key: cord-0770272-8d0wq524 authors: Cooke, Jessica E.; Eirich, Rachel; Racine, Nicole; Madigan, Assistant Professor Sheri title: Prevalence of Posttraumatic and General Psychological Stress during COVID:19: A Rapid Review and Meta-Analysis date: 2020-07-31 journal: Psychiatry Res DOI: 10.1016/j.psychres.2020.113347 sha: d9f1643ac47f1aff1f1d7deae022f821d9dc3edf doc_id: 770272 cord_uid: 8d0wq524 Emerging evidence suggests rates of posttraumatic stress and psychological stress in the general population are elevated due to COVID-19. However, a meta-analysis is needed to attain more precise prevalence estimates due to between study variability. Thus, we performed a rapid review and meta-analysis of posttraumatic stress and general psychological stress symptoms during COVID-19. Electronic searches were conducted up to May 26(th), 2020 using key terms: mental illness and COVID-19. A total of k = 14 non-overlapping studies were identified for inclusion. Random effects meta-analyses indicated that the pooled prevalence of posttraumatic stress symptoms and psychological stress in the general population was 23.88% and 24.84%, respectively. In both meta-analyses, the prevalence of stress symptoms was higher in unpublished compared to peer-reviewed studies. Overall, nearly one-in-four adults experienced significant stress due to the COVID-19 pandemic. Psychological resources and services must be allocated to help address the mental health burden of COVID-19. High quality, longitudinal research on the long-term mental health effects of the pandemic is greatly needed. On March 11 th , 2020, the novel coronavirus disease was declared a global pandemic, instantiating physical distancing and quarantine orders to mitigate its rapid transmission. Past studies have documented the effects of infectious outbreaks and subsequent quarantine orders, on both posttraumatic stress disturbance (Hawryluck et al., 2004) and psychological stress (Brooks et al., 2020; Lau et al., 2005) experienced in the general population. In addition to psychosocial stressors, such as financial strain and isolation , COVID-19 may also increase stress due to fear of infection to oneself or loved ones . Altogether, the uncontrollability and unpredictability of COIVD-19 has likely led to extraordinary stress in the general population. Emerging literature indicates stress reactions are occurring in response to COVID-19 (e.g., Wang et al., 2020) , however, prevalence estimates vary widely. The prevalence of posttraumatic and general stress disturbance may be attenuated or amplified by demographic (e.g., age, sex) or methodological variables (publication status). In order to guide policy-decisions regarding where to allocate psychological resource and to determine who may be in most need of services, meta-analytic estimates of posttraumatic and psychological stress due to COVID-19 are needed. The purpose of this rapid review and meta-analysis was to attain more precise estimates of general and posttraumatic stress symptoms experienced in population-based samples during COVID-19. We examine posttraumatic and general stress symptoms separately to distinguish symptoms specific to traumatic events (e.g., intrusion, avoidance) and experiences of stress (e.g., difficulty relaxing, nervous arousal) non-specific to events. We also examine factors that may explain between-study variation in prevalence estimates. This information was extracted from included studies: (1) brief 6-point study quality assessment (available from authors upon request); (2) participant age; (3) % female in sample; (4) geographical region; (5) type of stress measure (posttraumatic or psychological); and (6) prevalence data. Random agreement probabilities of extracted articles (20%) ranged from .73-1.00. Discrepancies were resolved among coders. Random effects meta-analyses were performed in Comprehensive Meta-Analysis Software (CMA, 3.0; Borenstein et al., 2009 ) to obtain pooled prevalence estimates, which give greater weight to studies with larger sample sizes, with associated 95% confidence intervals (CIs). Extreme cases were identified via box plot inspections in SPSS. Between-study heterogeneity was examined with Q-and I 2 -statistics (Higgins et al., 2003) . Categorical and continuous moderators were explored using group and meta-regression analysis, respectively. Publication bias was examined via inspection of funnel plots. Statistical significance was set at p < .05. In total, 3,405 non-duplicated abstracts were identified, 175 full-text articles were reviewed, and k = 14 non-overlapping studies (N = 21,744 participants) were identified for inclusion. No extreme cases were found. On average, participants were 29.47 years of age and 54.39% were female. All studies were cross-sectional and used self-reports of stress symptoms. The mean study quality was 3.07/6.0 (range = 2.00 to 4.00; see Table 1 for full description of study characteristics). The pooled prevalence of posttraumatic stress symptoms (k = 8) was 23.88% (95% CI: Results from the current meta-analysis document high levels of both posttraumatic (26.2%) and psychological (23.1%) stress associated with COVID-19. Although prevalence estimates were lower in peer-reviewed compared to unpublished studies, findings suggested approximately 1-in-4 adults require mental health services during the ongoing pandemic. While elevations in stress during a global pandemic are to be expected, the long-term implications of these elevations are cause for concern. Specifically, decades of research suggest elevations in overall stress are risk factors or precipitants for the onset of comorbid mental health difficulties such as anxiety, depression, or substance use (Conde et al., 2019) . Exposure to stress over time can also lead to accelerated disease processes and the exacerbation of chronic health conditions, further inflating healthcare costs (McEwen, 2000) . All told, the broader implications of large increases in stress during COVID-19 at a population level are significant and will require government and policy changes to help reduce stress, such as income supplements, childcare, and development of broadly available prevention and intervention programs that promote stressreduction strategies such as healthy eating, physical activity, and good sleep habits. Due to the rapidly evolving nature of COVID-19, the research presented in this rapid review is preliminary in nature and represents a snapshot of stress levels in the months immediately following the pandemic. Most studies to date have reported on cross-sectional data and without representative samples. Publication status moderated effect sizes. Methodological rigor is critical to adequately inform policy, practice, and public dialogue. Longitudinal studies are necessary to determine whether these elevations in stress are sustained, reduced, or exacerbated over time (Pierce et al., 2020) . Furthermore, studies from different geographic areas with varying severity of exposure to the disease, as well as differences in mitigative strategies (e.g., lockdown, school closures), are needed. Author contributions: NR and SM designed the search strategy with input from JC and RE. SM, NR, JC, and RE completed the literature search and screening. JC, RE, and NR performed data extraction. JC, RE, NR, and SM contributed to writing the manuscript, reviewing the manuscript with content expertise, and providing critical feedback. Note. PTS = posttraumatic stress symptoms. GS = general stress symptoms. 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The significance of sampling in mental health surveys during COVID-19 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 Estimating population prevalance of posttraumatic stress disorder: An example using the PTSD Checklist Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population 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 We would like to acknowledge Nicole Dunnewold, MLIS, from the NR and SM designed the search strategy with input from JC and RE. SM, NR, JC, and RE completed the literature search and screening. JC, RE, and NR performed data extraction. SM conducted analyses. JC, RE, NR, and SM contributed to writing the manuscript, reviewing the manuscript with content expertise, and providing critical feedback. ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: