The Risk of Post-Traumatic Stress Disorder (PTSD) among Frontline Healthcare Workers in Saudi Arabia during the COVID-19 Pandemic: A Cross-sectional Study

Background

PTSD can result from directly experiencing a traumatic event, from witnessing the event, from learning that a close family member or friend has experienced such an event, or from experiencing repeated or extreme exposure to aversive events, as in the case of first responders collecting human remains [1].

On March 11, 2020, the World Health Organization (WHO) declared COVID-19, the disease caused by the novel Coronavirus SARS-CoV2, a pandemic after a widespread outbreak of COVID-19 cases worldwide [2]. The severe impact of COVID-19 resulted in more than 131,000,000 cases and approximately 2,854,276 deaths worldwide, as of April 6, 2021 [3]. In Saudi Arabia, COVID-19 surpassed 394,169 cases and 6,711 deaths as of the same date [4].

Previous infectious epidemics, such as severe acute respiratory syndrome (SARS), were found to elevate stress levels and cause significant psychological disturbances among HCWs in Hong Kong and Toronto [5,6]. Furthermore fear caused by a novel avian-origin influenza H7N9 was a cause of PTSD among HCWs [7], and an Ebola outbreak resulted in social isolation, emotional and physical exhaustion, depression, extreme stress, and stigmatisation among HCWs [8,9]. The extreme environment of the Ebola outbreak may also have caused burnout, which is linked to PTSD [10].

COVID-19 has had a substantial impact on both preexisting and new-onset behavioral health problems, including a spike in the number of anxiety and depression cases worldwide [11,12]. Moreover, individuals with preexisting mental health disorders are at higher risk of becoming severely ill or suffering long-term complications due to COVID-19 [13,14]. Under these circumstances, WHO, along with many other health organisations, offered immediate support and guidance on mental health issues, particularly on how to overcome the disruption of mental health services during the COVID-19 crisis [12].

HCWs are not immune to mental health issues, particularly during disease outbreaks [11, 12]. Throughout the COVID-19 pandemic, they have provided patient care under stressful and uncertain circumstances, and experienced the deaths and severe illness of patients and colleagues. The traumatic nature of these events has been exacerbated by the stress associated with shortages of staff and medical equipment, recurrent risk of personal exposure, and the possibility of themselves or family members becoming infected [15]. Taken together, these factors increase the risk of HCWs developing PTSD [11, 16]. A range of psychological issues have been reported among HCWs during the current COVID-19 pandemic, including fear, anger, stress, stigma, anxiety, and isolation, which may also have negatively affected the quality of care provided to COVID-19 patients [11,17].

Studies have demonstrated a significant psychological impact of the COVID-19 pandemic on HCWs in Saudi Arabia. A study conducted among HCWs in the Ministry of Health during the pandemic found that more than half met the criteria for depressive disorder and generalised anxiety disorders (55.2% and 51.4%, respectively). Females, the 30-39 age group, and nurses had significantly higher scores for anxiety and depression [18]. Another study conducted between April and May 2020 found elevated scores on anxiety and depression measures among 35.6% and 27.9% of HCWs, respectively. The highest elevations were found among female HCWs and those with inadequate training [19]. In general, HCWs staffing the Emergency Department (ED) are more likely to experience significant stress compared with those working in other departments [20]. A cross-sectional study prior to the COVID-19 pandemic found that 26% of emergency medical services (EMS) personnel at one of the largest hospitals in Saudi Arabia screened positive for PTSD [21]. The PTSD risk among HCWs working in the ED during infectious outbreaks can be attributed to their role in being the first to confront an emerging public health crisis, when the cause, mode of transmission, and treatment are still uncertain. They are thus more prone to adverse psychological outcomes, such as PTSD, anxiety, and depression, when confronting emerging infectious diseases [22-24]. This study examined the prevalence of PTSD among HCWs in the ED during the COVID-19 pandemic in Saudi Arabia. II. METHODS STUDY DESIGN We conducted a cross-sectional study in eleven large public hospitals in Riyadh, Saudi Arabia, between June 01 and July 01, 2020. An online survey was used, targeting physicians, nurses, and paramedics working in adult emergency departments. A. Ethics approval and consent to participate: All participants provided written informed consent, and ethical approval was granted by the Institutional Review Board (IRB) at King Fahad Medical City, Riyadh, Saudi Arabia (no. 00010471). B. Participants A survey link was sent, via e-mail and WhatsApp (a multiplatform messaging application widely used in Saudi Arabia), to all emergency department chair-persons, head nurses, and EMS chairpersons at the eleven hospitals, asking them to participate and also to distribute the survey to their team members. All participation in the study was voluntary. C. Measurement

The PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (PCL-5), a 20-item instrument that measures the occurrence and severity of PTSD symptoms, was used in this study [25]. It is a self-screening tool developed by the U.S. Department of Veterans Affairs National Center for PTSD to assist in diagnosing PTSD [26]. The self-report rating scale is 0-4 for each symptom (0= "Not at all" and 4= "Extremely") with a total possible score ranging from 0 to 80. A total score of 33 or more suggested a provisional PTSD diagnosis [26]. Questions about demographic characteristics, including gender, age, nationality, position, years of experience, and marital status, were included, as were questions about access to mental health services. Participants were asked whether their hospitals provided resources for psychological and emotional support, and whether there was a clear process for accessing that support. D. Sample size There are approximately 2,980 HCWs employed in the emergency departments of governmental hospitals in Riyadh, distributed as follows: 722 physicians, 1881 nurses, and 377 paramedics. Of these, 613 participants responded to our survey. E. Data Analysis

All statistical analyses were conducted using SPSS version 25. We used the Mann-Whitney test, the Kruskal Wallis test, the linear-by-linear association test, and the chi-square test to analyse the data. Categorical variables are presented as percentage and frequency.

Results

A. Demographic Characteristics The demographic characteristics of the 613 respondents are illustrated in Table 1. The distribution of physicians, nurses and paramedics in our sample was 39% physicians (n=239), 48% nurses (n=294), and 13.1% paramedics (n=80). B. Posttraumatic stress disorder among participants 33.4% of the participants scored 33 or higher (n=205) on DSM-5 (PCL-5), suggesting a provisional PTSD diagnosis. Subgroup analysis was conducted to investigate the effects of gender, age, marital status, race, and years of experience, in addition to the possible influence of being a physician, a nurse, or a paramedic. Statistical analyses showed significant differences in PTSD scores according to marital status, job title, and years of experience. Married and divorced HCWs reported a higher score compared with other groups (Mdn= 1.2 and 1.25, respectively), while paramedics and nurses had higher scores (Mdn= 1.25 and 1.2, respectively) than physicians (Mdn=1.05). A simple linear regression was conducted to predict PTSD severity based on years of experience, and a significant regression was found (F=1,611)= 4.547, P<0.05 with R 2 = 0.007. Other factors, such as age, gender, and nationality, revealed no significant differences in PTSD scores. C. Hospitals and PTSD

The percentage and number of PTSD cases among participants at different hospitals is shown in Table 2. The nonparametric Kruskal Wallis test indicated significant differences in the prevalence of PTSD among HCWs in different hospitals (p< 0.001), X 2 (10)= 37.625. HCWs in the Security Force Hospital were found to have the highest prevalence of PTSD (Mdn= 2.05), followed by King Faisal Specialist Hospital (Mdn= 1.95). The lowest prevalence was found in King Saud Medical City and King Abdulaziz Medical City (Mdn= 0.65). D. Accessibility of psychological/emotional support and clarity of the process

We investigated the accessibility of psychological/emotional support in the studied hospitals, and whether the process for accessing such support was clear to the healthcare providers relative to several demographic variables (Table 3). We found that 48.6% of respondents perceived the process to be clear and the support accessible (n=298). We also found significant differences in perceptions of the clarity and accessibility between HCWs from different hospitals. Respondents from King Saud University Medical City, King Faisal Specialist Hospital & Research Centre, King Fahad Medical City, and King Abdulaziz Medical City were more likely to report the process as clear and accessible than those from the other hospitals; χ 2= 75.42 (10), p < 0.05. A chi-square test of independence suggested that men were less likely to report the process of obtaining psychological/emotional support as being clear and accessible compared with women; χ 2(1)= 6.233, p < 0.05. Moreover, nurses were more likely to report the process as being clear and accessible than physicians and paramedics; χ 2(1)=17.69, p < 0.05. The respondents' nationalities also influenced their perceptions: Saudis, Arabs, and Africans were more likely to deem the process unclear compared with Asians, Indians, Europeans, and Oceanians; Fisher's exact test=28.26, p < 0.05.

Age was not found to influence the perception of clarity or accessibility of mental support; χ 2(4)=7.422, p > 0.05. Marital status also had no influence; Fisher’s exact test=6.19, p > 0.05. Likewise, the number of years of experience did not differ between those who perceived the process to be accessible and clear and those who did not; linear-by-linear association test=0.076, p > 0.05.

Discussion

The prevalence of PTSD among HCWs in our analysis is 33.4%. These findings are comparable to those reported in previous studies that describe significant mental health problems among HCWs during pandemics [11, 27-34]. The study also revealed that married and divorced HCWs, paramedics and nurses, and HCWs with fewer years of experience were more likely to experience PTSD. Such findings are generally consistent with previous studies conducted during the SARS outbreak [29-31, 35].

Furthermore, we found that almost half of the participants perceived the process of obtaining psychological/emotional support to be clear, and the support accessible – especially women, nurses, and participants who are Asian, Indian, European, or Oceanian. There is some variation in the level of knowledge about available mental health support among HCWs in different institutions. One explanation for this finding is that HCWs who reported the availability and process of psychological/emotional support to be accessible and clear are working for large hospitals that are well equipped to offer such support. Internal communication with physicians, nurses, and other staff may also play a crucial role in how HCWs perceive the availability and usefulness of mental health care at their hospitals. As discussed elsewhere, provision of employee support services by employers can have a positive impact on employees' responses to a variety of disasters [36]. Interestingly, unlike previous studies that found an association between gender, age, and risk for PTSD [29,33,37], we did not find such a relationship.

It is noteworthy that PTSD mean scores were noted to be low among participants (M=1.27, SD= 0.88). This can be explained, again, by the fact that nearly half of the participants perceived the psychological/emotional support to be accessible. Another factor is the timely control interventions implemented by the Saudi government to prevent the spread of COVID-19 infection. The study protocol was approved by the Institutional Review Board (IRB) of King Fahad Medical City, Riyadh, Saudi Arabia (no. 00010471). All