key: cord-0689553-7fwpigtw
authors: Zhao, Yan-Jie; Jin, Yu; Rao, Wen-Wang; Li, Wen; Zhao, Na; Cheung, Teris; Ng, Chee H.; Wang, Yuan-Yuan; Zhang, Qing-E; Xiang, Yu-Tao
title: The prevalence of psychiatric comorbidities during the SARS and COVID-19 epidemics: a systematic review and meta-analysis of observational studies
date: 2021-03-11
journal: J Affect Disord
DOI: 10.1016/j.jad.2021.03.016
sha: e387c8a52559dd9073db6189a285e689ffd2c6dc
doc_id: 689553
cord_uid: 7fwpigtw

The coronavirus disease 2019 (COVID-19) and Severe Acute Respiratory Syndrome (SARS) are associated with various psychiatric comorbidities. This is a systematic review and meta-analysis comparing the prevalence of psychiatric comorbidities in all subpopulations during the SARS and COVID-19 epidemics. A systematic literature search was conducted in major international (PubMed, EMBASE, Web of Science, PsycINFO) and Chinese (China National Knowledge Internet (CNKI) and Wanfang) databases to identify studies reporting prevalence of psychiatric comorbidities in all subpopulations during the SARS and COVID-19 epidemics. Data analyses were conducted using the Comprehensive Meta-Analysis Version 2.0 (CMA V2.0). Eighty-two studies involving 96,100 participants were included. The overall prevalence of depressive symptoms (depression hereinafter), anxiety symptoms (anxiety hereinafter), stress, distress, insomnia symptoms, post-traumatic stress symptoms (PTSS) and poor mental health were 23.9% (95% CI: 18.4%-30.3%), 23.4% (95% CI: 19.9%-27.3%), 14.2% (95% CI: 8.4%-22.9%), 16.0% (95% CI: 8.4%-28.5%), 26.5% (95% CI: 19.1%-35.5%), 24.9% (95% CI: 11.0%-46.8%), 19.9% (95% CI: 11.7%-31.9%), respectively. Prevalence of poor mental health was higher in general populations than in health professionals (29.0% vs. 11.6%; Q=10.99, p=0.001). The prevalence of depression, anxiety, PTSS and poor mental health were similar between SARS and COVID-19 epidemics (all p values>0.05). Psychiatric comorbidities were common in different subpopulations during both the SARS and COVID-19 epidemics. Considering the negative impact of psychiatric comorbidities on health and wellbeing, timely screening and appropriate interventions for psychiatric comorbidities should be conducted for subpopulations affected by such serious epidemics.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first reported in Wuhan, Hubei province, China in December 2019 1,2 . Subsequently, the WHO declared COVID-19 as a Public Health Emergency of International Concern (PHEIC) on 30 January 2020 3, 4 . As of the end of February 2020, approximately 113 million cases had been confirmed and over 2.5 million deaths were reported worldwide 5 .

Severe acute respiratory syndrome (SARS) is an infectious disease caused by another coronavirus, severe acute respiratory syndrome coronavirus (SARS-CoV-1) 6 . SARS was first reported in southern China in November 2002, and later spread to Hong Kong 7 and many other Asian countries and territories.

By 31 December 2003, a total of 8,096 SARS cases were confirmed worldwide 8 .

Clinical features of SARS and COVID-19 are similar in some aspects, but also different in others. For example, most patients with SARS suffered from a fever above 38.0°C, chills, headache, lethargy, and muscle pain. After 2 to 7 days, they may develop a dry, nonproductive cough with low blood oxygen levels. Most SARS patients developed shortness of breath and pneumonia subsequently, either primary viral pneumonia or secondary bacterial pneumonia 9 . In contrast, COVID-19 patients usually experienced flu-like symptoms, including fever and/or dry cough. Severe cases may present difficult breathing, chest pain, sudden confusion, and bluish face or lips 10, 11 . Some COVID-19 patients eventually developed pneumonia, acute respiratory distress syndrome, sepsis, and kidney failure 12 . Further, SARS-CoV-1 and SARS-CoV-2 are different in both transmission characteristics and virulence. Compared to SARS-CoV-1, SARS-CoV-2 is more infectious with the reproduction number (R 0 ) of around 3.3 13, 14 , while the R 0 of SARS-CoV-1 is around 2.7 15, 16 . The SARS-CoV-1 is more virulent than SARS-CoV-2. As of the end of 2003, SARS caused 774 deaths, resulting in a mortality rate of 9.2% 8 . In contrast, as of 18 October 2020, the mortality rate of COVID-19 was 2.8% 17 .

In any major catastrophes including bio-disasters, psychiatric comorbidities and related problems, such as depression, anxiety, sleep disturbances, fear, and stigmatization, are common and may act as barriers to accessing appropriate medical and mental health care. In order to prevent or minimise the negative outcomes caused by psychiatric comorbidities, understanding their patterns and associated factors is important. Previous studies on prevalence of psychiatric comorbidities found that confusion symptoms (27.9%), depression (32.6%), memory impairment (34.1%) insomnia (41.9%) and steroid-induced mania and psychosis (0.7%) were common in patients with SARS or Middle East respiratory syndrome (MERS) 18 . In addition, psychiatric comorbidities also persisted after the SARS epidemic, such as post-traumatic stress disorder (PTSD) 19 In order to better understand the psychiatric comorbidities of SARS and COVID-19, it is necessary to compare the prevalence of psychiatric comorbidities in all subpopulations during the SARS and COVID-19 epidemics. Therefore, we conducted this systematic review and meta-analysis of observational studies to compare the overall prevalence of psychiatric comorbidities (e.g., depressive symptoms (depression hereinafter), anxiety symptoms (anxiety hereinafter), stress, distress, insomnia symptoms (insomnia hereinafter), post-traumatic stress symptoms (PTSS), post-traumatic stress disorder (PTSD), and poor mental health) during the SARS and COVID-19 epidemics across all subpopulations studied. We also explored the moderating effects of sociodemographic characteristics (e.g., sex, education level and marital status) on the results. We hypothesized that the overall prevalence of psychiatric comorbidities during the COVID-19 epidemic would be similar to that during the SARS epidemic; 2) the overall prevalence of psychiatric comorbidities in healthcare professionals would be higher than that in the general population during the COVID-19 epidemic.

This systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 29 , with the PROSPERO registration number of CRD42020211604.

Literature search was systematically and independently conducted by three researchers (WWR, YJ, WL) in PubMed, EMBASE, Web of Science, PsycINFO, China National Knowledge Internet (CNKI) and WanFang databases from their inception to May 25, 2020, using the following search terms: "novel coronavir*", "alphacoronavirus", "betacoronavirus", "COVID", "COVID-19", "severe acute respiratory syndrome" and "SARS". For the psychiatric outcome category, the following search terms were used: "psychiatr*", "mental", "psycholog*", "depress*", "anxiety", "posttraumatic stress disorder", "PTSD", "insomnia", "sleep", "epidemiology" and "prevalence". The references of retrieved articles were also searched by hand for additional studies.

The same three researchers independently screened titles and abstracts, and then two of the researchers (YJZ and YJ) read the full texts of relevant articles for eligibility. Inclusion criteria were: 1) studies that examined psychiatric comorbidities during the SARS or COVID-19 epidemics in any subpopulations; 2) studies that reported the prevalence of psychiatric comorbidities or relevant data that could generate the prevalence of psychiatric comorbidities during the SARS or COVID-19 epidemics in any subpopulations, as measured by standardized scales or diagnostic instruments; 3) case-control studies, cross-sectional or cohort studies. Case studies, reviews, systematic reviews, meta-analyses or commentaries were excluded. If more than one article were published using the same dataset, only the one with the most complete information or highest quality assessment score was included. Disagreement was resolved by consensus.

Relevant data were independently extracted by two researchers (YJZ and YJ) using a pre-designed data extraction sheet, including sex, education level, marital status, the first author, publication year, study design, study location, study period, study population, sample size, sampling method, prevalence of specific psychiatric co-morbidities. Disagreement was resolved by consensus, or a discussion with a senior researcher (YTX).

The quality of included studies was evaluated using the Loney's 8-item scale 30 which has been widely used previously 31,32 . This scale assesses the quality of observational studies in eight domains: target population, probability sampling, response rate, non-responders, sample representative of the target population, standardized data collection method, validated criteria for outcomes, and confidence intervals (CI) of the prevalence of target outcomes. The total quality score ranges from 0 to 8, with '7-8' as "high quality", '4-6' as "moderate quality" and '0-3' as "low quality". Two researchers (YJZ and YJ) independently evaluated the study quality, and disagreement was resolved by consensus or a discussion with the senior researcher (YTX).

Data analyses were performed using Comprehensive Meta-Analysis Version 2.0 (CMA V2.0, Biostat Inc., Englewood, New Jersey, USA). I 2 test was used to evaluate heterogeneity between studies, with I 2 > 50% indicating significant heterogeneity. The random-effects model was used in data syntheses due to different demographic characteristics between studies. In SARS related studies, December 31, 2003 was used as the cutoff date to classify acute SARS phase and SARS recovery phase. At least three articles were needed for data synthesis in each phrase. If the number of articles in either SARS phase was less than three, the relevant data in the two phrases were pooled.

Subgroup and meta-regression analyses were conducted to explore moderating effects of categorical (e.g. study population, sex, education level and marital status) and continuous variables (e.g., female percentage and quality assessment score) respectively, on the prevalence of psychiatric comorbidities in COVID-19 patients. Publication bias was examined by funnel plots, Egger's test and Duval and Tweedie trim-and-fill method. Two-tailed tests were conducted with the significance level of 0.05.

A total of 1,793 studies were identified in the literature search, and 82 met the eligibility criteria; of them, 74 studies with available data were included in the meta-analysis. Details of literature search, screening and selection are shown in Figure 1 . Study characteristics are presented in Table 1 . The included studies were conducted across 10 countries or areas including Asia, Europe, North America and South America.

Of the 36 studies on COVID-19, 21 studies reported prevalence of depression during the COVID-19 epidemic and the pooled prevalence of depression was 23.9% Table 2 . and SARS epidemics are shown in Table 3 .

The pooled prevalence of poor mental health in the general population and health professionals during the COVID-19 epidemic was 29.0% (95% CI: 18.1% -43.1%) and 11.6% (95% CI: 9.2% -14.6%), respectively. Subgroup analyses revealed that compared with health professionals, general populations were more likely to have poorer general mental health (Q=10.99, p=0.001). No significant difference was found between health professionals (28.0%, 95% CI: 9.5% -59.0%) and general populations (19.2%, 95% CI: 4.6% -54.2%) in prevalence of PTSS (Q=0.21, p=0.63). The prevalence estimates of depression and anxiety during the COVID-19 were similar between the general population and health professionals (Q=0.01, p=0.91 for depression; Q=0.23, p=0.64 for anxiety). Details of the comparisons are presented in Table 4 . No significant differences were found in prevalence of depression, anxiety, insomnia and PTSS during the COVID-19 epidemic between different sex, between different education levels and between different marital status (all p values > 0.05; Table   5 ).

Meta-regression analyses revealed that the prevalence estimates of depression (r=2.31), stress (r=4.54) and insomnia (r=3.97) were positively and significantly associated with proportion of female participants. Studies with higher quality scores reported higher prevalence of depression (r=0.64), anxiety (r=0.40) and PTSS (r=2.08). Details of meta-regression analyses are shown in Supplementary Table 2 .

A case-control study in Hong Kong reported that the prevalence of depression in pregnant women during the SARS epidemic was 12.3% 33 , while another cross-sectional study in mainland China reported that the prevalence of depression in pregnant women during the COVID-19 epidemic was 29.6% 34 . Two cross-sectional studies conducted in mainland China reported that the prevalence of depression in children and adolescents during the COVID-19 epidemic ranged from 22.6% to 43.7%, and the prevalence of anxiety in children and adolescents during the COVID-19 epidemic ranged from 18.9% to 37.4% 35,36 .

A cross-sectional study conducted in mainland China reported that during the COVID-19 epidemic, parents of children hospitalized for any reason had significantly more severe depression and anxiety than parents of non-hospitalized children (48.0% vs. 8 

Of the 82 included studies, the mean quality assessment score was 4.9, ranging from 3 to 7. Eighty studies are rated as "moderate quality", while one study was rated as "low quality" and one study was rated as "high quality" (Supplementary Table 2 ). Funnel plots are shown in Supplementary Figures 8-15 . A sensitivity analysis using the trim-and-fill method was performed with one imputed study, producing an approximately symmetrical funnel plot (Supplementary Figure 14) . Using the trim-and-fill method, the adjusted pooled prevalence of PTSS was 53.1% (95% CI: 30.2% -74.7%).

To the best of our knowledge, this was the first systematic review that compared the prevalence of psychiatric comorbidities between the SARS and COVID-19 epidemics in an unlimited population. We found that psychiatric comorbidities were common in different subpopulations in both epidemics, and the prevalence estimates of psychiatric comorbidities were similar between both epidemics.

The overall prevalence of depression in all subpopulations studied during the COVID-19 epidemic was 23.9% (95% CI: 18.4%-30.3%) in this systematic review, which is similar to the findings of an earlier meta-analysis (18.9%; 95% CI: 13.0% -26.6%) of depression during the COVID-19 epidemic 25 . We found the overall prevalence of anxiety in all subpopulations studied during the COVID-19 epidemic was 23.4% (95% CI: 19.9% -27.3%), which is significantly lower than the corresponding figure in an earlier meta-analysis (44.5%; 95% CI: 29.8% -60.1%) 25 . The reasons might be that the previous meta-analysis included studies published on or before 6 March 2020 (early stage of the COVID-19 epidemic), and conducted specifically on frontline health professionals, confirmed cases and quarantined populations. Another meta-analysis on COVID-19 patients also found higher prevalence of depression (45%; 95% CI 37% -54%) and anxiety (47%; 95% CI 37% -57%) 23 , probably due to uncertainty about the novel virus, lack of specific treatments and fear of transmission to vulnerable populations 41 . The pooled prevalence of insomnia in this systematic review was 26.5% (95% CI: 19.1% -35.5%), which is comparable with the findings of two earlier meta-analyses (49.8%, 95% CI: 18.6% -81.1% 25 ; and 34%, 95% CI: 19% -50% 23 ). The overall prevalence of stress and PTSS in this systematic review was 14.2% (95% CI: 8.4% -22.9%) and 24.9% (95% CI: 11.0% -46.8%), respectively, both of which are comparable with the corresponding figure in the previous meta-analysis (21.6%; 95% CI:

3.4%-68.1%) conducted in early stage of the COVID-19 epidemic 25 .

We found that the prevalence of depression and anxiety in all subpopulations studied between the SARS and COVID-19 epidemics were similar (Q=0.34, (95% CI: 28.4% -55.1%), respectively 25 . In contrast to the previous study, no significant difference in the prevalence of PTSS between the general population and health professionals was found in this meta-analysis. In the previous study, the prevalence of stress-related symptoms in health professionals (73.4%, 95% CI: 71.1% -75.5%) was higher than in the general population (2.3%, 95% CI: 0.6% -8.7%) 25 . However, the previous study only had one study each on stress-related symptoms in the general population and in health professionals respectively 25 , which could lead to unreliable results.

No gender difference was found in prevalence of depression, anxiety, insomnia and PTSS in all subpopulations studied during the COVID-19 epidemic in this meta-analysis, which is consistent with earlier meta-analyses conducted in COVID-19 patients 23 and health professionals 27 . However, we found that female gender was positively associated with higher risk of depression, stress and

insomnia. An earlier meta-analysis found that female health professionals were more likely to suffer from distress in coronavirus disease epidemics 24 . This may be attributed to hormonal influence in females and the socially sanctioned culture that encourages females to express more emotions than males 48-52 . Marital status and education level did not moderate the prevalence of insomnia in this meta-analysis. As no other meta-analysis examined this potential association, direct comparisons could not be made. We also found that higher quality studies were associated with higher prevalence of depression, anxiety and PTSS. Due to random sampling, large sample size, strict study design and better trained interviewers that were adopted in high quality studies, mental health problems were more likely to be identified compared to lower quality studies 53-55 . 

The study was supported by the National Science and Technology Major Project Notes: I 2 statistic was used to assess the heterogeneity of the studies.

The minimum number of studies required to synthesize data is 3. Studies involving anxiety during SARS were not divided into "acute SARS/recovery SARS" because only 2 studies were conducted during recovery phase of SARS and they didn't reach the minimum number of studies to synthesize data. Studies involving stress, distress, insomnia were not compared between COVID-19 and SARS due to the similar reason. Note: Only the first visit of longitudinal studies was included in order to avoid data duplication.

Studies involving stress, distress, insomnia were not compared between different populations because their numbers of studies in at least one population didn't reach the minimum number of studies to synthesize data. The minimum number of studies required to synthesize data is 3.

Novel Coronavirus -China

Naming the coronavirus disease (COVID-19) and the virus that causes it

Situation Report-10

Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV)

World Health Organization. Severe Acute Respiratory Syndrome (SARS)

World Health Organization. Summary of probable SARS cases with onset of illness from 1

Centers for Diseases Control and Prevention. Severe acute respiratory syndrome (SARS)

The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): A systematic review and meta-analysis of 148 studies from 9 countries

The reproductive number of COVID-19 is higher compared to SARS coronavirus

Epidemiologic, clinical, and laboratory findings of the COVID-19 in the current pandemic: systematic review and meta-analysis

Transmission dynamics of the etiological agent of SARS in Hong Kong: impact of public health interventions

Transmission dynamics and control of severe acute respiratory syndrome

Epidemic of COVID-19 in China and associated Psychological Problems

Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China

A cross-sectional study on mental health among health care workers during the outbreak of Corona Virus Disease

The psychological impact of the COVID-19 epidemic on college students in China

Psychological impact of the 2003 severe acute respiratory syndrome outbreak on health care workers in a medium size regional general hospital in Singapore

Mental health status and its influencing factors among college students during the epidemic of COVID-19 (in Chinese)

Psychological distress of nurses in Taiwan who worked during the outbreak of SARS

Prevalence of self-reported depression and anxiety among pediatric medical staff members during the COVID-19 outbreak in Guiyang, China

Adjustment outcomes in Chinese patients following one-month recovery from severe acute respiratory syndrome in Hong Kong

A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak

Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital

Epidemiological Aspects and Psychological Reactions to COVID-19 of Dental Practitioners in the Northern Italy Districts of Modena and Reggio Emilia

Survey on Mental Status of Subjects Recovered from SARS (in Chinese)

Mental health problems and social media exposure during COVID-19 outbreak

Posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: A 4-year follow-up study

Mental health survey of medical staff in a tertiary infectious disease hospital for COVID-19 (in Chinese)

Chinese mental health burden during the COVID-19 pandemic

Psychosocial impact among the public of the severe acute respiratory syndrome epidemic in Taiwan

Quality of life and psychological status in survivors of severe acute respiratory syndrome at 3 months postdischarge

Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease

Mental morbidities and chronic fatigue in severe acute respiratory syndrome survivors long-term follow-up

Prevalence of psychiatric disorders among Toronto hospital workers one to two years after the SARS outbreak

Positive mental health-related impacts of the SARS epidemic on the general public in Hong Kong and their associations with other negative impacts

Stress and psychological distress among SARS survivors 1 year after the outbreak

Comparison of Prevalence and Associated Factors of Anxiety and Depression Among People Affected by versus People Unaffected by Quarantine During the COVID-9 Epidemic in Southwestern China

Prevalence, risk factors, and clinical correlates of insomnia in volunteer and at home medical staff during the COVID-19

Psychological distress among health professional students during the COVID-19 outbreak

The Effect of COVID-19 on Youth Mental Health

The prevalence and influencing factors in anxiety in medical workers fighting COVID-19 in China: A cross-sectional survey

Prevalence and predictors of PTSS during COVID-19 outbreak in China hardest-hit areas: Gender differences matter

Depression after exposure to stressful events: Lessons learned from the severe acute respiratory syndrome epidemic

The mental health status of students from three universities in Beijing and its associative factors during SARS epidemic (in Chinese)

Perceived stress in general public during prevalence of severe acute respiratory syndrome and its impact on health behavior (in Chinese)

Psychological status of medical workforce during the COVID-19 pandemic: A cross-sectional study

The mental health of hospital workers dealing with severe acute respiratory syndrome

Mental Symptoms in Different Health Professionals During the SARS Attack: A Follow-up Study

Long-term psychiatric morbidities among SARS survivors

Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak

A Nationwide Survey of Psychological Distress among Italian People during the COVID-19 Pandemic: Immediate Psychological Responses and Associated Factors

Predictive factors of psychological disorder development during recovery following SARS outbreak

Mental Health, Risk Factors, and Social Media Use During the COVID-19 Epidemic and Cordon Sanitaire Among the Community and Health Professionals in Wuhan, China: Cross-Sectional Survey

Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution

Stress, anxiety, and depression levels in the initial stage of the COVID-19 outbreak in a population sample in the northern Spain

Population-based post-crisis psychological distress: An example from the SARS outbreak in Taiwan

Understanding, compliance and psychological impact of the SARS quarantine experience

COVID-19 Factors and Psychological Factors Associated with Elevated Psychological Distress among Dentists and Dental Hygienists in Israel

Severe acute respiratory syndrome-related psychiatric and posttraumatic morbidities and coping responses in medical staff within a primary health care setting in Singapore

Wen Soon S. Psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease

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

Is returning to work during the COVID-19 pandemic stressful? A study on immediate mental health status and psychoneuroimmunity prevention measures of Chinese workforce

Prevalence and correlates of PTSD and depressive symptoms one month after the outbreak of the COVID-19 epidemic in a sample of home-quarantined Chinese university students

Psychiatric morbidity among emergency department doctors and nurses after the SARS outbreak

The change of health related behavior during and after severe acute respiratory syndrome prevalence (in Chinese)

Psychological symptoms of ordinary Chinese citizens based on SCL-90 during the level I emergency response to COVID-19

Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) Epidemic among the General Population in China

Sleep disturbances among medical workers during the outbreak of COVID-2019

Analysis of Psychological and Sleep Status and Exercise Rehabilitation of Front-Line Clinical Staff in the Fight Against COVID-19 in China

Posttraumatic Stress Symptoms of Health Care Workers during the Corona Virus Disease 2019 (COVID-19)

Survey of Insomnia and Related Social Psychological Factors Among Medical Staff Involved in the 2019 Novel Coronavirus Disease Outbreak

Controlled study of posttraumatic stress disorder among patients with severe acute respiratory syndrome and first-line hospital staffs as well as public in prevalent areas (in Chinese)

Mental Health and Psychosocial Problems of Medical Health Workers during the COVID-19 Epidemic in China

Impact of the COVID-19 Pandemic on Mental Health and Quality of Life among Local Residents in Liaoning Province, China: A Cross-Sectional Study

Prevalence and Influencing Factors of Anxiety and Depression Symptoms in the First-Line Medical Staff Fighting Against COVID-19 in Gansu

The immediate mental health impacts of the COVID-19 pandemic among people with or without quarantine managements

Analysis on SARS-related post-traumatic stress disorder and its correlative factors (in Chinese)

The mental health status of community population in Hefei city during SARS epidemic (in Chinese)

SARS-related cognitive behavior and mental health survey in residents from Wuhan city (in Chinese)

The depressive, anxious and somatic symptoms in COVID-19 patients

A follow-up study on post-traumatic stress disorder in SARS patients

A follow-up study on depressive and anxious symptoms of convalescent SARS patients in one hospital (in Chinese)

The correlation analysis on illness state, steroids application and convalescent mental status in SARS-infected health professionals (in Chinese)

Psychological distress and negative appraisals in survivors of severe acute respiratory syndrome (SARS)

Posttraumatic stress after SARS

None.

There is no conflict of interest related to the topic of this manuscript.