Prevalence of PTSD Symptoms Among Psychiatric Patients During the COVID-19 Pandemic

Background: The outbreak of the COVID-19 pandemic has caused extensive public health concern and posed great challenges to the medical services, including the mental health concern for psychiatric patients who were one of neglected groups. The current study aimed to assess the prevalence and risk factors of post-traumatic stress disorder (PTSD) symptoms among psychiatric patients in China during the pandemic. Method: Self-reported questionnaires were distributed to psychiatric patients in several psychiatric hospitals in Beijing China from 28 April to 30 May 2020. The socio-demographic information and psychiatric symptoms such as PTSD, anxiety and depressive symptoms were collected by using The Impact of Event Scale- Revised (IES-R), the 7-item Generalized Anxiety Disorder Scale (GAD-7) and the 9-item Patient Health Questionnaire depression scale (PHQ-9). Multivariate regression was used to analysis the related factors for PTSD symptoms. Results: 1,055 psychiatric patients were included in the nal sample. The prevalence of PTSD symptoms was 41.3%. Risk factors for PTSD symptoms and its subscales included old age, high risk perception, symptoms of anxiety, symptoms of depression. Conclusions: The prevalence of PTSD symptoms is high among psychiatric patients during the COVID-19 pandemic in China. We call for more concern and PTSD interventions to relieve the psychological stress of psychiatric patients during the pandemic. pandemic Information about diagnosis of mental disorder, medication status during pandemic, and effects of COVID-19 on original mental disease (Clinical treatment during pandemic, Mental health guidance during pandemic, Medication barriers due to pandemic) were collected. present study. Sleep quality was assessed by 3 items of Pittsburgh Sleep Questionnaire (PSQI-PT) [20] on a 5 Linkert scale i.How many hours of sleep you usually get per night during the epidemic (not equal to bed time)? ii. Do you take sleeping drugs to help you sleep during the epidemic? iii. During the epidemic, in general, you think of your sense of sleep? With higher scores indicating worse quality of sleep. Cronbach’s α = 0.52. Social support was assessed by 6 items: i. During the epidemic, when I encounter problems, some people (leaders, relatives, colleagues or classmates) will appear beside me? ii. During the epidemic, I was able to share happiness and sadness with some people (leaders, relatives, colleagues or classmates). iii. During the epidemic, my family was able to give me practical and concrete help. iv. During the epidemic, I was able to get emotional help and support from my family when needed. v. My friends can really help me during the epidemic. vi. My friends can share happiness and sadness with me during the epidemic. Social support is item1-2, family support item is 3–4 and friend support is 5–6. It is on a 5 point scale(1 = strongly disagree, 2 = disagree, 3 = not sure, 4 = agree, 5 = strongly agree). Cronbach’s α = 0.75 ~ 0.87.


Introduction
The COVID-19 pandemic has made huge impact around the whole world in many aspects, including physical and mental health among public [1]. Psychotic symptoms were increasing among general population and infected patients during the pandemic [2][3][4]. Many people show numbness, stiffness, high vigilance and other psychotic symptoms in face of the pandemic [5].
The epidemiological survey showed that the prevalence of mental disorders among adults in four provinces in China was 17.5% [6]. Several researchers and experts stated that the COVID-19 pandemic might have an even more bad effect on individuals with pre-existing mental disorders [7][8][9][10]. Some surveys conducted in China among the general population after COVID-19 outbreak reported moderate to severe anxiety and depressive symptoms in general population (16.5%-35.1%) [11]. As a special and often neglected group, psychiatric patients also have showed some mental health problems during the pandemic, even they were not infected by COVID-19 [10]. Psychiatry patients diagnosed as severe mental illnesses, including affective disorders and schizophrenia spectrum illnesses were at much higher risk for negative outcomes in mental health related to the pandemic [12].
PTSD is caused after exposure to one or more traumatic events [13]. Characteristic symptoms include three subscale types: intrusion (including intrusive thoughts, intrusive feelings and imagery, nightmares, dissociative-like re-experiencing), avoidance (including numbing of responsiveness, avoidance of situations, feelings, and ideas), and hyperarousal (including irritability, anger, di culty concentrating, hypervigilance, heightened startle) [14]. Prolonged exposure to stress can accelerate disease progression and worsen chronic health conditions, increasing health care costs and economic burdens [5]. We assume that the prevalence of PTSD symptoms among psychiatric patients is high due to their susceptibility and vulnerability to crisis [8,9]. This study aims to examine the prevalence of PTSD symptoms among psychiatric patients during the COVID-19, and investigate the risk and protective factors of PTSD symptoms and its subscale symptoms.

Methods
Study participants [15,16] and has demonstrated sound validity in China [17]. While there is no speci c cut-off score, the IES-R is not used to be diagnostic. In this study with scores equal or higher than 24 was of clinical concern according to previous research [14]. We calculated the composite score for PTSD (Cronbach's α = 0.93) and its subsclaes (Cronbach's α = 0.84 ~ 0.84).

Psychosomatics factors
Anxiety was assessed with the Generalized Anxiety Disorder Scale (GAD-7), it is used to measure the frequency of anxiety symptoms in the past two weeks. GAD-7 is on a scale ranging from to 3 (0 = "not at all" and 3 = "nearly every day"). The Chinese version of GAD-7 has been validated in previous studies (α = 0.90) [18]. The Cronbach's α was 0.95 in the present study. Depressive symptoms was measured by Patient health Questionnaire-9 (PHQ-9). It measures the frequency of depressive symptoms in the past two weeks. Each symptom have a possible score of 0-3 points (0 = no, 1 = a few days, 2 = more than half of the days, 3 = almost every day). The total score of the scale is 27 points, higher than 5 points indicate mild depression, higher than 10 points indicate moderate depression, and higher than 15 points indicate severe depression. The Chinese version of PHQ-9 has been validated in previous studies (α = 0.94) [19].
Loneliness was assessed by one question "Do you feel lonely?" on a 5 Linkert points: (1 = never, 2 = rarely, 3 = occasionally, 4 = often, 5 = almost every day). With higher scores indicating higher levels of loneliness. Quality of life was assessed by 2 question "How do you feel about the quality of your life?" and "Are you satis ed with your present state of health?" of 1-5 points: (1 = extremely unsatisfactory, 2 = rarely not satis ed, 3 = not satis ed or dissatis ed, 4 = very satis ed, 5 = extremely satisfactory). The Cronbach's α was 0.76 in the present study. Sleep quality was assessed by 3 items of Pittsburgh Sleep Questionnaire (PSQI-PT) [20] on a 5 Linkert scale i.How many hours of sleep you usually get per night during the epidemic (not equal to bed time)? ii. Do you take sleeping drugs to help you sleep during the epidemic? iii. During the epidemic, in general, you think of your sense of sleep? With higher scores indicating worse quality of sleep. Cronbach's α = 0.52. Social support was assessed by 6 items: i. During the epidemic, when I encounter problems, some people (leaders, relatives, colleagues or classmates) will appear beside me? ii. During the epidemic, I was able to share happiness and sadness with some people (leaders, relatives, colleagues or classmates). iii. During the epidemic, my family was able to give me practical and concrete help. iv. During the epidemic, I was able to get emotional help and support from my family when needed. v. My friends can really help me during the epidemic. vi. My friends can share happiness and sadness with me during the epidemic. Social support is item1-2, family support item is 3-4 and friend support is 5-6. It is on a 5 point scale(1 = strongly disagree, 2 = disagree, 3 = not sure, 4 = agree, 5 = strongly agree). Cronbach's α = 0.75 ~ 0.87.

Data analysis
The characteristics of the sample were presented using means and standardized deviation (SD) for continuous variables and percentage was applied for categorical variables. Hierarchical liner regression models were done to investigate the related factors of PTSD symptoms and its subscales. First, we entered socio-demographic factors in the model, in step 2 followed by Risk awareness and Effects of COVID-19 on original mental disease, in step 3Psychosomatics factors, and in step 4 Support. The increasing of R 2 further veri ed the importance of the independent variables on dependent variables. In addition, one-way analysis of variance (one-way ANOVA) and post-hoc comparison were used to compare PTSD symptoms between different diagnosis groups. Analyses were conducted by SPSS package, Version 20.0, and R software, version 3.6.1. p < 0.05 (two-tails) were considered to have statistical signi cance in this study.

Socio-demographic and clinical characteristics of the sample
In the survey there were 1,055 psychiatry patients who completed. As in Table 1, Over one-third of the patients of the patients were male (34.5%), and the average age of the patients were 37.15 (SD = 13.21) years old. Only half of the patients (47.4%) were married and the majority of participants had high school degree or higher degree (82.6%). A quarter of participants were unemployed (26.8%). Some reported living alone during pandemic (10.4%). The majority of the psychiatry patients lived in urban areas (88.4%), and 28.1% had family annual income equal or above 150, 000 RMB (Chinese Yuan). Of the sample, all participants had pre-existing diagnosis, anxiety disorder (35.4%), were Major depressive disorder (26.7%),bipolar disorder (17.6%) and schizophrenia (20.3%).
During the COVID-19 pandemic period, almost a half of them reported that they didn't seek mental health services (47.7%). More than half of them were taking psychiatric medicine (79.7%) although they had high barriers due to inconveniences caused by COVID-19 to continue treatment. In addition, more than a half of participants had anxiety symptoms (51.0%) and depressive symptoms (57.3%). .08, SD = 5.30), in which the depression group was signi cantly higher than that in the anxiety group (Mean difference = 12.21, SD = 5.30, p < 0.05) and depression was signi cantly higher than that in the schizophrenia group (Mean difference = 11.74, SD = 4.94, p < 0.05) (see Fig. 1).

Associated factors with PTSD symptoms
Hierarchical linear regression results showed that risk factors including risk awareness, symptoms of anxiety and symptoms of depression are the shared risk factors for the total PTSD symptoms and the subscales as in Table 2. Beside the shared common risk factors, unique contributing risk factors were identi ed for PTSD subscales. Residence (town) was the shared risk factor across PTSD avoidance subscale (β = 0.06, p < 0.05) and hyperarousal subscale (β = 0.05, p < 0.01). Medication use was the unique risk factor of PTSD avoidance subscale (β = 0.08, p < 0.05). Loneliness was the unique risk factor of PTSD hyperarousal subscale (β = 0.06, p < 0.05). Sleep quality was the unique risk factor of PTSD hyperarousal subscale (β = 0.05, p < 0.05).

Discussion
This is the rst study for screening PTSD symptoms in psychiatry patients in Beijing China. The prevalence of PTSD symptoms (41.3%) in our study was much higher than the lifetime prevalence of PTSD symptoms in the general population (ranges from 2-9%) as shown in earlier research [21]. A longitudinal study about the mental health condition of general population during COVID-19 in China found that the mean IES-R scores of the survey respondents (from 32.98 to 30.76) were above 24 for PTSD symptoms. During the initial evaluation, moderate-to-severe stress were 8.1% [22]. The prevalence of PTSD symptoms in our study was even higher than medical assistance workers (31.6%) during the COVID-19 pandemic. The ndings in this study suggest a great need for screening PTSD symptoms in psychiatry patients.
In our study in the PTSD high-arousal subscales: the major depressive disorder group is higher than the anxiety disorder group and the schizophrenia group. There was no signi cant difference in PTSD level among the four diagnosis, that is, the history itself may not affect the onset of PTSD. symptoms. There have been reports that anxiety, stress and depression often co-existing and comorbid with post-traumatic stress disorder [23,24]. Recent neuroscience research showed higher anxiety sensitivity tends to increase PTSD severity [25]. People with higher levels of stress could nd it easy to be impatient, feel upset or agitated, and di cult to relax resulting in bad impacts on PTSD symptoms [26]. The result is similar to other studies in general population. A study in Austria showed that the COVID-19 pandemic and lockdown was reported stressful for younger adults (< 35 years), and people without work [1]. Self-rated poor health during an outbreak is signi cantly associated with greater psychological impact and higher levels of stress, according to a study in China [11].
As for the hypothesis on social relationship is associated with PTSD symptoms, this study did not nd a signi cant association between support (including social support, family support and friends support) and PTSD symptoms. However, some factors including loneliness, sleep quality, resided in town, medication use, mental health guidance during pandemic, employment status is student and friends support are related to the PTSD subscales. We could do more research about this. Further studies should be done to examine how long PTSD symptoms may persist or develop in the future among the psychiatry patients over time.

Limitations
There are several limitations should be considered in mind as reading the ndings of this study. 1. This study is cross-sectional design. It is unclear in what way PTSD symptoms among the psychiatry patients change over time. Longitudinal study is needed to be conducted to examine the protective factors and long-term impacts of PTSD in psychiatric patients during the COVID-19 pandemic. 2. The sample was only in several hospitals in Beijing China, a multicenter study in the whole country or the world is needed to be done in order to know more about PTSD symptoms in psychiatry patients. Figure 1 The value of PTSD symptoms in arousal subscale among different diagnosis group (anxiety disorder group, major depressive disorder group, bipolar disorder group and schizophrenia group)