Understanding the mental health impacts of COVID-19 through a trauma lens

A Global Call for Action to Prioritize Healthcare Worker Suicide Prevention During the COVID-19 Pandemic and Beyond.

The aim of this study was to confirm and extend the authors' previous work indicating that symptoms of traumatic grief are predictors of future physical and mental health outcomes. The study group consisted of 150 future widows and widowers interviewed at the time of their spouse's hospital admission and at 6-week and 6-, 13-, and 25- month follow-ups. Traumatic grief was measured with a modified version of the Grief Measurement Scale. Mental and physical health outcomes were assessed by self-report and interviewer evaluation. Survival analysis and linear and logistic regressions were used to determine the risk for adverse mental and physical health outcomes posed by traumatic grief. Survival and regression analyses indicated that the presence of traumatic grief symptoms approximately 6 months after the death of the spouse predicted such negative health outcomes as cancer, heart trouble, high blood pressure, suicidal ideation, and changes in eating habits at 13- or 25-month follow-up. The results suggest that it may not be the stress of bereavement, per se, that puts individuals at risk for long-term mental and physical health impairments and adverse health behaviors. Rather, it appears that psychiatric sequelae such as traumatic grief are of critical importance in determining which bereaved individuals will be at risk for long-term dysfunction.

This Special Issue of the European Journal of Psychotraumatology (EJPT) presents 51 articles published between 2021 and 2023 and follows the Special Issue on pandemic-related traumatic stress research published in 2021 (O'Donnell, M. L., & Greene, T. [2021]. Understanding the mental health impacts of COVID-19 through a trauma lens. European Journal of Psychotraumatology, 12(1), 1982502). Research on traumatic stress during the pandemic has cast the spotlight on vulnerable populations and groups, notably front-line healthcare workers; people faced with major losses including the deaths of loved ones; those who personally survived debilitating and often life-threatening viral infection; and students who were isolated and experienced profound delays in their education, relationships, and emerging independence. The papers in this collection underscore the associations between COVID-19 related stressors and a plethora of adverse mental health sequelae, including posttraumatic stress reactions, and draw attention to the ubiquity of grief and moral injury and their wide-ranging and detrimental impact. Currently, there is a paucity of evidence on interventions to enhance resources, self-efficacy, and hope for affected groups and individuals through societal, organisational, and healthcare systems; however early research on the prevention of COVID-related traumatic stress disorders provides a basis for both hope and preparedness for the future.

The Complexity of Complex PTSD

Distressing and intrusive reexperiencing of the trauma is a hallmark symptom of posttraumatic stress disorder (PTSD; American Psychiatric Association, 1994). However, unwanted memories of trauma are not a sign of pathology per se. In the initial weeks after a traumatic experience, intrusive memories are common. For most trauma survivors, intrusions become less frequent and distressing over time. A central question for understanding and treating patients with PTSD is therefore what maintains distressing intrusive reexperiencing in these people. Three factors appear to be important: (1) memory processes responsible for the easy triggering of intrusive memories, (2) the individuals’ interpretations of their trauma memories, and (3) their cognitive and behavioral responses to trauma memories.

The authors' objective was to explore aspects of trauma associated with severity of posttraumatic stress disorder (PTSD) in Vietnam veterans. Several ratings of stress exposure and symptom severity were administered to 40 patients with combat-related PTSD. A significant relationship was observed between exposure to atrocities and the impact of PTSD on veterans' lives, as measured by the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder. Exposure to atrocities was also significantly correlated with current symptom severity. In contrast, combat exposure alone was not significantly associated with overall symptom severity. Both atrocity and combat exposure, however, were significantly related to reexperiencing symptoms. The data suggest that the enduring effect and severity of PTSD symptoms on an individual are associated more with exposure to brutal human death and suffering than the threat of death associated with combat.

Moral injury is an emerging concept that captures the psychosocial consequences of involvement in and exposure to morally transgressive events. In the past decade, research on moral injury has grown exponentially. In this special collection we review papers on moral injury published in the European Journal of Psychotraumatology from its inception until December 2022, that have a primary focus on moral injury as evidenced by the words ‘moral injury’ in the title or abstract. We included 19 papers on quantitative (n = 9) and qualitative (n = 5) studies of different populations including (former) military personnel (n = 9), healthcare workers (n = 4) and refugees (n = 2). Most papers (n = 15) focused on the occurrence of potentially morally injurious experiences (PMIEs), moral injury and associated factors, while four papers primarily concerned treatment. Together, the papers offer a fascinating overview of aspects of moral injury in different populations. Research is clearly widening from military personnel to other populations such as healthcare workers and refugees. Focal points included the impact of PMIEs involving children, the association of PMIEs and personal childhood victimisation, the prevalence of betrayal trauma, and the relationship between moral injury and empathy. As for treatment, points of interest included new treatment initiatives as well as findings that PMIE exposure does not impede help-seeking behaviour and response to PTSD treatment. We further discuss the wide range of phenomena that fall under moral injury definitions, the limited diversity of the moral injury literature, and the clinical utility of the moral injury construct. From conceptualisation to clinical utility and treatment, the concept of moral injury matures. Whether or not moral injury becomes a formal diagnosis, the need to examine tailored interventions to alleviate moral injury is clear.

The purpose of this study was to examine factors predicting the development of posttraumatic stress symptoms after a traumatic event, the 1991 Oakland/Berkeley firestorm. The major predictive factors of interest were dissociative, anxiety, and loss of personal autonomy symptoms reported in the immediate aftermath of the fire; contact with the fire; and life stressors before and after the fire. Subjects were recruited from several sources so that they would vary in their extent of contact with the fire. Of 187 participants who completed self-report measures about their experiences in the aftermath of the firestorm, 154 completed a follow-up assessment. Of these 154 subjects, 97% completed the follow-up questionnaires 7-9 months after the fire. The questionnaires included measures of posttraumatic stress and life events since the fire. Dissociative and loss of personal autonomy symptoms experienced in the fire's immediate aftermath, as well as stressful life experiences occurring later, significantly predicted posttraumatic stress symptoms measured 7-9 months after the firestorm by a civilian version of the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder and the Impact of Event Scale. Dissociative symptoms more strongly predicted posttraumatic symptoms than did anxiety and loss of personal autonomy symptoms. Intrusive thinking differs from other kinds of posttraumatic symptoms in being related directly to the trauma and previous stressful life events. These findings suggest that dissociative symptoms experienced in the immediate aftermath of a traumatic experience and subsequent stressful experiences are indicative of risk for the later development of posttraumatic stress symptoms. Such measures may be useful as screening procedures for identifying those most likely to need clinical care to help them work through their reactions to the traumatic event and to subsequent stressful experiences.

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Seventeen definitions of the severely and persistently mentally ill have appeared in the literature over the past decade. These definitions have been used by 13 authors to formulate service programs and to estimate the prevalence of serious mental illness in the population. To test the applicability of these definitions, the authors operationalized each definition and applied it to a representative sample of 222 patients receiving services in one of Philadelphia's inner-city neighborhoods. The analysis showed estimates of prevalence of serious mental illness ranging from 4% to 88% of the treated population, depending on the definition applied. The NIMH (1987) definition was representative of the middle-range estimates of 45% to 55% arrived at by eight authors.

Moral injury: the effect on mental health and implications for treatment

This study sought to determine whether a set of symptoms interpreted as complicated grief could be identified and distinguished from bereavement-related depression and whether the presence of complicated grief would predict enduring functional impairments. Data were derived from a study group of 82 recently widowed elderly individuals recruited for an investigation of physiological changes in bereaved persons. Baseline data were collected 3-6 months after the deaths of the subjects' spouses, and follow-up data were collected from 56 of the subjects 18 months after the baseline assessments. Candidate items for assessing complicated grief came from a variety of scales used to evaluate emotional functioning (e.g., the Hamilton Depression Rating Scale, the Brief Symptom Inventory). The outcome variables measured were global functioning, medical illness burden, sleep, mood, self-esteem, and anxiety. A principal-components analysis conducted on intake data (N = 82) revealed a complicated grief factor and a bereavement-depression factor. Seven symptoms constituted complicated grief: searching, yearning, preoccupation with thoughts of the deceased, crying, disbelief regarding the death, feeling stunned by the death, and lack of acceptance of the death. Baseline complicated grief scores were significantly associated with impairments in global functioning, mood, sleep, and self-esteem in the 56 subjects available for follow-up. The symptoms of complicated grief may be distinct from depressive symptoms and appear to be associated with enduring functional impairments. The symptoms of complicated grief, therefore, appear to define a unique disorder deserving of specialized treatment.

Moral injury (MI) and post-traumatic growth (PTG) are critical psychological outcomes for healthcare workers who are frequently exposed to ethically challenging and traumatic situations. Thriving from work (TFW), characterized by vitality and learning at work, is proposed as a key contextual resource linking these constructs. The current cross-sectional study examined the mediating role of TFW in the relationship between MI and PTG among 4685 Chinese healthcare workers with an overall response rate of 36%. Measures included the Moral Injury Symptoms Scale-Health Professional (MISS-HP), Posttraumatic Growth Inventory-Short Form (PTGI-SF), and Thriving from Work Questionnaire (TFWQ). Correlation and mediation analyses revealed that TFW fully mediated the MI-PTG relationship, accounting for 91.67% of the total effect. MI negatively affected PTG by impairing TFW, while greater TFW reduced MI's adverse effects on PTG. These findings help to explain how healthcare professionals adapt to trauma in healthcare settings and suggest practical pathways to help safeguard healthcare workers' mental health through organizational and individual interventions targeting TFW.

A subpopulation of chronically mentally ill patients, sometimes referred to as "revolving door" patients, are frequently readmitted to psychiatric units. This study examined the relationships among demographic features, diagnostic characteristics, and frequency of hospitalization of patients from four state hospitals. Two semistructured, standardized instruments, the Schedule for Affective Disorders and Schizophrenia and a life events history, were administered to 135 inpatients who met the Research Diagnostic Criteria for schizophrenia (N = 56), schizoaffective disorder (N = 33), unipolar major depressive disorder (N = 23), and bipolar disorder (N = 23). Criminal history was assessed by arrest records. The main outcome measure was the number of hospitalizations. Chi-square and trend test analyses indicated that substance abuse and noncompliance with medication regimens were significantly associated with higher frequencies of hospitalization. A multiple regression model, which included alcohol/drug problems, medication noncompliance, and six sociodemographic and diagnostic variables (age, gender, race, marital status, years of education, and diagnosis) accounted for a significant proportion of the ability to predict frequency of hospitalization. Half of this predictability was due to the relationship of substance abuse and medication noncompliance with number of hospitalizations. Alcohol/drug problems and noncompliance with medication were the most important factors related to frequency of hospitalization. Preventing these behaviors through patient education may reduce rehospitalization rates.

The authors evaluated changes in symptoms and levels of perceived distress of 21 Cambodian, 13 Hmong/Laotian, and 18 Vietnamese patients before and after a 6-month treatment period. Most of the patients improved significantly. Cambodians had the greatest and Hmong/Laotians had the least reductions in depressive symptoms. Although psychological symptoms improved, many somatic symptoms worsened. The authors conclude that refugee survivors of multiple traumata and torture can be aided by psychiatric care. They recommend investigations with larger samples and suitable control groups to further clarify the relative contributions of trauma, diagnosis, and acculturation stress to treatment outcome.