The Role of Post-Traumatic Stress Symptoms and Psychological Distress on Quality of Life of COVID-19 Survivors

Masha Asad Khan*, Hafiza Ayesha Siddiqa, & Zara Haroon

Kinnaird College for Women, Lahore.

This study aims to examine connection of posttraumatic stress symptoms, psychological distress, and quality of life in Covid-19 survivors. Participants were N=120 Corona survivors (MA = 29.03; SD = 10), where 56.7 % were males and 43.3% were females from Lahore, Pakistan. In order to gather data, Depression Anxiety and Stress Scale (DASS), PTSD Checklist for DSM-5, World Health Organizations Quality of Life, and Demographic form were administered. Correlation research design was employed. Data was analyzed using Pearson Coefficient and Multiple Linear Regression. Results indicated moderate to severe depression, anxiety and distress symptoms, 53.3%, 56.6% and 39.1% respectively. Moreover, common symptoms reported by survivors included fever (68.3%), dry cough (54.2%), headache (49.2%), loss of sense of smell (39.2%) and taste (37.5%). Results revealed a significant relation between the study variables, whereas psychological distress and post-traumatic stress symptoms significantly predicted lower quality of life. The findings of the present study have implications for psychologists, psychiatrists, mental health professionals and social workers the results also provide concrete bases in forming and implementing mental health intervention policies to cope with post Covid-19 challenges effectively. The psychological interventions and mental health strategies provide psychological support that may elevate mental well-being, and quality of life and better coping strategies.

Keywords: psychological distress; post-traumatic stress; quality of life; Covid-19

Covid-19 has been declared as a pandemic by World Health Organization [WHO, (2020)] after its widespread around the globe. Historically, pandemics and epidemic diseases have always adversely affected masses all around the globe leaving aftershocks in terms of changes in people’s lives, lifestyles, health, economies etc. (Rehman et al., 2020). Covid-19 was first identified in Wuhan, Hubei, China in the last month of 2019. It includes the set of atypical warning signs ranging from mild to moderate symptoms of cough, cold, fever, body aches and pain, breathing problems, leading to pneumonia, severe respiratory failure and ultimately to death (Haleem et al., 2020).

Psychological distress (PD) is classified broadly as manifestation of issues related to mental health which predominantly include depression, anxiety, and stress. PD is an unpleasant emotion or feeling that has adverse effects on person’s general life functioning and which gives rise to certain negative feelings related to self, others and his/her environment (Arvidsdotter et al., 2016). A research in Karachi suggested that the majority of the participants experienced moderate to extreme levels of depression, anxiety and stress (Sandesh et al., 2020). During Covid-19 pandemic, people vulnerable to develop psychological distress may include persons infected with Covid-19, and who are socially isolated in quarantine. Being isolated is known to have detrimental effects on mental health (Leigh-Hunt et al., 2017). Furthermore, presence of general psychopathological symptoms also has an adverse influence on individual’s life quality. Quality of Life (QoL) is demarcated as the phenomenon which is influenced by certain factors such as personal psychological well-being, environmental factors like interactions with environment, emotional well-being and social functioning. It is a measure of how individual’s interactions affect overall wellbeing and satisfaction which includes physical health, mental functioning, and religious beliefs, financial status, and social support etc. (Herrman & Chopra, 2009).

It is found that people who live during the pandemics and epidemics have significantly a lower quality of life (Chen et al., 2020). A research executed by Tansey et al. (2007) revealed that the majority patients who survived SARS, experienced a significant decline in their quality of lives.

In literature, it is known that people who went through such health-related emergencies also developed the symptoms of post-traumatic stress disorder, PTSD (Brooks et al., 2018). During SARS outbreak, many survivors experienced prolonged psychological distress that led to trauma related symptoms ultimately leading to the diagnosis of PTSD (Wu et al., 2009; Mak et al., 2009). PTSD is described as a psychological disorder that may befall after individuals have gone through any traumatic experience(s) directly or indirectly (Haleem et al., 2020). Traumatic experience can also be defined as being diseased in a corporeal ailment that can be life menacing.

Pakistan, like all developing countries has high poverty proportion. Due to forced closure of businesses, many individuals were compromised financially, forcing them to continue with the basic necessities of lives. This strain in their economic status might result in being a major reason causing negative impact on their quality of lives (Haleem et al., 2020). Bo et al. (2020) research found out that the majority of sample experienced post-traumatic stress symptoms and psychological distress before their discharge from the isolation/quarantine that had detrimental impact on their quality of life.

Rehman et al. (2020) performed a cross-sectional research in India with the aim to find PD in general population in times on Covid-19. Sample included 403 participants (females = 291, males = 110) with the mean age of 28.95 years. Participants were administered DASS and Family Affluence Scale (FAS). Statistical analyses included Pearson Correlation, t-test, and ANOVA. Results indicated that stress, anxiety, and depression were negatively correlated with family affluence. It was also concluded that healthcare professionals (doctors and nurses) and students were more liable to depression, anxiety, and stress in comparison to rest of the sample. Further, Samlani et al. (2020) conducted a cross sectional research in Morocco with the aim of finding the impression of Covid-19 on well-being and QoL on general population. The total number of participants were 279 (males = 277, females = 135, M.A=34.75, SD=11.8). Participants were administered SF-12 to ascertain QoL. Results of t student test showed that participant’s physical quality of life (mean = 36.10, SD = 5.82) was more disrupted than mental well-being (Mean = 34.49, SD = 6.44).

Kugler et al. (2016) conducted a cross sectional research with an aim to find the role of anxiety in the relationship between PTSS and QoL. Participants included 120 trauma exposed adults with the mean age of 23.84 years (SD = 6.84), where 68.9% were females and 31.1% were males. Participants were administered the PCL-Civilian, WHOQOL-BREF, DASS- 21, The Trauma History Questionnaire-Short, Sheehan Disability Scale, the Anxiety Sensitivity Index-3, and the Economic Impact Questionnaire-Revised. Results of Pearson Correlation found significant negative relationship of PTSS with domains of QOL i.e. social (r = -0.31, p< 0.01), physical (r = -0.28, p< 0.01), psychological (r = -0.42, p< 0.01), and environmental (r = -0.24, p< 0.01). Mediation analysis found that anxiety sensitivity mediated the relationship of PTSS and physical health of quality of life.

Literature review findings generally show that Covid-19 leaves negative impacts such as psychological distress, post-traumatic stress symptoms, and QoL in people who are directly or indirectly exposed to the virus. Pandemics not only affect the people of its origin, but people from around the globe also become affected. It has been seen in previous research that following the pandemics and/or epidemics people experience depression, stress, anxiety, PTSD symptoms etc. (Beaglehole et al., 2018; Park et al., 2020). The current pandemic has also already created a lot of disturbance in the lives of people around the globe. The conditions, where people are facing Covid-19 pandemic are those of uncertainty related to vaccination, fear and worry of the future, and may make people more prone to psychological distress. With the prolonged preventative measures in the form of lock down and social distancing, along with depression and anxiety, there is also a considerable upsurge in loneliness, anger, domestic violence, child abuse, depression, anxiety and PTSS. These psychological changes likewise influence the life style individuals, hence impacting the quality of life. All of the mentioned factors call for the need to study the effect of Covid-19 on people’s mental health and quality of life. In our country Pakistan, mental health is already given less attention. This study has implications for psychologists, psychiatrists, mental health practitioners, social workers and policy makers where the results would provide a concrete bases for forming and implementing of relevant mental health psychosocial intervention policies to cope with post Covid-19 challenges effectively and efficiently.

Method

Correlational research design was used in the present research in order to find the relationship between PD, PTSS, and QoL in Covid-19 survivor patients. With help of this research design the strength of association among the mentioned variable can be assessed (Wang, 2015). Data was collected from N=120 participants who survived Covid-19 from Lahore, Pakistan. The purposive and convenience sampling strategy was useful in collecting sample which included 56.7 % males (n = 68) and 43.3% females (n = 52). Their ages ranged between 18-59 years with the mean age 29.03 years (SD = 10.00). Mean days of isolation were13.84 days (SD =7.88) where they took 15.37 days (SD = 9.91) to recover fully. Participant with physical disability or any preexisting medical conditions were excluded from the study.

Assessment Measures

Depression, Anxiety and Stress Scale

Depression, Anxiety and Stress Scale (DASS) was selected to measure PD. Scale has 21 statements with response on a 4 point likert scale where 0 means “Did not apply to me at all (never)”, to 3 means “Applied to me very much, or most of the time (almost always)”. Final scores are labeled according to their severity levels. The cut-off scores of depression, anxiety and stress are 9, 7 and 14 respectively. Psychometric properties of the scale is well defined [(α=0.84- 0.91), Lovibond & Lovibond, 1996].

PTSD Checklist for DSM-5

The PTSD Checklist for DSM-5 was employed to find the post-traumatic stress symptoms of participants (Weathers et al., 2013). It includes 20 items to be scored using 5 point Likert scale where 0 means “Not at all’ and 5 means “Extremely”. Maximum score is 80, where higher score with the cut off of above 30 indicates more serious symptomatology of PTSD that requires clinical attention. The psychometric properties of the scale are well defined [(α=0.94), Blevins, Weathers, Davis, Witte, & Domino, 2015].

World Health Organization Quality of Life

This self-reported questionnaire in includes total of 26 items that are arranged into four different domains which cover the areas of physical health, psychological wellbeing, socialization and environmental health. The Likert scale has the range of score of each item between 1 and 5; higher score in each domain means higher quality of life. Cronbach’s alpha values of four domains ranged between 0.66-0.94 (Whoqol Group, 1998).

Demographic Form

A self-developed form was administered to gather demographic data of participants i.e. age, symptoms, presentations, recovery time, and impact on income etc.

Procedure

First of all, permission was sought by email from the authors of the mentioned tools and instruments to use the tools in the study. Then after getting the permission from the Institutional Board Review of Kinnaird College for Women; pilot study was conducted with 20 participants in order to assess any potential problem during data collection. For online data collection, Google form was shared containing all the measures and instruments and electronic participation consent was obtained. Partakers were briefed about the aim of the study; written consent was obtained from Covid-19 survivors who accomplished the inclusion criteria. Participants were administered Demographic Form, DASS, PCL-5 and WHOQOL-BREF, respectively. Permission was taken from the authors for using scales in this research. Aim of research was elucidated to the participants also written consent was taken. Participants were assured about the safety of the provided information and they were told that participation is voluntary and they can leave research at any time. Assurance was provided to the participants that the study would not do any physical or psychological harm.

Statistical Analyses

To find out the relationship between study variables Pearson Product Moment Coefficient of Correlation was used. In order to find the prediction, multiple linear regression analyses were used (SPSS; Pallant, 2013). Reliability analysis was done for finding psychometric properties of the tools. Pictorial depiction of data was done using bar chart.

Results

Table 1

Psychometric Properties of Study Variables calculated from the present data (N=120)

Note. PD = Psychological Distress, QOL = Quality of Life, k = Total no. of Items,

Table 1 shows sound psychometric properties where strong level of Cronbach’s alpha value is observed. By looking at the values of skewness and kurtosis it can also be seen that the distribution of sample data is free of significant skewness and kurtosis as values fall between the acceptable ranges of ± 0.96, indicating that the distribution is approximately normal.

Table 2

Frequency Distribution of Symptoms Severity of Depression, Anxiety and Stress (N=120)

Table 2 shows that 20.8 % and 12.5 % people experienced severe and extremely severe levels of depression respectively. Whereas, among participants only 13.3 % experienced severe and 35.8 % of participants shows extremely severe levels of anxiety. 15% participants showed severe stress and 5.8 % of participants experienced extremely severe stress levels.

Table 3

Shows cutoff of people on PCL-5 (N=120).

Table 4

Pearson Product Moment Coefficient of Correlation between Post-Traumatic Stress Symptoms, Psychological Distress and Quality of Life in Covid-19 Survivors (N = 120)

Note. M=Mean; SD=Standard Deviation; PTSS=Post-Traumatic Stress Symptoms; QoL=Quality of Life; Ph-QoL=Physical Health-Quality of Life; Env-QoL=Environmental Quality of Life.

*p<0.05; **p<0.01

Table 4 shows the results of Pearson Product Moment Coefficient of Correlation between PTSS, PD and QoL in Covid-19 survivors. Results shows a strong positive correlation between PTSS and all of the domains of PD (depression, anxiety & stress) which means that people who suffer more from psychological distress also suffers from PTSS. Both variables show negative relation with domains of quality of life which means that people who are more psychologically distress and experience greater symptoms of PTSD experience low QoL and vice versa during COVID-19.

Table 5

Multiple Linear Regression between Post-Traumatic Stress Symptoms, Psychological and Quality of Life in Covid-19 Survivors (N = 120)

Note. QOL = Quality of life, B = Unstandardized Regression Coefficient, β = Standardized Regression Coefficient, SE = Standard Error for Beta, * = p < 0.05, ** = p<0.01.

Results of table 4 reveal the result of multiple linear regressions. Negative values of standardized regression coefficient show inverse direction between two variables. It was found that PD and PTSS inversely predicted QoL. Where, participants who had the symptoms of depression, anxiety, stress and PTSS, had negative and poor physical, psychological, and social quality of life. Moreover, post-traumatic stress symptoms, depression and stress also predicted poor environment and quality of life during COVID-19.

Discussion

The purpose of present research was to find relationship between psychological distress, post-traumatic stress symptoms, and quality of life in Covid-19 survivors. Another purpose was to find the role of PD and PTSS in predicting the quality of life of participants. Additionally, this research also aimed at finding the prevalence of psychological distress and post-traumatic stress symptoms in Covid-19 survivors.

Socio-demographic analyses showed that the majority of the survivors were males which is in accord with existing literature (Sharif et al., 2020; Khan et al., 2020; Shehryar et al., 2020). In Pakistani society, men being the breadwinner of the family and have the responsibility to go out and work in order to support the family; hence they are more exposed to the virus whereas, females having the role of a homemaker are not directly exposed. Additionally, the present research also highlighted that other than males, sample had the mean age of 29.03 years and most of them had graduation and above qualification, also takes up the workforce in Pakistani households. Most dominant clinical presentations of Covid-19 among participants included fever (68.3 %), dry cough (54.2%), headache (49.2 %), lost sense of smell (39.2 %) and taste (37.5%). Research carried out by Sharif et al., (2020) found similar trends of clinical presentations among their participants.

The present research contributes to the literature where the incidence of depression, anxiety and stress symptoms were also observed, and overall participants showed moderate to severe depression, anxiety and distress symptoms, 53.3 %, 56.6% and 39.l % respectively. In line with literature (Sandesh et al., 2020), similar results were reported in research carried out in China where 50% of sample showed significant psychological impact of this pandemic (Wang et al., 2020). Findings also revealed higher rates of post-traumatic stress symptoms among participants where more than half of participants (51.7 %) scored higher than cut off suggesting the need of clinical attention. Similar trends were also observed in literature, where high rate of PTSD was found in Covid-19 survivors (Alshehri et al., 2020; Bo et al., 2020). Psychological symptoms have been linked with pandemic in general population and healthcare workers (Vindegaard et al., 2020). Luo et al., (2020) reviewed 43 research studies and revealed high rates of depression (28%) and anxiety (33%) among health care workers and the general population (Luo et al., 2020).

Correlation findings demonstrated that participants who experienced higher levels of depression, anxiety, stress and post-traumatic stress symptoms reported lower quality of life. Where, their psychological and physical health, social relationships and environmental conditions were deteriorated. In literature it can be seen that pandemics or epidemic have the tendency to leave certain kind of aftershocks where individual’s wellbeing gets impacted including both their mental and physical wellbeing (Tansey et al., 2007; Batawi et al., 2016; Raman et al., 2020; Bo et al., 2020). The negative effect of psychological distress and PTSS on QoL during Covid is also evident in the present research; similar correlations have also been documented in literature (Wang et al., 2005; Schnurr et al., 2006).

In India, research also found that with Covid-19 pandemic person’s level of anxiety is increasing which is negatively impacting the quality of life (Kharshiing et al., 2020). Keeping in mind the human-to-human transmission, the outbreak of Covid-19 pandemic came with certain preventive measures of self-isolation and social distancing. These measures have challenged all the aspects of mental health, where person’s emotional health, psychological wellbeing and social wellness are all impacted at a collective level (Mukhtar, 2020). This might be because in Pakistani collectivist culture, a basic family unit comprises extended families with multiple generations living together, therefore the social distancing practices brings a negative impact on mental health of all household members. Being socially isolated, staying without the physical company of people may result in the increased levels of loneliness, frustration, fear of missing out etc., resultantly proliferating the psychological distress (Majeed & Ashraf, 2020). With the short-term mental consequences of psychological distress, literature has shown that during past pandemics (SARS and MERS) PTSD was found to be one of the utmost conjoint long-standing mental disorders, which is also predicted in Covid-19 (Mak et al., 2009; Lee et al., 2006; Xu, et al., 2011; Khan et al., 2020; Tan et al., 2020).

Research support that that major psychological impacts of quarantine included frustration, confusion and most importantly PTSD (Brooks et al., 2020). Interpersonal factors including negative affect, stringent relations and household environment, domestic abuse, privation, and financial instability might result in lower quality of life as suggested by results. Lockdown resulting in restrictions in movement makes person feel that their environmental mastery and autonomy is compromised. Because of the said factors he/she might feel the decrease in their physical health, might question their life, its meaning in life or socially they might harbor negative emotions about the relationships with others too (Velden et al., 2020). Salman et al., 2020 in their research found difficulty doing daily activities, taking care of personal wellbeing and not getting along with others, being the major source of psychological distress the impacted their quality of their lives.

Results of multiple linear regressions between PTSS, PD and life quality of Covid-19 survivors also confirmed the hypothesis that psychological distress and PTSS does in fact influence and predict negative quality of life. Research carried out by Wang et al. (2005) on individuals with traffic-related injuries, they also found that depression, anxiety, and PTSS significantly predicted a lower quality of life in survivors with this traumatic experience.

 In Pakistani history, Covid-19 is the pandemic we are facing for the first time where people have suffered more than people from other countries with experience of pandemics (MERS & SARS etc.). The substantial burden of the present pandemic has led to increased feelings of uncertainty and fear of unknown. The debilitating effects of pandemic are seen in the form of depression, anxiety, and stress in people from all walks of life. The idea of being infected by a virus without any available vaccine is in itself a great source of psychological distress, but with this the variations in recovery time, annoyance, fear of death, feelings of solitude, being isolated and alone in quarantine enhanced the psychophysical symptoms of patients. These conditions mark the beginning of PTSS where person’s quality of life gets reduced both short term and long term (Junaid et al., 2020).

Pakistan, being a low‐income country, has many people (55 million) living below the poverty line, where a large portion is of the people who work on daily wages. New strategies in order to prevent the widespread has cause many businesses to shut down, affecting people to lose their job security, suddenly going to unemployment, or even reduction the salaries result in the increase of distress hence reducing quality of life (Hussain, 2020). In the present research it was revealed that 70% of the participant’s economic income was impacted because of Covid-19. With the sudden changes of lifestyle, Covid-19 has proven to be the biggest threat to person’s mental and physical well-being. In accord with other pandemics and epidemics, it is agreed that people have to live with this virus for some time, therefore understanding the psychosocial, quality of life and demographical factors affecting it would help in order to form an effective rehabilitation plan.

Conclusion

It is concluded that Covid-19 has instigated drastic vicissitudes in the lives of people. Survivors have been struggling with mental health difficulties where they face symptoms of depression, anxiety, stress and post-traumatic stress hence lowered quality of life is significantly predicted. The majority of participants experienced mild to moderate levels of psychological distress and scored higher than cutoff scorers of PTSS indicating the need to attain clinical attention. The tenacious symptoms of COVID-19 affected the mental and bodily function, quality of life, and involvement in society.

Limitations and Suggestions

One of the limitations of the present research was that the study followed cross section design, where causality of the variables was not addressed. Self-reporting questionnaires were administered online which inhibits the exclusion of response biases. Due to lack of time, a limited number of participants selected which inhibits the generalization of results. Another limitation of the research is that the data was collected during the time when the cases were still rising, now the second wave is in progress. Moreover, this research did not comprise children, which must be researched in future research. In future it is suggested that comparative and longitude researches might give better inferences on the impact of Covid-19 on psycho-social functioning. Mixed research designs are also suggested in order to gather the in-depth information. Future comparison studies are required to determine the most efficient early therapies that could reduce psychiatric morbidity in COVID-19 survivors.

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