a relatively higher state of anxiety compared to those from central and south italy, no other differences were observed in psychopathological symptoms and ptsd risk [ ] . these results would seem to underline that psychological status is not only influenced by the direct effects of a justifiable fear of contagion but also by the indirect consequences of the covid- outbreak such as the restrictive measures, that equally influenced people of all the italian regions, generating a similar psychological pattern. this assumption would be confirmed by the comparison of our results with data from the general italian population. the differences in the selection of the sample do not allow a generalizability of these results. most of the psychological symptoms assessed by the scl- subscales are significantly higher in our sample compared to data from the general population. only somatization and paranoid ideation resulted in being not significantly different from data on the general population. these last findings do not agree with recent data on the chinese population [ ] , and they could appear incongruous because medical emergencies might induce higher somatization and intrusive and threatening thoughts. however, these results concord with those found during the sars epidemic [ ] . the high prevalence of anxiety evidenced in our sample highlights that the covid- pandemic has increased alert levels and generated a high level of state anxiety in the population, confirming results of previous studies on sars, influenza a virus subtype h n [ ] [ ] [ ] , and covid- [ ] [ ] [ ] . in our sample, . % of the respondents presented ptsd symptomatology, and risk of ptsd higher than that reported in the general population, at least as regards the symptoms evaluated with the ies-r questionnaire [ ] . this result should be interpreted with caution because it referred to the first weeks of the emergency when people could perceive the rapid spread of the virus and the extraordinary measures adopted by the government as sudden stressors, and it is known that sudden stressors affect the daily lives of individuals drastically. on the other hand, this first italian perception of the current situation would seem to give a photograph of the real impact of the covid- outbreak on mental health. another interesting result concerns the impact of the pandemic on mood. respondents perceived a significant change in their mood, with a sensitive decrease of positive mood (e.g., happiness, serenity) and a high increase of negative mood (e.g., sadness, preoccupation, boredom) after the covid- spread and the consequent social distancing measures. from a clinical point of view, this result could suggest a possible risk of mood disorders, such as depression, as long-term consequences of a pandemic [ ] . however, it must be underlined that these data are not obtained prospectively, and the causal relationship cannot be confirmed. self-reported moods are subject to memory distortions and bias, and they should be taken with caution. overall, the results highlighted high levels of anxiety, psychopathological symptoms and ptsd symptoms in italian respondents during the first critical phase of the spread of the covid- pandemic and of the government measures taken to contain it. however, the results of the present study also suggested which people are most vulnerable to the psychological consequences of the covid- outbreak. this unexpected situation seems to have had a higher impact on females and people under years. moreover, to have had direct contact with people infected by the virus, and to know people more or less severely infected by the covid- (i.e., people hospitalized in an intensive care unit or people dying as consequences of covid- infection) emerged as other relevant risk factors for psychological well-being. all these characteristics would make people more vulnerable to developing anxiety, psychopathological symptoms, and ptsd-related symptoms, confirming results observed in previous studies [ , ] . these risk factors may depend on different aspects of the covid- pandemic. the high psychopathological risk related to direct experience with the covid- infection could depend on the fear of contagion, while being younger could be a risk factor due to the sense of constraint caused by social distancing and the other measures taken by the italian government [ ]. our study reports that covid- infected . % of the sample. this result is higher than the data on the general italian population ( . %), updated on the march [ ] , but it indicates the high rate of healthy individuals in the sample. both this consideration and the data on risk factors would confirm that, even without real exposure to the covid- and an actual infection, fighting against an invisible enemy could affect mental health. uncertainty, fear about infection and social consequences of a pandemic could be triggers for psychopathological symptoms, and they should be considered in further studies. although some psychological characteristics are linked to medical conditions [ ] [ ] [ ] [ ] , psychological consequences of at-risk people are often overlooked during an epidemic emergency as reported for sars and h n [ , , ] . once again, the importance of not disregarding mental health and intervening during and after the pandemic emergency in the most affected psychological dimensions appear relevant in a long-term perspective. this study gives a picture of the psychological well-being of the italian population at the beginning of the covid- emergency. however, some limitations must be considered. despite the large sample size, it is not possible to overcome the limitation of a cross-sectional study, which does not allow us to determine a causal relationship between the variables. also, the use of an online survey presents other limitations. selection bias of participant recruitment is a consequence of this methodological choice. this bias is expressed by some characteristics of our sample, such as the higher number of respondents younger than years, and the high number of females and people from south italy. another limit related to the online survey can be associated with convenience sampling that may have induced the collection of responses primarily from people who feel strongly about the considered issue. these limitations reduce the representativeness of our findings and may have influenced the results of the study. therefore, they must be considered. however, the adoption of an online survey was the best solution in this emergency in which social distancing measures limit data collection. in conclusion, a global response is desperately needed to prepare health systems to face the new challenge of the covid- outbreak. despite the underlined limitations, these preliminary findings, in line with the results of previous studies, evidenced that the diffusion of this pandemic can be related to anxiety, changes in mood, high psychopathological symptomatology, and could be associated with the development of ptsd. moreover, similarly to the results of other studies on the covid- pandemic, these findings should be considered preliminary, but they can be useful to predispose interventions aimed at improving the psychological conditions of the population. generally, there is still a lack of relevant research on psychological aspects during the covid- epidemic. it would be essential to analyse further psychological dimensions related to the covid- outcomes, such as lifestyle changes, fear, and perception of the emergency, to assess their role in influencing the psychological status of the italian population. we hope that these preliminary data can be useful to other researchers in analysing the impact of the infection and social isolation due to covid- diffusion. it is our desire that covid- be defeated but also that the research on this topic grows so that we can start thinking about the mental health of those involved in this severe emergency. coronavirus disease (covid- ) situation reports the psychological impact of quarantine and how to reduce it: rapid review of the evidence mental health outcomes of quarantine and isolation for infection prevention: a systematic umbrella review of the global evidence the psychological impact of the covid- epidemic on college students in china prevalence and risk factors of acute posttraumatic 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responses to the outbreak: results from national telephone surveys in the uk psychosocial effects of an ebola outbreak at individual, community and international levels depressive symptoms among survivors of ebola virus disease in conakry (guinea): preliminary results of the postebogui cohort prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured sars caring unit during outbreak: a prospective and periodic assessment study in taiwan alexithymia: a facet of uncontrolled hypertension coping styles in individuals with hypertension of varying severity emotion and overeating behavior: effects of alexithymia and emotional regulation on overweight and obesity the night effect of anger: relationship with nocturnal blood pressure dipping funding: this research received no specific grant from any funding agency, commercial or not-for-profit sectors. there is no funding support for this survey. we would like to thank gianluca pistore and all the people who helped in the data collection by sharing our survey on various social media. the authors declare no conflict of interest. key: cord- -cq vjib authors: croizier, carolyne; bouillon-minois, jean-baptiste; bay, jacques-olivier; dutheil, frédéric title: covid- lockdown and mental health: why we must look into oncology units date: - - journal: psychological medicine doi: . /s sha: doc_id: cord_uid: cq vjib nan we read with interest the article by lazarov et al. ( ) in psychological medicine which demonstrates that 'depressive and posttraumatic symptoms constitute two separate diagnostic entities, but with meaningful between-disorder connections, suggesting two mutually-influential systems'. post-traumatic stress disorder (ptsd) is a mental health condition that is triggered by a terrifying event − either experiencing it or witnessing it. symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. they get worse, for months or even years, and finally interfere with day-to-day functioning. with corona virus disease (covid- ), more than . billion people globally were under lockdown. the local epidemic that initially appeared in wuhan, hubei, china (chan et al., ) quickly became a global pandemic that forced worldwide governments to enact quarantine status and massive lockdown, in an effort to contain the propagation of the virus (gostin, hodge, & wiley, ) . in oncology, especially in clinical hematology units, lockdown has been a common practice for years. when a diagnosis of acute leukemia requires a rapid intensive induction chemotherapy, a patient can get locked in a cleanroom for a long period ( − weeks) to prevent infectious complications of aplasia (döhner et al., ) . an allogenic or autologous hematopoietic stem cell transplantation (hsct) can require a long hospitalization for the same reasons, although patients in this situation are more prepared to these strict conditions of treatment. these treatments require cleanroom and strict hygienic measures, such as regularly washing one's hands with an alcoholbased hand rub, wearing a mask, maintaining social distancing during visits, or limiting visits to one per day (holý & matoušková, ) . these measures invade the everyday of patients. both meant to prevent infections, lockdown measures in oncology and in the covid- world therefore have close durations and measures. but, a sudden lockdown cannot be done without psychological repercussions, and studies have already been done to know the psychological consequences in oncology. for acute leukemia patients, stress disorders and ptsd are common. they have been proven to be associated with the level of pain, the quality of the relationships with health-care providers, and other individual psychological characteristics of the patients (rodin et al., ) . mental consequences are crucial issues for patients who have gone through an hsct or induction for acute leukemia, certainly due to lockdown. six months after an hsct, a significant proportion of patients meet criteria for ptsd and depression (el-jawahri et al., ) , which seems logical in the view of conclusions derived by lazarov et al. ( ) . psychological consequences of covid- quarantine are already studied and ptsd is obviously mentioned (brooks et al., ) . several risk factors are implicated in the development of these psychological disorders but the 'lockdown' factor seems to be important. in this regard, mental health studies on patients who have been treated in oncology may very well be of use to approach the global impacts of lockdown measures on half the world's population's health condition. conflict of interest. the authors of this letter declare no conflict of interest. a familial cluster of pneumonia associated with the novel coronavirus indicating person-to-person transmission: a study of a family cluster diagnosis and management of aml in adults: eln recommendations from an international expert panel quality of life and mood predict posttraumatic stress disorder after hematopoietic stem cell transplantation presidential powers and response to covid- the importance of cleanrooms for the treatment of haemato-oncological patients symptom structure of ptsd and co-morbid depressive symptoms -a network analysis of combat veteran patients traumatic stress in patients with acute leukemia: a prospective cohort study key: cord- - mvcyvbl authors: liu, cindy h.; zhang, emily; wong, ga tin fifi; hyun, sunah; hahm, hyeouk “chris” title: factors associated with depression, anxiety, and ptsd symptomatology during the covid- pandemic: clinical implications for u.s. young adult mental health date: - - journal: psychiatry res doi: . /j.psychres. . sha: doc_id: cord_uid: mvcyvbl this study sought to identify factors associated with depression, anxiety, and ptsd symptomatology in u.s. young adults ( - years) during the covid- pandemic. this cross-sectional online study assessed participants from april , to may , , approximately one month after the u.s. declared a state of emergency due to covid- and prior to the initial lifting of restrictions across u.s. states. respondents reported high levels of depression ( . %, phq- scores ≥ ), high anxiety scores ( . %, gad- scores ≥ ), and high levels of ptsd symptoms ( . %, pcl-c scores ≥ ). high levels of loneliness, high levels of covid- -specific worries, and low distress tolerance were significantly associated with clinical levels of depression, anxiety, and ptsd symptoms. resilience was associated with low levels of depression and anxiety symptoms but not ptsd. most respondents had high levels of social support; social support from family, but not from partner or peers, was associated with low levels of depression and ptsd. compared to whites, asian americans were less likely to report high levels across mental health symptoms, and hispanic/latinos were less likely to report high levels of anxiety. these factors provide initial guidance regarding clinical management for covid- -related mental health problems. the covid- pandemic that has upended the lives of individuals worldwide escalated in the u.s. beginning in march of . although research on acute and widescale stressors (e.g., natural disasters), demonstrates severe implications for mental health (kessler et al., ) , there is no precedent for understanding mental health effects due to covid- , as prospective studies investigating the effects of a pandemic are virtually non-existent. in particular, the identification of risk factors associated with depression, anxiety, and post-traumatic stress disorder (ptsd) among u.s. young adults ( - years) is urgently needed. comprising more than one-third of the current u.s. workforce, young adults (often referred to as -millennials‖ and -generation z‖) will be a dominant workforce group for the next decade, and our societal functioning depends on how they emerge from the pandemic. understanding their health and well-being during the pandemic is crucial as it sets the stage for later outcomes. certain risk and protective factors are likely to be implicated in pandemic-related mental health. covid- -related worry (e.g., maintaining employment, getting tested for coronavirus) may be linked to mental health symptoms. the early weeks of the pandemic saw rapid changes in daily routines, with students moving following university closures and attending classes remotely, and for other young adults, transitioning to remote work or facing job loss. these disruptions may put an already vulnerable group at greater risk for mental health challenges (conrad, ) . furthermore, loneliness may be particularly prevalent and devastating during the pandemic given directives for social distancing and isolation. those under the age of already show elevated levels of loneliness (domagala-krecioch and majerek, ) , and the pandemic may exacerbate these feelings. despite the critical role that social support plays in mitigating the risks to mental health problems, directives on social distancing may impede on one's typical means for obtaining such support. individual resilience, which refers to one's ability to cope with stress, and distress tolerance, which describes one's ability to manage and tolerate emotional distress, may be salient characteristics that protect against the mental health symptoms that follow major stressors. individual resilience is a significant protective factor for depression, ptsd, and general health after natural disasters (kukihara et al., ) . findings have generally demonstrated distress tolerance to be associated with lower symptoms of depression and ptsd following tornadoes (cohen et al., ) . however, the extent to which these factors are associated with mental health symptoms during a pandemic is unknown. this study sought to identify potential factors that contribute to mental health outcomes among young adults during the covid- pandemic. the cares project (covid- adult resilience experiences study, www.cares .com) was launched to track the health and well-being of young adults in the u.s. across multiple time points in and . this present analysis assessed depression, anxiety, and ptsd symptomatology, and psychological experiences including distress tolerance, resilience, social support, and loneliness. we included depression and anxiety as these are common mental health symptoms among young adults (blazer et al., ; chen et al., ; eisenberg et al., ; liu et al., ; mojtabai et al., ) . we assessed ptsd symptoms given documented high rates of trauma by young adulthood (costello et al., ; reynolds et al., ; vrana and lauterbach, ) ; a concern was that the pandemic would either create and/or exacerbate symptoms related to prior trauma (breslau et al., (breslau et al., , brunet et al., ) . new items that specifically assessed covid- specific concerns were also included. the objective of this work is to identify salient psychosocial risks for mental health symptoms and to prioritize intervention targets for addressing mental health symptoms among young adults. the present cross-sectional study assessed potential risk and protective factors for mental health outcomes based on preliminary cares data obtained from wave data collection (n = ) conducted from april , to may , , approximately one month after the u.s. declared a state of emergency due to covid- and prior to the initial lifting of restrictions across u.s. states. eligible participants were young adults aged to years currently living in the u.s. or receiving education from a u.s. institution. participants were recruited online via email list serves, social media, and word of mouth (i.e., list serves and facebook groups for school organizations or clubs, alumni groups, classes, churches). this took place initially through organizations from the new england area before additional list serves from other regions of the u.s. (midwest, south, and west) were targeted. respondents were asked to complete a minute online qualtrics survey regarding covid- -related experiences, risk and resilience, and physical and mental health outcomes. to ensure data quality, human verification and attention checks were implemented throughout the survey; the data was further inspected visually for response irregularities indicative of bots. participants were compensated via raffle in which one out of every participants received a $ gift card. all procedures were approved by the institutional review board at boston university. binary scores were created after calculating the mean or sum of each measure. rather than relying on the sample characteristics to categorize our data (e.g., mean, median, tertile or quartile split), the determination of the cutoff score was based on standard cutoffs from previous research; when a standard was not available, scale response descriptors to determine the cutoffs. psychological resilience was measured using the -item connor-davidson resilience scale (cd-risc- , connor and davidson, ) , which assesses one's ability to cope with adverse experiences. participants indicated how they felt in the past month on a -point scale, with indicating -not true at all‖ and indicating -true nearly all the time.‖ sum scores were recoded dichotomously into -high resilience‖ and -low resilience‖ with a cutoff score of or greater. this cutoff score characterizes responses that tended to be -often true‖ and -true nearly all the time,‖ with those endorsing a score ≥ considered to be at -very high risk with mental disorders‖ (andrews and slade, ; kessler and mroczek, ) . the distress tolerance scale is a -item measure that assesses participants' abilities to withstand and cope with emotional distress (simons and gaher, ) . respondents rated personal attitudes towards feelings of emotional distress on a -point scale, ranging from (-strongly agree‖) to (-strongly disagree‖), with higher ratings indicating greater distress tolerance. a global mean score of distress tolerance was calculated. we considered the scale descriptors and followed the cutoffs used for the cd-risc, which was also a -point scale. as such, scores were dichotomously recoded so that global mean scores less than indicated -low distress tolerance‖ and scores of -to- indicated -high distress tolerance.‖ perceived social support was measured using the multidimensional scale of perceived social support (mspss, zimet et al., ) , in which participants rated perceived emotional support using a -point likert scale ranging from (-very strongly disagree‖) to (-very strongly agree‖). this measure includes three subscales assessing perceived support quality from family, friends, and partners. because mean scores greater than reflected responses indicating -mildly agree,‖ -strongly agree,‖ and -very strongly agree,‖ each subscale mean scores were recoded so that scores or greater referred to -high perceived social support,‖ and scores below were referred to as -low perceived social support.‖ instrumental support was assessed through a -item subscale of the two-way social support scale (shakespeare-finch and obst, ). participants indicated the extent of their received instrumental support based on a -point likert scale ranging from (-not at all‖) to (-always‖). items were summed to create a total score with a possible range of -to- . given cutoffs used for the other -point scale in our survey and the scale descriptors, a cutoff score with a sum of or greater indicated -high instrumental support,‖ whereas scores lower than indicated -low instrumental support.‖ loneliness was measured using an adapted -item version of the ucla loneliness scale short form (hughes et al., ) . participants rated lack of companionship, feelings of being left out, and isolation from others on a scale of to , with as -hardly ever,‖ as -some of the time,‖ and as -often.‖ a sum score for loneliness was calculated with a total possible range of -to- and recoded dichotomously; a cutoff score of or greater indicated -high loneliness‖ as used in prior studies (lowthian et al., ; tymoszuk et al., ) . severity of covid- pandemic-related worry was assessed using a newly developed measure consisting of items, which included the following concerns: -having enough groceries during city lockdowns/social distancing protocols‖, -obtaining a covid- test if i become sick‖, -getting treated for covid- if i contract it‖, -keeping in touch with loved ones during social distancing protocols‖, -maintaining employment during the subsequent economic downturn‖, and -having enough money to pay for rent and buy basic necessities.‖ participants were asked to indicate their level of worry for each item on a scale of to , with being -not worried at all,‖ and being -very worried.‖ sum scores were calculated with a total possible range of -to- and recoded into a dichotomous variable with a cutoff score of or greater as -highly worried.‖ cronbach's alpha for measure items was . , indicating good reliability. depression was assessed with the -item version of the patient health questionnaire (phq- , kroenke et al., ) which assessed frequency of depressive symptoms in the past two weeks on a scale of (-not at all‖) to (-nearly every day‖). sum scores of the phq- had a total possible range of -to- and were recoded dichotomously based on a cutoff score of or higher (wu et al., ) . anxiety was assessed with the generalized anxiety disorder scale (gad- , spitzer et al., ) a widely used measure assessing the frequency of anxiety symptoms in the past two weeks on a scale of to , with being -not at all‖ and being -nearly every day.‖ sum scores ranged from -to- . following the convention of other studies (plummer et al., ) , responses were recoded dichotomously based on a cutoff score of or higher to determine elevated anxiety. the ptsd checklist-civilian version (pcl-c), a validated -item measure, was administered to assess ptsd symptoms (weathers et al., ) . participants indicated how much they were bothered by problems and experiences in response to stressful life events in the past month, with as -not at all‖ and as -extremely.‖ sum scores of the items were calculated and created into a dichotomous variable with a cutoff score of or greater, based on the psychometric properties for the measure and as suggested by the national center for ptsd (blanchard et al., ) . the variables were normally distributed, with predictors indicating acceptable levels of collinearity (vif < ). to identify potential risk and protective factors of mental health symptoms, three logistic regression models were performed to examine depression, anxiety, and ptsd symptoms as primary outcomes. resilience, distress tolerance, perceived social support, instrumental social support, loneliness, and covid- -specific worries were entered as predictors in unadjusted models. age, gender, income, and race were entered in each of the three adjusted models. all variables were binary with exception to age and income, which were continuous. two-tailed p-values were used. to guard against type i error, bonferroniadjustments were made to consider the predictors and covariates used in each model (. / =. ). our results and interpretations are therefore based on a significance set at a p<. (note that the significance in the tables remain unadjusted to provide more rather than less information to the reader). all analyses were performed using spss . . table shows demographic characteristics of our participants and descriptive data on all predictors and outcomes. the sample was racially and ethnically diverse, with . % white, . % asian, . % black, . % hispanic/latino, . % ai/na, . % mixed race, and . % indicating another race. the majority of respondents were women ( . %), u.s. born ( . %), employed ( . %), students ( . %), and those who earned less than $ , per year ( . %). among those identifying as students, . % were enrolled as full-time and . % were international students. overall, participants scored as having high loneliness ( . %), low resilience ( . %), and low distress tolerance ( . %). at the same time, the majority of respondents reported having high levels of social support (family, partners, peer, and instrumental). finally, . % of our sample had high levels of depression (phq- scores ≥ ), . % had high anxiety scores (gad- scores ≥ ) and . % had high levels of ptsd symptoms (pcl-c scores ≥ ). table displays the associations between predictors and mental health outcomes in each of the three models adjusted for the age, gender, race, and income. the results described here pertain only to significance set at p < . with bonferroni corrections. predictors that were significantly associated with depression, anxiety, and ptsd included loneliness (or range = . - . ), covid- -specific worries (or range = . - . ), and distress tolerance (or range = . - . ). specifically, those who endorsed high levels of loneliness and worries about covid- and low levels of distress tolerance were more likely to score above the clinical cutoffs for depression, anxiety, and ptsd. those with high levels of resilience were less likely to score above the cutoff for depression and anxiety. those with high levels of family support were less likely to score above the clinical cutoff for depression and ptsd (or = . and . , respectively). instrumental support was negatively associated with depression. no associations were obtained between support from partners and friends. in analyses of associations between covariates and outcomes, age and income were not associated with depression, anxiety, or ptsd. with regard to gender, men who identified as transgender were more likely to report high levels of ptsd (or = . , ci = . - . , p=. ); no differences were observed between men and women. asian americans compared to whites were less likely to report high levels of depression (or = . , ci = . - . , p=. ) and ptsd (or = . , ci = . - . , p<. ). asians americans and hispanic/latinos were less likely to report high levels of anxiety (or = . , ci = . - . , p<. , or = . , ci = . - . , p=. , respectively ). our findings highlight major psychological challenges faced by young adults during the initial weeks of the covid- pandemic. at least one-third of young adults reported having clinically elevated levels of depression ( . %), anxiety ( . %), and ptsd symptoms ( . %). the rates of depression, anxiety, and ptsd in our study are considerably higher compared to prior studies that have used the same cut points (phq- ≥ ; gad- ≥ ; and pcl-c ≥ ). year ( . %; zhang et al., ) . the high rates from our sample may reflect ongoing distress, as we measured the symptoms in the weeks following the government directives for closures. young adults may have been particularly distressed in managing school or work responsibilities during this time while having no sense of certainty regarding the pandemic's end. as well, the high rate of mental health concerns among study participants may be partially attributable to the specific characteristics of our sample; given that the study was launched on the east coast, our young adult respondents may have been located at pandemic -hot spots,‖ with proximity to a greater number of covid- cases potentially being an added stressor for our sample. strikingly, the majority of respondents reported feeling lonely during the first two months of the pandemic, as well as having low resilience and low ability to tolerate distress. however, the majority reported having social support from family, partners, and peers, as well as instrumental support during this time. we note that the absolute rates of low perceived social support remains seem problematic. for instance, approximately % of respondents reported low family support. these findings highlight major psychological challenges currently faced by young adults during the initial weeks of the covid- pandemic. our study also identified factors associated with clinical levels of depression, anxiety, and ptsd symptoms. high loneliness and low distress tolerance levels were consistently associated with high levels of depression, anxiety, and ptsd. high levels of resilience were associated with low anxiety. social support from family was associated with low levels of depression, and ptsd symptoms, whereas support from partners or friends were not associated with any mental health outcomes. high levels of instrumental support were associated with low levels of depression. our data is consistent with findings demonstrating loneliness as a risk factor for mental health (banerjee et al., ; hawkley and cacioppo, ; okruszek et al., ) ; this is particularly salient with government directives for social distancing and isolation. feeling cut off from social groups may lead one to feel vulnerable and pessimistic about one's circumstances, altogether producing negative mood states and anxiety (muyan et al., ) , that are further heightened during a pandemic. the high levels of reported loneliness in our sample and its association with depression, anxiety, and ptsd symptoms underscore the severity of experiences of young adults during the pandemic. distress tolerance, or one's ability to manage and tolerate emotional distress, was strongly associated low levels of depressive and anxiety, and ptsd symptoms; individual resilience was associated with low levels of depression and anxiety symptoms, but not ptsd. individual resilience, which encompasses personal competence and trust in one's instincts (connor and davidson, ) , has been associated with low levels of depression, anxiety, and ptsd symptomatology after disasters (blackmon et al., ) . one's perceived ability to tolerate negative or aversive emotional and/or physical states may be more protective than the personal qualities that comprise psychological resilience, especially for those experiencing symptoms of ptsd during a pandemic. the pandemic is worldwide stressor without a foreseeable endpoint, and the effects of the pandemic cannot be controlled by a single individual. furthermore, the pandemic simultaneously impacts various domains (e.g., financial, relational, and health) with this stress potentially exacerbating the sensations associated with ptsd symptoms. as such, psychological resilience that is typically associated with overcoming setbacks may not be sufficient for protecting against ptsd symptoms within the first several weeks of a widespread pandemic. interventions that target distress tolerance, such as mindfulness-based interventions, may be more effective than cognitive interventions targeting core beliefs about the self especially for those with ptsd symptoms (nila et al., ) . longitudinal approaches would help to examine this possibility further. emotional support from family but not from friends and significant others was associated with low levels of depression and ptsd. friends and significant others may have or are perceived to have less capacity to validate other's emotional experiences during a pandemic, considering that they may be young adults who are experiencing similar struggles. emotional support provided by family may be more stable and coupled with the provision of material resources that young adults may still receive from parents. our findings are consistent with prior work showing that family support but not friend and partner support mediates the effects of stress on health (lee et al., ) . family support may be more meaningful in providing reassurance to young adults, considering the possible concrete needs during the pandemic. instrumental support, or tangible assistance, may be an important factor for the mental health of young adults during the immediate weeks of the covid- pandemic onset given that many were faced with acute disruptions, such as unemployment, financial stress, and relocation following university campus closures. however, instrumental support was not significantly associated with any of the outcomes after adjusting the p-value to . . additional research is needed to clarify the respective roles on both emotional and instrument support given variations in their potential effects on depression, anxiety, and ptsd. our newly developed covid- worries measure uniquely predicted mental health symptoms, underscoring how the specific features of this pandemic give rise to acute stress. the stress resulting from lifestyle changes due to features of covid- itself may lead to greater mental health concerns distinct from the endorsement of other risks. our analyses showed that the six items in our measure were reliable and the total subscale score was significantly associated with the symptoms assessed in this study; however, additional work is required to determine the validity of this measure. in general, asian americans were less likely to report high levels of mental health symptoms compared to whites, with hispanic/latino respondents also being less likely to report high anxiety. asian and latino immigrants compared to those who are born in the u.s. are less likely to endorse psychological distress (dey and lucas, ; takeuchi et al., ) . it is possible that other experiences such as ethnic identity, social networking, and family cohesion serve as a protective factor for mental health, especially for non-u.s. born participants (leong et al., ) . the under-recognition of distress symptoms may also be possible among ethnic minorities (liu et al., ) . although our sample size of gender minorities was small, men who identified as transgender were more likely to report a high level of ptsd symptoms, consistent with prior research (reisner et al., ; shipherd et al., ) . greater attention to gender differences in mental health symptoms as well as a deeper study regarding the specific experiences faced by racial/ethnic and gender minorities during pandemic is warranted. the cross-sectional design limits our ability to infer causality involved in leading to mental health problems. we used a convenience sample, and caution must be taken in the generalizability of our findings to the broader population of young adults in the u.s. given the uneven sampling of subgroups. the reliance of self-report itself has limitations, such that it may be prone to misinterpretation. future analyses with the anticipated waves of data collection will enable us to examine the association of our predictors to outcome measures of mental health and to adjust for additional confounds. as well, we will have an opportunity to examine potential moderation effects to understand whether outcomes vary by circumstances or individual characteristics, such as socioeconomic capital, social support type, distress tolerance, and resilience. to our knowledge, our study is the first prospective cohort study to assess mental health outcomes and risk and resilience factors in u.s. young adults during the first several weeks of the covid- pandemic. in our study, one in three u.s. young adults reported clinical cut-off symptoms of depression, anxiety, and ptsd as well as high levels of loneliness. we present new evidence that signifies the roles of loneliness, distress tolerance, family support, and covid- worries on mental health outcomes during the first month of the 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the national science foundation key: cord- -ilxaurgt authors: jung, heeja; jung, sun young; lee, mi hyang; kim, mi sun title: assessing the presence of post-traumatic stress and turnover intention among nurses post–middle east respiratory syndrome outbreak: the importance of supervisor support date: - - journal: workplace health saf doi: . / sha: doc_id: cord_uid: ilxaurgt background: south korea faced the middle east respiratory syndrome (mers) outbreak for the first time in , which resulted in infected patients and deaths. this study investigated the level of post-traumatic stress disorder (ptsd) and turnover intention, the relationship between ptsd and turnover intention, and the buffering effect of supervisor support among nurses post-mers outbreak. methods: in total, nurses from three of isolation hospitals in south korea were invited to participate. we collected data pertaining to ptsd, turnover intention, supervisor support, work-related factors, and socio-demographic factors through a structured survey distributed to the nurses at the hospitals after the outbreak. for the statistical analyses, descriptive statistics and multiple regression were employed. findings: of the participants, . % were involved in the direct care of the infected patients, whereas . % were involved in the direct care of the suspected patients. more than half ( . %) of the nurses experienced ptsd, with . % experienced full ptsd and . % with moderate or some level of ptsd. the mean score of turnover intention was . , with the score range of to . the multiple regression analysis revealed that ptsd was positively associated with turnover intention, and supervisor support had a strong buffering effect. conclusion/application to practice: these findings confirmed that after a fatal infectious disease outbreak like mers, nurses experience high level of ptsd and show high intention to leave. organizational strategies to help nurses to cope with stress and to prevent turnover intention, especially using supervisor support, would be beneficial. among the total infected patients, . % (n = ), . % (n = ), and . % (n = ) were pre-admitted patients, family members or visitors, and health care professionals, respectively. out of the infected health care professionals, were nurses. due to the lack of vaccine or special treatment along with a high mortality rate ( %), nurses directly involved in the care of mers patients showed high levels of stress and fear (khalid et al., ; who, ) . similarly, taiwanese nurses who were directly involved with the care of patients of severe acute respiratory syndrome (sars) in reported more severe post-traumatic stress compared with the nurses who were not involved in the direct care (chen et al., ) . post-traumatic stress disorder (ptsd) is associated with exposure to traumatic events resulting in a state of psychological unbalance (blake et al., ) . medical staff, including nurses, are more likely to be in environments that increase their sensitivity to ptsd (tang et al., ; wu et al., ) . another consistent issue of the nursing industry is the workforce shortage and high turnover rates. particularly in korea, less than % of registered nurses are actively working, and the average turnover rate is . %, with a rate of % for newly graduated nurses (ministry of ). prior studies on the relationship between posttraumatic stress and turnover intention reported strong associations among nurses working in emergency rooms (han & lee, ; maeng & sung, ) . many other factors, including socio-demographic factors, organizational commitment, perceived advancement opportunities, job and career satisfaction, salary level, and workplace relationships and support, have also been found to influence turnover intention (ayalew et al., ; brunetto et al., ; y. kim & kang, ; laschinger, ; oyeleye et al., ; takase et al., ) . however, workplace relationships and support, especially supervisor support, have been proven to be strong buffers on work-related traumatic stress, work-related stress, and turnover (larocco et al., ; stephens & long, ) ; supervisor support has shown to be positively associated with job and career satisfaction (nissly et al., ) . to date, there is a lack of studies investigating the relationship between post-traumatic stress and turnover intention among nurses in the event of outbreak epidemics, such as mers. the purpose of this study was to examine the levels of ptsd and intention to leave among a sample of korean nurses who were directly involved in the care during the mers outbreak, as well as the buffering effects of supervisor support on this relationship. we conducted a cross-sectional study, in which quantitative data were collected through a survey from october through november , , shortly after the mers epidemic ended. during the mers outbreak, hospitals were designated as cohort isolation facilities. we contacted all hospitals and three agreed to participate in the study. these included two hospitals in daejeon city that were isolated for infection control from june through june , and the third hospital in gyeonggi province which was isolated from may through june (kcdc, ). the kcdc ( ) announced the end of the cohort isolations on july . we conducted the surveys approximately months after the announcement; we considered that the nurses have recovered to normal working conditions by this time. the nurses were asked to recall during the period of the mers outbreak and answer the survey questionnaires based on that prior time period. a total of nurses from three general hospitals, who provided either direct or indirect care for mers, were invited to participate in the study. the participants included in the final analysis were those who provided direct care during the mers outbreak. this study was conducted after receiving the institutional review board approval from the konyang university hospital (irb kyuh - - - ) as well as informed consent from the participants. post-traumatic stress disorder was assessed by using the impact of event scale-revised korean version (ies-r-k; eun et al., ) . the original impact of event scale-revised (ies-r; weiss & marmar, ) was composed of three subdimensions (avoidance, intrusion, and hyperarousal) consisting of questions, and the ies-r-k is composed of five subdimensions (avoidance, intrusion, hyperarousal, and sleep problems and numbness). the ies-r-k consists of questions including six items on hyperarousal (score range of - ), six items on avoidance (score range of - ), five items on intrusion (score range of - ), and five items on sleep problems and numbness (score range of - ). the -point likert-type scale ( - points) consists of the total sum of scores for the four sub-dimensions ranging from to , with higher scores indicating higher level of post-traumatic stress. eun et al. ( ) presented the total ptsd score of as the cutoff point for experiencing full ptsd, and the score of to indicating moderate or some level of ptsd. the cronbach's alpha of the original ies-r was . , and that of the ies-r-k was . (eun et al., ; weiss & marmar, ) . the cronbach's alpha of the ies-r-k in this study was . . the nurses were asked to recall their feelings and emotions associated with the mers outbreak time period. supervisor support was measured using the korean version of the job content questionnaire (k-jcq; eum et al., ) . the k-jcq consists of three sub-domains (autonomy of work, job demands, and social support of the workplace), with a total of items. the social support domain of the k-jcq includes supervisor support, co-worker support, and job instability. in this study, we used four questions regarding the supervisor support, including questions ("my boss is interested in the welfare of his or her subordinates"), ("my boss is interested in my opinion and listens carefully."), ("my boss helps me to accomplish my tasks."), and ("my boss is good at making people work together"). a -point likert-type scale ( = strongly disagree, = disagree, = agree, = strongly agree) was used. the total possible score ranges between and , with higher scores indicating higher supervisor support. cronbach's alpha was . at the time of development of the among nurses who were involved with the direct care of either infected or suspected middle east respiratory syndrome (mers) patients, . % experienced full post-traumatic stress disorder (ptsd) and . % experienced moderate or some level of ptsd. turnover intention was also high among this cohort. high ptsd scores were positively associated with high turnover intention, and supervisor support was proven to have a strong buffering effect. these findings suggest that supervisor support is a successful management strategy to lower turnover intention post epidemic outbreak. organizational strategies to help nurses to cope with stress and to prevent turnover intention, especially using supervisor support, would be beneficial. measurement (karasek et al., ) and that of the k-jcq (eum et al., ) was . ; the cronbach's alpha in this study was . . turnover intention was estimated by the turnover intention measurement (h. s. park, ) , which is the korean version of the scale originally developed by lawler ( ) . the measurement consists of four items, each of which is a -point likert-type scale ( = very unlikely, = unlikely, = neutral, = likely, = very likely). the possible range of scores is from to , with higher scores indicating higher intention to leave. the cronbach's alpha for the original measurement was . (h. s. park, ) and that of the current study was . . the general health questionnaire (ghq) was used to measure current self-reported mental health. we used the ghq- , a reliable and sensitive short form which is ideal for research studies (liang et al., ) . the scale consists of items and is a -point likert-type scale ( = much less than usual, = same as usual, = more than usual, = much more than usual), with a total score ranging from to . the cutoff point in the scores of ghq- is , indicating the presence of mental health problems (makowska et al., ) . the ghq was included as one of the confounding variables. to measure the difference of stress levels between the period of the mers outbreak and after the outbreak, nurses were asked to recall their stress levels during the mers outbreak and compare it with their current day-to-day stress levels after the outbreak. a question asking the stress level during the outbreak in a -point likert-type scale and another question asking the stress level after the outbreak were included in the survey. the authors, then, calculated the difference between the two levels of the stress. data were analyzed using the statistical package for social sciences, version . (spss, inc., ). the descriptive statistics were calculated using frequency and percentage, as well as means and standard deviation. cross-tabulation, including t test and f test, was conducted to examine the characteristics of participants according to ptsd, supervisor support, and turnover intention measures. the relationship between ptsd (independent variable) and turnover intention (dependent variable), as well as the buffering effect of supervisor support as an effect modifier, was examined by multiple regression analysis. work experience, work position, shift work, department, marital status, level of education, annual income, mental health status, difference in stress levels, and level of involvement in the care of mers patients were considered as covariates (jeong et al., ; mosadeghrad, ; yang & kim, ) . table describes the general characteristics of the study participants. of the invited participants, responded with providing usable data (response rate: %). all of the participants were female, of which . % had work experience of to years, . % with less than year, . % with to years, and . % with over years of work experience. the majority were staff nurses ( . %) who worked in rotating shifts ( %). approximately . % of the nurses worked in either intensive care or in emergency services, whereas . % of them worked in general medicine departments. the majority of the nurses were single ( . %) and completed years of college or higher ( . %), and earned an annual salary of more than us$ , ( . %). of the nurses, . % of them were directly involved with the treatment of confirmed infected patients, whereas . % of them were directly involved with the treatment of suspected patients. the mental health of the nurses, measured by ghq, showed the mean score of . (of ), indicating problematic self-rated mental health. the difference of stress levels between every day and the days during the outbreak was . , which showed that the stress level during the outbreak was higher. a total of . % (n = ) of the nurses experienced ptsd. considering the score of and above as experiencing full ptsd, . % (n = ) experienced full ptsd and . % (n = ) experienced some level of ptsd, with scores of to . the mean score of supervisor support was . with the range of to , which indicated moderate supervisor support. the turnover intention score ranged from to , and the mean turnover intention in this study was . , which was high. table shows the characteristics of participants according to the ptsd, supervisor support, and turnover intention measures. department (p < . ), mental health (p < . ), and the level of involvement during the mers outbreak (p < . ) were associated with post-traumatic stress. mental health was negatively associated with supervisor support (p < . ). years of work experience (p < . ), shift work (p < . ), marital status (p < . ), annual income (p < . ), and self-reported mental health (negative association, p < . ) were associated with turnover intention. table shows the results from the multiple regression analysis in which we observed that nurses with work experience of between and years (β = . ), direct involvement with the treatment of a suspected patient (β = . ), and high score of ptsd (β = . ) were positively associated with higher intention to leave. higher supervisor support (β = −. ) was, on the contrary, associated with lower turnover intention. the interaction between ptsd and supervisor support was significant (β = . ) with intention to leave, illustrating the buffering effect of supervisor support. the purpose of this study was to examine the levels of ptsd and turnover intention of nurses after the mers outbreak in korea. the result showed that . % of the nurses who were involved with the direct care of either infected or suspected mers patients experienced ptsd. in particular, . % of the nurses experienced full level of ptsd, which is higher than . % of nurses experiencing full level of ptsd using the same ies-r-k from a study on nurses working at emergency departments (han & lee, ) . another study on japanese firefighters using the original ies-r measure showed that only . % of the participants experienced full level of ptsd (saijo et al., ) . a study of medical staff involved with patient care during the sars outbreak found that % of the respondents had experienced high levels of ptsd (wu et al., ) . another study found that around % of participating doctors and nurses showed ptsd symptoms that were involved in the care of avian influenza a (h n ) patients during the h n influenza epidemic in to (tang et al., ) . the average turnover intention of nurses in this study was . when the total score range is from to , showing high turnover intention. a previous study that used the same measurement revealed average score of . among nurses working at emergency department (lee & ahn, ) . other studies also showed lower scores compared with that of our research, which were . among nurses working at general hospitals (c.-h. kim et al., ) and . among nurse managers (k. o. park et al., ) . additional aim of this study was to investigate the relationship between ptsd and turnover intention. the result of this study validated significant and positive relationship between ptsd and turnover intention among nurses who were involved with the care during the mers outbreak. prior studies on nurses have presented the same results. a study on korean nurses working at emergency departments revealed significant and positive association between ptsd and turnover intention (han & lee, ) . also, after a traumatic incident, more than % of nurses working at emergency departments displayed high turnover intention. the final investigation was to see whether supervisor support has buffering effect between ptsd and turnover intention, which was proven to be legitimate. social support of workplace, including supervisor support, has been known to act as a moderator against the impact of high stress on well-being and related health outcomes on the buffering hypothesis of cohen and wills ( ) . other study has investigated the buffering effect of social support and higher level of organizational stress as well as turnover intention (nissly et al., ) . however, majority of studies on buffering effect of social support studies were done on the relationship between general or job stress and turnover intention, so future studies should be specified on the relationship between ptsd and turnover intention during fetal epidemic events as well as the buffering effect of social support, such as supervisor support. despite the fact that this is one of the few studies on nurses who were involved with the direct patient care during the mers outbreak in korea, it has some limitations. fifteen hospitals were cohort isolated during the mers breakouts; however, only three hospitals agreed to participated in the study. the small sample size limits our ability to generalize the findings beyond the study hospitals. in addition, the three hospitals that agreed to participate are those that were praised by the media for their successful response to the pandemic. therefore, the levels of ptsd and the buffering effect of supervisor support might have different results if all of hospitals participated in the research. in addition, data were collected after the outbreak due to facility isolation during the outbreak. post-traumatic stress disorder, turnover intention, and supervisor supports were all asked as recall questions months after the outbreak, introducing possible recall bias. the results of this study are significant and relevant because the participants were nurses who were involved with direct patient care during the mers outbreak. more than half ( . %) of the nurses experienced ptsd- . % with full level and . % with some level of ptsd. also, ptsd and turnover intention were significantly and positively related. in addition, the results of this study suggest that social support, particularly supervisor support, should be provided to reduce the impact of ptsd on nurses' turnover intentions in the case of serious infectious diseases. support system should be discussed at departmental, organizational, and national levels. infectious disease and occupational health professionals should consider developing and implementing coping management strategies to reduce ptsd and turnover intention related to epidemic outbreaks as well as providing educational programs to supervisors to provide adequate support to nurses. this study was approved by the konyang university hospital institutional review board (irb kyuh - - - ). the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the 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altruistic acceptance of risk factors influencing turnover intention in clinical nurses: compassion fatigue, coping, social support, and job satisfaction heeja jung, rn, phd, key: cord- -m xwsqdk authors: cheng, peng; xu, li-zhi; zheng, wan-hong; ng, roger m.k.; zhang, li; li, ling-jiang; li, wei-hui title: psychometric property study of the posttraumatic stress disorder checklist for dsm- (pcl- ) in chinese healthcare workers during the outbreak of corona virus disease date: - - journal: j affect disord doi: . /j.jad. . . sha: doc_id: cord_uid: m xwsqdk background: previous studies about the reliability and validity of the updated pcl version for the fifth edition of the diagnostic and statistical manual for mental disorders (pcl- ) have only been evaluated in certain samples of the population, which lacks in the sample of healthcare workers. our study focused on the factor structure, reliability and validity of the pcl- among chinese healthcare workers during the outbreak of corona virus disease . methods: we conducted an online survey of frontline healthcare workers using the pcl- for ptsd. total of frontline healthcare providers were included in this study. results: the findings showed that pcl- is a reliable instrument in our sample. the total and subscale scores showed good internal consistency. the convergent and discriminant validity of the pcl- were also well demonstrated. our result showed a better fit with the seven-factor hybrid model compared with other models and supported that the pcl- chinese version can be used as a reliable screening tool to conduct psychological screening for chinese healthcare workers. limitation: we could not examine other aspects of reliability and validity like test-retest reliability or criterion validity. we didn't use the gold-standard structured interview for ptsd in our study. besides, most of our samples were young people who had access to the internet. not all professional levels and seniorities were presented because our sample had a lower mean income and educational level. conclusion: our study shows that the chinese pcl- has good validity and reliability in frontline healthcare workers during the outbreak. post-traumatic stress disorder (ptsd) is a mental health condition that occurs when an individual experienced or witnessed a terrifying and traumatic event that exceeds the limit of personal psychological endurance. ptsd can cause significant psychological distress, cognitive dysfunction, and impairment in social and occupational functionality. the serious negative effects can extend to other individuals, families, and even society (horesh & brown, ) . the four core symptoms of ptsd are repeated recurrence of traumatic experience, continuous avoidance of stimuli related to the traumatic event, negative cognitive and mood changes, and sustained increased alertness (american psychiatric association, ). ptsd is a commonly studied psychopathology in the aftermath of disasters because of its high incidence and burden among people who were exposed to disasters (north et al. ; galea et al. ) . while the rate of ptsd in the general population is between % and %, the incidence of ptsd can be as high as . % among direct victims of disasters and ranges between % and % among rescue workers (neria et al. , luo et al. . a global meta-analysis of a total of which included , earthquake survivors shows demonstrated that shows nearly a quarter of earthquake survivors were diagnosed with ptsd (dai et al., ) . in addition, a survey of the survivors after following the wenchuan earthquake in china showed an incidence of ptsd as high as . % (luo et al. ). also, results from a one-year follow-up study of severe acute respiratory syndrome (sars) patients documented a ptsd diagnosis rate of . % (gao, hui, & lan, ) . with covid- patients were . % more likely to have symptoms of depression, . % more likely to have symptoms of anxiety (lai et al. ). the escalating ptsd among healthcare workers in this large public disaster call for a reliable assessment tool that can be used to evaluate this treatable condition. while there are many other instruments studied and being used in different settings, this article focuses on the posttraumatic stress disorder checklist for dsm- (pcl- ), a -item self-report measure that assesses the presence and severity of ptsd symptoms (weathers fw et al., number of core symptoms, it appears to be effective and reliable, and performs as well yields similar results as longer and more complex measurements (brewin, ) . with the release of the fifth edition of the diagnostic and statistical manual of mental disorders (dsm- ), the pcl has been updated to meet the new diagnostic criteria for ptsd (weathers fw et al., ) . the dsm- revised the diagnostic structure of ptsd from a three-factor-model with symptoms to a four-factor-model comprising symptoms. this change required a re-examination of reliability and validity of both the total and subscale of pcl- . for the purpose of introduction of our current research, we briefly summarized the relevant studies on the psychometric properties of pcl- : the reliability and validity of pcl- have been well studied in different populations. the internal consistency of the total score has been reported as . - . (for for the four subscales respectively, intrusions: α = . - . ; avoidance: α = . although the dsm- proposed a four-factor model of ptsd that was based on a large collection of research evidence, many studies applying confirmatory factor analytic (cfa) have shown poor fit of dsm- model with the studied population. : a seven-factor model that was integrated from several six-factor models. it recently caught the most attention because it has been closely studied in different populations and proven to be the best fit for chinese earthquake survivors, trauma-exposed college students, veterans receiving care at a medical center and military service members seeking ptsd treatment while the rampant -ncov outbreak in china calls close mental health attention, especially to those front-line healthcare workers. close contacts with those infected make them highly vulnerable, not only medically to infection but also psychologically to mental health illnesses. in order to better evaluate their mental health condition, and also to predict ptsd during and after this public health emergency, we developed a chinese version of pcl- and tested its reliability, convergent and divergent validity. as the factor model of the pcl- was inconclusive from previous studies, given that the seven-factor model has been proven to fit well in different studies, this study aims to test the structural validity of this pcl- chinese version and compare the seven-factor hybrid model with other models suggested in the literature. convenience sampling was used in this study. participants were recruited from a hospital in the second xiangya hospital, affiliated with central south university. which was one of the designated hospitals for suspected fever patients -ncov the hospital is located in changsha city, hunan province, china. we conductedthis study within was conducted between two months of the outbreak from february st and to february th , , within two months of the coronavirus outbreak. during which time, the peak number of confirmed cases during the study period was , in china. the study hospital is a general hospital with a capacity of beds. it is one of the designated hospitals by the chinese government to admit febrile patients to rule out -ncov infection .to take care of all patients with fever and suspected -ncov infection. the participants were were all actively involved in the direct care of these patients. all participants in this study were frontline medical residents or clinical lab specialists at a high risk of infection and psychological stress. we chose an online questionnaire to survey because: ( ) face-to-face survey was impractical given the requirement of quarantine and risk of viral transmission from close personal interaction. ( ) the online survey is was fast, easy and convenient for efficient data collection and analysis. participants were selected from those hospital departments of the hospital that are involved either direct contact care to suspected or confirmed -ncov cases or direct handling of biospecimen. this includes included the emergency department, outpatient clinic, clinical lab, radiology, infectious disease, pulmonology, and intensive care unit. the policy of central south university required every radiology resident to conduct direct patient interview and be involved in performing image scanning with the radiology technologist. the studied clinical lab specialists are medical doctor equivalent trainees who graduated from medical school with a preventive medicine degree. one selection criterion is was that the current working environment is at high risk of infection, i.e, reported close contact with -ncov patients or pathgen. a total of subjects were successfully recruited in this study. the sample (n = ) was diverse in terms of demographic characteristics (table ). since this survey was a web-based self-report, in order to ensure the accuracy, only the individuals aged from to were included. the exclusion criteria included inability to consent, cognitive deficit, severe depression, schizophrenia, bipolar disorder or other mental disorders. the inclusion and exclusion criteria questions were asked by the study personnel to assess the participant's eligibility at the beginning of the survey. this cross-sectional study was approved by the ethics committee of the second xiangya hospital, central south university. the pcl- is a self-report measure that consists consisting of items that correspond to the dsm- criteria for ptsd. the pcl- has subscales, corresponding to each of the symptom clusters in the dsm- . participants rate how much a problem described in the item statement bothered them over the past month on a -point scale from (not at all) to (extremely). item scores are summed to yield a total score ranging from to . a chinese version of pcl- was developed and used in a previous study on the earthquake-related ptsd symptomatology (wang et al., ) . we revised this previously studied pcl- chinese version by using translating-callback method (f, c, & d, ). after the original version was translated into chinese by two chinese native speaker researchers, the translation was then back-translated into english by two medical english specialists. the back-translation was compared with the original english version. then a psychiatrist and two clinical psychologists reviewed and verified the accuracy of the translation. minor edits were subsequently made until the chinese version of the pcl- was adequate. descriptive analysis was used to characterize the study sample in terms of demographic information. for reliability test, the internal consistency of pcl- was accessed using cronbach's alpha coefficient, where . was considered satisfactory (santos, ) . analyses were performed using the spss . and amos . . we summarized the participants' characteristics in table . a total of healthcare providers were included in this study. more than % of the participants were recruited from the emergency room, the infectious disease and the pulmonolgy department. together with the intensive care unit, they represented the mainstream medical staff responsible for the diagnosis and treatment of all suspected and confirmed -ncov patients. the monthly income of the majority of subjects was less than , cny, only . % reported a monthly income greater than , cny. the income level of subjects was relatively low, due to them still being in the rotation training phase. participants reported an average sum score of . (sd = . ) on the pcl- . means, standard deviations, minimum and maximum values for pcl- are presented in table . participants reported an average sum score of . (sd = . ) on the pcl- . because the cut score is for provisional ptsd diagnosis, % of the sample met the criteria of provisional ptsd diagnosis. cronbach's alphas were calculated for the internal consistency of pcl- . the cronbach's coefficients of subscale scores in terms of the seven-factor model and dsm- four-factor model were summarized in table . the cronbach's alpha coefficient of the total score was . , which exceeds the . level and indicates the high reliability of the pcl- chinese version. internal consistency reliability for each subscale is also satisfactory( . - . ). first, we performed an efa with the sample data to explore the underlying structure of pcl- . the efa showed that the data were appropriate for factoring as shown in table , the factor load of each item on all corresponding subscales was greater than . in the seven-factor model. average variance extracted (ave) was greater than . , and composite reliability (cr) was greater than . . these results supported a good convergent and discriminant validity of the chinese version of pcl- we developed. table , there is an obvious correlation between all subscales, and the correlation coefficient was less than . and the corresponding square root of ave. this indicates indicated that there was a certain correlation between the factors but also a certain degree of discrimination, indicating demonstrating a good discrimination validity. the current study was designed to test the reliability and validity of a chinese version of pcl- in -ncov epidemic direct care healthcare workers. the study focused primarily on -ncov related trauma. we showed that the pcl- chinese version has satisfactory internal consistency and validity. besides additionally, we tested the underlying latent structure of the questionnaire. our results indicated that the seven-factor structure of pcl- is a reasonable screening instrument among chinese this study also demonstrated proved that the chinese version of pcl- has good convergent validity and discriminant validity of the chinese version of pcl- . the load of each item in its corresponding dimension was greater than . , which confirmed that the high representativeness of the items it contains. we can interpret that the chinese version of pcl- has this translated to a good convergent validity, and t the fact that those items have better correlation between items and its with their corresponding subscale or summary score was higher than that between item and with the non-corresponding subscales or summary score, indicates indicated a good divergent validity of the instrument. another outcome of this study is was that a high percentage of subjects ( %) reported ptsd symptoms (average sum score of . ) and met the criteria of provisional ptsd diagnosis. this is wasconsistent with the findings from another recently published chinese study in the covid- crisis (lai et al., ) that reported among nearly , chinese frontline healthcare workers, . % reported feelings of distress, although a lower percentage ( . %) had symptoms of anxiety. in this article, the authors used the -item impact of event scale-revised (ies-r) and the -item generalized anxiety disorder (gad- ) scale to assess the severity of symptoms of distress and anxiety. the ies-r is a -item self-report measure of ptsd symptom severity with broader coverage than pcl- . the majority of participants ( . %) were medical staff in wuhan -the most affected city in china. another difference is that they used the gad- to assess generalized anxiety in the past two weeks. as pcl- also evaluates other ptsd symptoms than anxiety, those people who scored high in our study may not be detected from gad- . despite the important findings of this study, tthere are limitations with this studywhich warrant disclosure. first, due to the limited number of test scales, we could not examine other aspects of reliability and validity such as test-retest reliability or criterion validity. and we did not use other scales to evaluate ptsd symptoms and other psychological characteristics to assess convergent and divergent validities of the pcl- . further research is needed to compare the pcl- results with the diagnosis and symptoms determined using the gold-standard structured interview for ptsd, such as the clinician administered ptsd scale for dsm- (caps- ). it is also necessary to test the relevance of pcl- to other scales to assess convergent and divergent validity. second, the participants were limited to frontline healthcare workers in a designated treatment hospital for -ncov. the traumatic event was relatively simplistic, only limited to the risk of infection of one kind of disease. to generalize the results, we need further studies to test the psychometric properties of pcl- in different populations and various traumatic events. third, due to contagious property of the new coronavirus, our study was conducted online with an intention to minimize the risk of virus transmission. the findings may not apply to paper-and-pencil based assessments. however, the psychometric information we obtained can offer some insights into similar research conducted remotely. forth, the samples of our study were from the departments with a relatively high risk of exposure to -ncov, medical staff in other departments with lower exposure risks may have different symptomology therefore deserves future study. however, the psychometric information we obtained can offer some insights into similar research conducted remotely. finally, our participants did not represent all age groups because only those with access to the online questionnaire, mostly young, were able to complete the survey. not all professional levels and seniorities were presented because our sample had a lower mean income and educational level in comparison with the general population of healthcare providers in china. to our knowledge, this study is the first to test the reliability and validity of the chinese version of pcl- using a representative sample of frontline healthcare workers during the -ncov outbreak. we have shown that the pcl- chinese version is a feasible, reliable, and structurally valid instrument for screening ptsd in frontline healthcare workers. our result demonstrated a better fit with the seven-factor hybrid model compared with other models and supported that the pcl- chinese version can be used as a reliable screening tool to conduct psychological screening for chinese healthcare workers during the outbreak of -ncov. we also found that almost % of healthcare workers met the criteria of provisional ptsd diagnosis. this helps establish and improve the warning mechanism of ptsd crisis for early intervention of potential ptsd patients during and after covid -ncov disaster. limitations of this study include the small sample size and health disaster focus. for better generalizability, future studies on a larger population and other occupational samples are needed. the authors declared that they have no conflicts of interest to this work. we declare that we do not have any commercial or associative interest that represents a conflict of interest in connection with the work submitted. peng cheng: data collection, literature review, translation and manuscript drafting. of the funding source: this study was supported by the national key r&d program of china hunan provincial natural science foundation of china jennifer marton and dr. ahmed aboraya for the help of english language proofreading and editing. thanks also to dr diagnostic and statistical manual of mental disorders structural equation modeling in practice: a review and recommended two-step approach a systematic literature review of ptsd's latent structure in the diagnostic and statistical manual of mental disorders: dsm-iv to dsm- dimensional structure of dsm- posttraumatic stress symptoms: support for a hybrid anhedonia and externalizing behaviors model psychometric validation of the english and 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