The MERS outbreak in 2015 is a noteworthy example of a national disaster that impacted most Korean people. Its early and rapid dissemination via hospitals concentrated in metropolitan areas [2], high fatality rate of nearly 20% [2], and unfamiliarity as a novel infectious disease [26] may have led to high levels of anxiety and fear about being infected among the public and about death among affected people [7]. The present findings confirmed high prevalence of mental health problems in survivors at the recovery phase after the outbreak.
The prevalence of PTSD in survivors at 12 months post-MERS in the present study was comparable to the rate of 41.7% observed in a study of 63 SARS survivors at 3 months post-discharge from a hospital in Singapore [27] and higher or comparable to the rates of PTSD in patients with HIV (30–35%), adult survivors of a human-made disaster (30–60%) [28], and survivors of a stay in an intensive care unit (14–59%) [29, 30]. This indicates that an EID is not only a serious medical illness but also a psychologically traumatic experience for patients that can result in long-term psychological burdens. Additionally, the result suggests that mental health problems caused by an EID outbreak can continue for a long period. For example, another study showed that 42.5% of SARS survivors in Hong Kong still showed active psychiatric illnesses at 3 years post-SARS infection [31]. Furthermore, a second study demonstrated that 42% of Chinese SARS survivors still experienced PTSD at 4 years post-SARS [13]. Assuming that the experiences of the patients in the MERS outbreak are similar in terms of EIDs, the mental health problems of the MERS survivors in the present study may persist for longer than 12 months. Therefore, a study on mental health outcomes after 12 months post-MERS will be required.
Of the premorbid characteristics of the subjects, only a history of a visit to a psychiatric clinic was independently related to PTSD and depression at 12 months post-MERS, whereas demographic factors, such as gender, age, and level of education were not. On the other hand, high anxiety levels, perceived stigma about MERS, and having a family member who died from MERS predicted the development of PTSD or depression. These findings indicate that the psychological outcomes associated with an EID are mainly affected by factors during the outbreak period. Furthermore, the presence of a physical illness prior to the MERS-CoV infection and the severity of MERS were not associated with PTSD or depression. Thus, psychosocial factors, rather than medical factors, may play an important role during MERS-CoV infection in terms of mental health status. These findings differ from those of a study investigating SARS survivors at 30 months post-infection, which found that the risk factors of PTSD included being female, the pre-SARS presence of chronic medical illness, and the presence of complications caused by SARS treatment [32]. It is possible that the relatively small sample size of the present study was insufficient to statistically identify the influences of demographic characteristics and medical severity on adverse psychological outcomes. However, psychological burdens, such as widespread and extreme fear or feelings of isolation caused by MERS [7], may have outweighed the possible contributions of these other factors. A previous report showing that only a history of mental disease and financial burden are related to anxiety in MERS patients [8] supports this assumption.
The present findings suggest a need for appropriate psychosocial support during infectious outbreaks to reduce psychological distress in patients [1]. Therefore, healthcare professionals who treat these patients should be aware of the risk of developing adverse psychological outcomes during the acute stage of the illness as well as during the follow-up period. In particular, patients with a prior psychiatric history, high levels of psychological distress during the illness, or a negative perception about MERS should be given more attention. Interestingly, on our univariate analysis, we can assume that negative coping strategy such as denial, substance use, and self-blame may affect the development of PTSD. This relationship between negative coping style and PTSD is consistent with the previous findings in natural disaster and infectious disease [33, 34]. It suggests that providing what is a useful coping strategy should be included in psychosocial support for survivors from EID.
Similarly, the governmental strategy for the management of EIDs should include psychosocial support based on group characteristics, risk factors, and severity of distress. The White Paper, ‘MERS 2015,’ issued by the Korean government proposed that the national policy for EIDs should include content for “improving ethical problems and strengthening psychological support in EID control.” [1] The present findings suggest several considerations in this regard. In general, during the early outbreak phase, it is important that effective risk communication is incorporated into the overall strategy to reduce fear among the general public and quarantined people [35]; when developing such a strategy for this phase, it is also important to consider the ethical issues related to patients and quarantined people to minimize stigma [36]. More specifically, due to the high prevalence of mental health problems, routine care for EID patients should include effective psychological support that reflects individual risk factors and the current level of distress. In fact, the central and local Korean governments provided psychological support for quarantined people, patients, and families who had a member die from MERS using designated public mental health care centers and telephone counseling during the outbreak [1]. The core value associated with this program was adequate public accessibility; indeed, rather than rely on the passive provision of information, the program was implemented in a proactive manner [37].
In addition, we should pay attention to stigma as a risk factor amenable to change rather than other psychosocial variables for PTSD in the study. In EID outbreak, the perspective is easily made that an infected patient is regarded as a dangerous vector or perpetrator to spread virus who should be isolated from the society [38]. It can be maintained even after the outbreak [39]. The stigma may produce discrimination and exclusion from a community regardless of medical indications. It would significantly threaten a patient’s mental health and social relationship. Consequently, their life could be influenced in a variety of domains such as residence, occupation and the use of healthcare for a long time [40]. This study showed that reducing stigma can be an effective strategy to ameliorate psychological consequence after an EID. Media and government should respect a patient or quarantined people as a citizen who are suffering and be sensitive to words or actions that might stigmatize a specific person or group. A community and healthcare service need to provide active support for an isolated patient to relieve their burden from the stigma [41].
The present study has several limitations that should be noted. Because this study assessed only 43% of the overall MERS survivors, the results may not reflect the status of all survivors. However, the distributions of the demographic data on age, gender, and area of residence in the present study were similar to those in the official reports for all MERS patients [1]. Second, psychological distress and stigma during the pre-MERS period and during the MERS-CoV infection were evaluated based on participant recall and may not accurately represent the actual status of the subjects. Additionally, the relatively small sample size may have limited the ability to identify risk factors due to low statistical power. However, given that 47.2% of 34 patients reported anxiety using the same scale in a previous study conducted during the isolation period [8], it can be assumed that the subjects in the present study were not likely to overestimate their symptoms during recall. Finally, we assessed only with self-questionnaire that could be considered less accurate than the ratings of a clinician.