Mental health among COVID-19 survivors and healthcare workers exposed to COVID-19 in Wuhan, China: a cross-sectional study

Then novel coronavirus disease (COVID-19) epidemic was considered to be the worst and complex virus outbreak, which caused 56,985 deaths as of April 22, 2020 already. The epidemic infectious may cause mental health crisis. Meanwhile, little is known about the specic psychological status of the COVID-19 survivors and healthcare workers. This cross-sectional study surveyed the mental health among 20 COVID-19 survivors, 54 nurses, and 24 hygienists in Wuhan, China and analyze the possible impact factors using the Symptom Check List 90 - Revised (SCL90-R) questionnaire. 3 indices and 9 dimensions were compared among job, education level, gender, age, marriage classication. This study found that mental distress among participants was not very serious in general. The survivors presented a highest score, then the hygienists, and the lowest in nurses. Low-educated and women showed signicant increase. No signicant difference was noted in age and marriage classication. Our study indicated that the survivors need psychological support immediately. Meanwhile, healthcare workers warrant more attention, especially low-educated and women. Comprehensive emergency response plan was warranted.


Introduction
The novel coronavirus disease (COVID- 19) was rst reported in Wuhan, China in December, 2019 1 . After a latent period of 1-14 days (mostly 3-7 days), most patients infected with COVID-19 had clinical manifestations of fever, dry cough, and fatigue 2 . Due to the person-to-person transmission via respiratory droplets when patients coughed or sneezed and close contact 3 , the COVID-19 outbreak rapidly across Sustained growth of infections and death caused social fear and panic 7 . During the treatment, isolation made patients gradually alienate to each other. On the other hand, uncertainty of disease prognosis and the threat of death, psychological health problems like depression or anxiety were more likely to occur and worsen 8 . A study found that COVID-19 con rmed patients suffered severe mental distress even after rehabilitation and discharge 9 . These mental health problems may lead to some bad results, such as reducing the quality of life and affecting work performance 10 . Previous studies showed that during the period of Severe Acute Respiratory Syndrome (SARS) outbreak in 2003, proportion of SARS survivors in mental distress status was 9.8% in the beginning, what was worse, it has increased to 25.6% after 30 months 11 . This reminded us paying attention to mental health of COVID- 19 survivors, yet, recent studies mainly focused on medical treatment and virus prevention.
Furthermore, healthcare workers rushing to rescue Wuhan also faced great pressure, including high risk of infection, inadequate of personal protection equipment, no speci c medication, heavy workload, isolation, negative emotions of patients, lack of contact with family members, and fatigue 12 . These acute conditions may lead to severe psychological health status such as stress, anxiety, depression, insomnia, and fear. These mental health problems will not only affect the attention, understanding and decisionmaking ability of healthcare workers, may hamper them from ghting against COVID-19, but also have a lasting in uence on their overall health 13 . Therefore, protecting the mental health of frontline healthcare workers was of great signi cance to control the epidemic situation and their own long-term health.
In view of the severe mental health problems, the National Health Commission of China published guidelines for emergency psychological intervention for COVID-19 survivors and healthcare workers 14 .
Speci c methods included establishment of psychological intervention working groups, psychological assistance hotlines, online mental health services, etc 4,10,15 . However, due to the unsatisfactory overall planning, lack of communications among medical services and mental health institutions, shortage of professional and experienced psychologists and psychiatrists 16 , survivors and healthcare workers didn't acquire enough psychological support.
To solve the psychological health problems, we need to make clear of the mental health status of COVID-19 survivors and healthcare workers, and the impacting factors. The Symptom Check List 90 -Revised (SCL90-R) questionnaire was a multidimensional self-reported symptom scale which was used to estimate participants' psychological status 17 . Indeed, it was widely used in clinical research of medicine since its naissance 18 . Therefore, we quoted SCL90-R questionnaire to measure mental health status of survivors and healthcare workers, which could provide valuable evidence for psychological intervention among COVID-19 survivors and healthcare workers.

Study design and participants
This study is a cross-sectional, survey-based study which collected demographic information and mental health data via SCL90-R questionnaire from March 15 to 25, 2020 in Wuhan, China. A total of 20 COVID-19 survivors and 78 healthcare workers were enrolled in the study. All participants were willing to complete the questionnaire, without mental disorders, 18 years of age or older, and other inclusion criteria were able to understand, speak, and write Chinese in order to nish the SCL90-R questionnaire smoothly.
The study was approved by the Medical Ethics Committee of A liated Hospital of Nanjing University of Chinese Medicine. Written informed consent was provided by all enrolled participants before the initial of study, and all subjects were informed that this study was anonymous, all information was con dential, and participants had the right to end the questionnaire anytime without responsibility. 20 patients with conforming COVID-19 were also surveyed in our study, who were admitted and treated in Cabin Hospital of Jiangxia District in March 2020. The included patients were diagnosed as COVID-19 and were discharged from the Cabin Hospital after recovery. Patients combined other diseases such as enteritis, or pulmonary occupying lesions were ruled out. The diagnostic criteria of COVID-19 were suspected case also has one of the following etiological or serological evidence: 1. The COVID-19 nucleic acid was identi ed positively by real-time uorescence RT-PCR; 2. The virus is very homologous to COVID-19 via virus gene sequencing; 3. Serum COVID-19 speci c IgM antibody and IgG antibody were positive; serum COVID-19 speci c IgG antibody changed from negative to positive or rising speed in the recovery period was 4 times or more than the acute period. The discharge standard was met the following 4 requirements at the same time: 1. The body temperature returned to normal for more than 3 days; 2. Symptoms of respiratory tract greatly improved; 3. Pulmonary imaging showed that the acute exudation lesions were signi cantly improved; 4. The nucleic acid test of respiratory tract samples such as sputum and nasopharyngeal swab was negative for two consecutive time, sampling time shall be at least 24 hours apart. The above 2 criteria referenced "COVID-19 Diagnosis and Treatment Plan (Trial Version 7)" printed and distributed by the National Health Commission of the People's Republic of China on March 4, 2020 19 .

Participants evaluation
Demographic characteristics and psychological health status data were gathered. All participants and researchers were Chinese. Therefore Chinese language was chosen during the whole research process. Demographic data were self-reported by the interviewees, including gender (male or female), age (<32 or ≥32), classi cation (COVID-19 survivor, nurse, or hygienist), marriage status (married, or unmarried), and education level (high school and below, college, or bachelor and above).
Paranoid ideation (PAR); 9. Psychoticism (PSY). All items were single choice questions, and answers to each entry were rated on a ve-point scale from 1 to 5. Mental health status results corresponding to each score were "none", "mild", "moderate", "relatively serious", and "serious", respectively. The survey was conducted in private environment spending about 25-30 minutes for each interviewee.

De nitions and scores
Previous studies have demonstrated that the SCL-90-R tests have good internal consistency, reliability, and validity [20][21][22][23] . Overall mental health status was evaluated via 3 global scales: 1. The Global Severity Index (GSI), indicating a global scale; 2. Positive Symptom Total (PST), expressing all items more than 1 point to display number of items did the subjects presenting symptoms; and 3. Positive Symptom Distress Index (PSDI), meaning the sum of values of none-zero items by PST, re ecting the extent of severity of items that subjects feel bad about themselves. Higher score indicated more seriously mental health status.

Statistical analysis
Analysis of all data was performed using the SPSS 25.0 for windows (SPSS Inc., IL, USA). Descriptive analysis was conducted to express the data; continuous variables were expressed as mean ± standard deviation, while categorical variables were shown as percentages. A chi-squared test was used for statistical analysis and Fisher's exact test when appropriate. P≤0.05 was considered signi cant.
No statistical signi cance was discovered among participants within different age (Figure 5a, b) or marriage status (Figure 6a, b) for each aspect and dimension of the measurements.

Discussion
The COVID-19 outbreak was thought to be the most prevalent and serious epidemic since the end of December of 2019. Over 200 countries, areas or territories were suffering from the virus and more than 2 million persons infected by the acute infectious disease with over 130 thousand con rmed death globally6 6 . Owing to the signi cant morbidity and mortality, the COVID-19 caused large scale public panic and serious psychological health stress 24 . The WHO had emphasized the importance of psychological support and released some advice to survivors and health care workers [25][26][27] . However, to our knowledge, there is only a few researches focusing on mental health of COVID-19 survivors and frontline healthcare workers. Thus it is necessary to conduct scienti c research to evaluate the mental health status of the COVID-19 outbreak. This study was to assess psychological health status of COVID-19 survivors, nurses, and hygienists in Wuhan, China, analyze the risk factors to in uence the outcome, and provide help for mental health assistance for survivors and healthcare workers.
Results of the present research indicated that psychological health status among all participants in Wuhan, China was not very serious, and the main problems were anxiety and psychoticism. Possible reasons may be as follows: 1. Our assessment time was set on over 2 months after the outbreak when the worst situation has passed and under controlled effectively in Wuhan, China. The COVID-19 has been intensively studied through advanced medical scienti c techniques and released to the public in time, making participants very familiar with the new virus and reducing their fear of the new virus; 2. The Chinese government and some medical organizations have taken a serious of measures for psychological support to the con rmed patients and healthcare professionals 28,29 ; 3. Latest daily report was released by authorities, thus the public could receive the speci c trends of the epidemic situation. In addition, energy propaganda was carried out by the mainstream media to ght the virus epidemic, encouraging everyone to face it positively; 4. The epidemic crisis was under control in China, and there was still newly increased con rmed death cases. What's more, the epidemic was further expanded in other countries 5 . Under the background of globalization, and a community of sharing future for mankind, participants still felt anxiety to the COVID-19 and showed poor mental status.
Our studies showed that COVID-19 survivors suffered severe somatization, obsession-compulsion, interpersonal sensitivity, anxiety, anger-hostility, paranoid ideation, psychoticism, and highest PST score which meant they had worse psychological status compared with healthcare workers. This was consistent with a previous study about comparison of psychological symptoms between Ebola survivors and healthcare workers 30 . Possible reasons were maybe the novel virus was characterized by a high possibility of being infected, and high mortality which was a life threatening event 31 . Patients were forced isolation in speci c hospitals, which divided them from work, family, and conventional daily life, so that to plumb the depths of loneliness, humiliation, and even despair 32 . Besides, some bad media reported false news to mislead public which aggravated patients' panic and anxiety 33 . Results analysis showed that it was important to construct an appropriate emergency response mechanism of serious infectious disease and recovery system of post-traumatic stress. Speci c methods included establishing professional psychological intervention team which consisted of all mental health professionals, conducting online psychological counselling services (eg, on WeChat), etc 7,8,10 . Under the guidance of government 34 , we were required to pay attention to patients' mental health and psychological response. Psychological evaluation, counseling, and supporting should be provided to recovered patients.
This study showed that psychological status of healthcare workers including nurses and hygienists was not very serious generally, and nurses presented higher score in somatization than hygienists. It was comparable to the previous study about comparison of hygienists and nurses during the COVID-19 crisis 35 . Possible reasons probably were nurses contacted with patients directly and frequently with wearing sealed personal protective equipment which made them sultry, dyspnea, facial skin indentation or even damaged 36 . What was worse, they need to work longer hours than usual without break or going to the toilet, causing high risk of infection. Physical fatigue made a damage to the body and performed severe physical symptoms 37 . However, nurses presented lower score in phobic anxiety than hygienists which was contrary to previous study 35 . To our consideration, reason for this result may be the hygienists were responsible for making treating plan for patients, and they need to be very careful in each step because of the high mortality. Facing too many death and feeling powerless may lead to phobic anxiety.
Though healthcare workers' mental health was not serious, attention should be paid to increasing levels of somatization, obsession-compulsion, anxiety, and phobic anxiety. Psychological counselling, disaster rescue knowledge training and simulation exercise, formulation of relevant processes and emergency plans should be implemented 13 .
In this study, there was a negative correlation between the severity of mental state and education level, which is consistent with a previous study 30 . These ndings indicated education was an import and effective aspect leading people to know virus correctly and confront it positively. People with higher education level might think more about the accepted news and information, instead of believing every information they received, even rumors and false beliefs. More proper education of the novel virus applied, less mental problems they would have. Thus, we need to construct proper educational channels of major infectious disease to the public.
Of note, female participants showed worse PSDI, somatization, obsessive-compulsive, depression, and anger-hostility. It was consisted with a previous study that women had more mental problems in the COVID-19 outbreak 35 . Reasons may be in face of sudden changes, women can't be as calm as men.
Women usually had rich inner activities as facing such an emergency crisis, and they worried about their family members or daily social interaction. This indicated us to take particular attention to female survivors and healthcare workers, more family and social support, and psychological intervention was warranted.
We also interested in whether there was divergence in different ages and marriage status.  Scores of gender difference Scores of age difference Scores of marriage difference