A longitudinal study examining PTSD and other mental health problems in NHS workers during the COVID-19 pandemic

doi:10.21203/rs.3.rs-4304035/v1

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Research Article

A longitudinal study examining PTSD and other mental health problems in NHS workers during the COVID-19 pandemic

https://doi.org/10.21203/rs.3.rs-4304035/v1

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A cross-sectional longitudinal study was conducted to examine the impact of the Covid-19 pandemic on the mental health of NHS medical staff, and its relationship with levels of social support received, and levels of Covid-19 related worries. Participants were contacted via Health Boards and Royal Colleges in England and Wales. 476 participants completed the study in Wave 1 and 129 of those completed the same survey in Wave 2 a year later. Participants completed the Crisis Support Scale, a Covid-19 Anxieties Questionnaire, the DASS-21, and the PTSD checklist. First, high levels of support during the pandemic, were associated with lower levels of depression, anxiety, stress, and PTSD. Second, high levels on the Covid-19 Anxieties Questionnaire were associated with high levels of Common Mental health Difficulties (CMDs) and PTSD scores during both waves. Third, social support led to lower Covid-19 health worries scores in Wave 1. Finally, scores on the Covid-19 anxieties questionnaire significantly reduced 12 months into the pandemic, while effects on mental health did not. Social support during the crisis can reduce anxieties about the crisis and self-reported levels of CMDs and PTSD. Even when anxieties relating to the pandemic eased, the prevalence of CMDs and PTSD were long-lasting.

mental health

post-traumatic stress

NHS workers

COVID-19 pandemic

social support.

Although being an NHS frontline worker can be a stressful job, staff typically have the necessary training and experience to deal with the everyday challenges of their workplace. There are structures and training in place that contribute to overall sense of security and safety in their work environment. The Covid-19 pandemic, however, had a significant and rapid impact on their work environment. In March 2020 the pandemic threatened to result in the deaths of thousands of people in the United Kingdom, with the UK set to follow a similar trajectory of Covid-19 cases as Italy. As the pandemic spread to Europe reports were coming from Italian healthcare settings about frontline medical staff having to make life and death decisions regarding the care of Covid-19 patients, including which patients should and should not receive ventilators.

During the SARS, MERS, and Ebola disease outbreaks, working in healthcare role was associated with increased reports of common mental health difficulties (CMDs), including depression, anxiety, and stress (e.g., Allan, Bealey, Birch, et al., 2020; Brooks, Dunn, Amlôt, Rubin, & Greenberg, 2018; de Pablo, Vaquerizo-Serrano, Catalan et al., 2020; Preti, Di Mattei, Perego et al., 2020). Additional challenges were posed to NHS workers during the Covid-19 pandemic due to government measures to constrain the spread of the disease, robing workers of their network of social and childcare support.

Recently, research on the psychological effects of Covid-19 shows that frontline staff can experience detrimental effects to their mental health. For instance, Greene, et al., (2021) showed 57% prevalence of anxiety and depression among frontline health and social care workers. In a longitudinal study, De Kock, et al. (2022) found over 30% prevalence in depression in health and social care staff, 20.1% in anxiety, with an increase to 27.2% at a 6-week follow-up. Evidence from other countries also show increases in reports of mental health difficulties, including China, India, Italy, and USA (e.g., Braquehais et al., 2020; Carmassi et al., 2020; Chew, et al., 2020; Li, Zhou, & Xu, 2021; Krishnamoorthy, Nagarajan, Saya, & Menon, 2020; Pappa, Ntella, Giannakas, Giannakoulis, Papoutsi, & Katsaounou, 2020; Riello, Purgato, Bove, MacTaggart, & Rusconi, 2021; Shechter, et al., 2020).

Being exposed to traumatic events such as those NHS workers may have encountered during the Covid-19 pandemic can result in increased anxiety and post-traumatic stress disorder (PTSD). Risk factors PTSD and CMDs during the COVID-19 pandemic include: being a nurse has been identified as a risk factor (e.g., Luceño-Moreno, et al., 2020), having been in recent contact with a Covid-positive person (e.g., Riello et al., 2020; Greene et al., 2021), and annual income (e.g., Greene, et al., 2021). Worries related to Covid-19 are found to be significant predictors of increased reports of PTSD and CMDs (e.g., Greene, et al., 2021).

Another significant predictor of psychological well-being and resilience is social support (e.g., Elklit et al., 2001; Ozbay, et al., 2007). Social support encompasses both structural components, such as the extent of the network and the frequency of social interactions, and functional components, such emotional and practical support (e.g., Wills & Fegan, 2001). Although both types of support are important during times of crisis, its quality as opposed to the extent of the social network is a better predictor of psychological health, and PTSD (Southwick, et al., 2005). In a pandemic situation, such as the Covid-19, both aspects of social support, but predominantly the emotional and practical levels of support, are taken away from people indiscriminately. In the current study we included a measure of social and emotional support as a predictor variable for PTSD and CMDs scores of frontline NHS staff.

The aim of the current study was two-fold. First, to examine the incidence of posttraumatic stress in frontline medical staff at two time-points: 1) as soon as possible during the outbreak (i.e., immediate testing), and 2) a year after the outbreak (approximately 1 year after the initial testing). Second, to explore the relationship between the traumatic and stressful impact of Covid 19 on frontline NHS staff and common mental health conditions (such as anxiety and depression), levels of social support received (before and during the pandemic), and levels of anxiety related to Covid-19.

The current study was approved by the Swansea University College of Human & Health Sciences Research Ethics Committee (Ethics approval ID: 3867).

Design and Recruitment

A longitudinal correlational cross-sectional design was employed. Our primary focus was on establishing the prevalence of mental health symptoms in workers in the immediate aftermath of the first COVID-19 outbreak and a year later. Additionally, we sought to explore relationship between the traumatic and stressful impact of COVID 19 on frontline NHS staff and common mental health conditions (such as anxiety and depression), levels of social support received (before and during the pandemic), and levels of anxiety related to Covid-19. To this aim, we sent out recruitment emails across the Health Boards in England and Wales in late March 2020. We emailed the management of 108 health boards in England and 9 in Wales, as well 9 Royal Colleges to introduce ourselves and the study aims before asking their willingness to circulate the survey among their staff.

Participants

Participants consisted of frontline medical staff, who completed 4 questionnaires at two timepoints (waves): 1) at the start of the outbreak (i.e., immediate testing), and 2) towards the end of the outbreak (approximately 1 year after the initial testing). Before completing the questionnaires, participants were presented with an information sheet about the study followed by a consent form. Only participants who provided informed consent by ticking a ‘consent’ box were allowed to proceed to the study; any participants who did not consent were taken directly to an ‘end’ page and did not take part in the study.

Wave 1: A total of 476 respondents clicked on the survey link. Of the who clicked on the link, 240 completed the Covid-19 Anxieties Questionnaire; 225 completed the CSS, 216 participants completed the DASS-21 questionnaire, and 194 completed the PCL-5. All participants who completed the first questionnaire of the survey were included in the study. This provided a sample of 240 participants (193 females; 47 males). Participants ranged from 21 to 74 years of age (M = 42.82; SD = 11.68). The mean number of years participants spent working in the NHS was 16.8 (SD = 11.66). Most participants considered themselves frontline NHS staff (189, 78.75%). Of the 240 participants who took part, 194 (80.8%) were medical or health care staff, whilst 46 (19.2%) were technical and administrative staff. Forty-seven participants (19.58%) reported that they had been re-allocated to work on the frontline for the COVID-19 pandemic. A total of 125 (52.08%) participants reported that they had come in to contact with someone confirmed to have COVID-19 in the past seven days during work; 56 (23.33%) participants reported that they had not been in contact with someone confirmed to have COVID-19, whilst 59 (24.58%) did not know if they had meet someone confirmed to have COVID-19.

Wave 2: A total of 129 respondents who had taken part in the Wave 1 data collection clicked on the survey link. Of the who clicked on the link, 95 completed the Covid-19 Anxieties questionnaire, 92 the CSS, 85 the DASS, and 78 the PCL-5. All participants who completed the Covid-19 Anxieties questionnaire were included in the final sample for analysis. This provided a sample of 95 participants (76 females; 19 males). Participants ranged from 22 to 73 years of age (M = 42.66; SD = 11.46). The mean number of years participants spent working in the NHS was 16.99 (SD = 10.94). Seventy-seven participants considered themselves frontline NHS staff. Of the 95 participants, 83 (87.36%) were medical or health care staff, whilst 12 (12.63%) were technical and administrative staff. Seventy-seven participants (81.05%) reported that they had not been re-allocated to work on the frontline for the COVID-19 pandemic. A total of 13 (13.68%) participants reported that they had come in to contact with someone confirmed to have COVID-19 in the past seven days during work; 67 (70.53%) participants reported that they had not been in contact with someone confirmed to have COVID-19, whilst 15 (15.79%) did not know if they had meet someone confirmed to have COVID-19.

Measures

COVID-19 anxiety questionnaire

The COVID − 19 anxiety questionnaire was in-house built questionnaire. It contained 11 questions (see Table 1) pertaining to the participants’ worries related to the pandemic and specifically their worries about their own and their family’s health, their finances, and other people’s behaviour (e.g., ‘I am worried that a close family member might die of COVID-19’ or ‘I am worried about my family’s finances during the COVID-19 pandemic’ or ‘I am frustrated /upset that people do not respect social distancing rules’). Each question was followed by a 5-point Likert scale, with the choices being Strongly disagree (1), Disagree (2), Undecided (3), Agree (4), and Strongly agree (5).

The mean score on the Covid-19 questionnaire from all Wave 1 participants was 3.45 (SD = .62) out of a maximum score of 5. A one-sample t-test against zero was significant, t(239) = 86.7, p < .001. Based on Wave 1 data, a Cronbach’s alpha reliability analysis on the whole scale (all 11 items) showed the questionnaire to reach acceptable reliability, α = 0.77. Most items appeared to be worthy of retention, resulting in a decrease in the alpha if deleted.

Principal Components analysis (PCA)

A principal component analysis (PCA) with an orthogonal rotation was used to analyse the data. The measures of sampling adequacy were good. Specifically, the value of the Kaiser-Meyer-Olkin test of sampling adequacy was .073, and Bartlett’s test of sphericity was significant [approximate chi-square (df = 55) = 828.327, p < .001], suggesting that the correlations between items was sufficiently strong to carry out a PCA. Four components were identified in the initial analysis, with Eigenvalues greater than Kaiser’s criterion of 1 and combined those components explained 68.1% of the variance. We present the factor loadings both for four and for two factors (Table 1 and Table 2 respectively). In Table 1, component 1 represents a fear about health (own and family), component 2 a fear about family health, component 3 to finances and component 4 to fears relating to social distancing.

Table 1

Summary of the exploratory factor analysis results for the COVID-19 questionnaire data from Wave 1 with items loading onto four principal components (N = 240).
	Rotated factor loadings
Item	Fear about own health	Fears about family health	Fears about finances	Fear about social distancing
1. I am worried that I am going to become infected by COVID-19.	.79	.33	.07	.09
2. I am worried that I could die of COVID-19.	.82	− .19	− .03	− .01
3. I am worried that a close member of family might die of COVID-19.	.25	.86	.08	.08
4. I am worried that a close member of family will become infected by COVID-19.	.25	.87	.01	.02
5. I am worried about my finances during the COVID-19 pandemic	.15	− .03	.89	.07
6. I feel unsafe to work during this pandemic.	.76	.08	.21	.06
7. I am worried about my family’s finances during the COVID-19 pandemic.	.04	.15	.89	.08
8. Adhering to social distancing has made it stressful to do my job.	.50	− .03	.10	.54
9. Social distancing has made it very difficult for me to run every day errands.	.02	− .01	.01	.85
10. I am frustrated/upset that people do not respect social distancing rules.	.39	.26	.00	.34
11. I need to support vulnerable people in my family and find it difficult to run their errands.	− .01	.43	.22	.52

When reduced to two components (Table 2), the items clustering around component 1 related to fears about health (own and close family) and fears about the ability to support oneself and others (financially and generally). When two components were extracted, they explained 48% of the variance, while with four components 68% of the variance was explained.

Table 2

Summary of the exploratory factor analysis results for the COVID-19 questionnaire data from Wave 1 (N = 240), with items loading onto two principal components.
	Rotated factor loadings
Item	Worries about caring for own & other’s health	Worries about the ability to (financially) support others
1. I am worried that I am going to become infected by COVID-19.	.82	.09
2. I am worried that I could die of COVID-19.	.92	− .06
3. I am worried that a close member of family might die of COVID-19.	.54	.16
4. I am worried that a close member of family will become infected by COVID-19.	.45	.07
5. I am worried about my finances during the COVID-19 pandemic.	.04	.97
6. I feel unsafe to work during this pandemic.	.74	.01
7. I am worried about my family’s finances during the COVID-19 pandemic.	.03	1.1
8. Adhering to social distancing has made it stressful to do my job.	.66	.27
9. Social distancing has made it very difficult for me to run every day errands.	.25	.29
10. I am frustrated/upset that people do not respect social distancing rules.	.51	.12
11. I need to support vulnerable people in my family and find it difficult to run their errands.	.47	.61

COVID-19 questionnaire - sub-scale reliability analysis

A Cronbach’s alpha reliability analysis on the ‘fears about health’ sub-scale revealed a Cronbach’s alpha of high reliability, α = 0.79. All items were retained as none of the items resulted in an increase if the item was deleted. For the second subscale on ‘fears about ability to support others’, Cronbach’s alpha was .57. Removal of item 9 (Social distancing has made it very difficult for me to run everyday errands) resulted in an increase of alpha to .61. However, it was decided to retain this item given the small increase in reliability.

Crisis Support Scale

The Crisis Support Scale (CSS; Joseph et al., 1992; Elklit et al., 2001) consists of 6 questions on perceived level of social support after a crisis. Here, we amended the scale to measure social support before and during the pandemic and amended the wording to include the word ‘pandemic’. The same 6 questions referring to perceived support were amended so that 6 referred to support before the pandemic and 6 during the pandemic. Statements such as ‘Whenever you wanted to talk, how often was there someone willing to listen just before the pandemic?’ or ‘Did people you expected to be supportive make you feel worse at any time during the pandemic?’ were followed by a 7-point Likert scale ranging from Never (0) to Always (7).

Depression, Anxiety and Stress Scales-21 (DASS-21).

The DASS-21 (Antony, et al., 1998) is a 21-item version of the Depression, Anxiety and Stress Scales (DASS). There are three scales (depression, anxiety, and stress) each with seven items which refer to the past week and are scored using a 4-point Likert scale with the options being Never (0), Sometimes (1), Often (2), Almost always (3). Summing the total points for each scale produces three corresponding scores between 0 and 28 which are each subsequently doubled to create three final score which fall into five possible severities (normal, mild, moderate, severe, extremely severe). Examples of questions include: “I found it difficult to work up the initiative to do things” (depression); “I felt I was close to panic” (anxiety); and “I tended to over-react to situations” (stress). Research has demonstrated positive psychometric properties of the DASS in adults and older adults with anxiety and mood disorders (e.g., Antony et al., 1998). The three scales have excellent internal consistencies (depression range = .91 to .97; anxiety range = .81 to .92; stress range = .88 to .95). Inter-scale correlations range from .50 and below for depression and anxiety; .65 to .73 for anxiety and stress; and .57 to .79 for depression and stress.

Post-Traumatic Stress Disorder (PTSD) checklist.

For the current study we asked participants to fucus on the past month. The presence and severity of post-traumatic stress disorder symptoms was measured by post-traumatic stress disorder checklist (PCL-5), a 20-item self-report measure. The measure has strong reliability and validity, with Cronbach's alpha coefficient of 0.94 and the retest reliability was 0.82 (Blevins et al., 2015). PCL-5 reflects fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) changes to the PTSD criteria (e.g., Blevins et al., 2015). Each item has five-point Likert (0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit and 4 = extremely). The PCL-5 scores can range from 0 to 80 with higher scores indicating higher PTSD symptoms (e.g., Chiang, et al., 2020). For the current study we asked participants to focus on how they felt during the past month.

Procedure

A correlational cross-sectional design was employed. Participants were sent a link from their manager to the Qualtrics survey via an email to their NHS email address. Upon clicking on the link, participants were first given information about the survey and the study’s purpose before being asked for consent. They were then asked questions about their age, sex, occupation, whether they consider themselves to be frontline NHS staff, whether they have encountered someone suffering with COVID during the last 7 days, and whether they were re-allocated on the frontline due to the pandemic. They were asked the date they took part in the survey and to give their email address if they were happy to be contacted for a follow-up survey in a year’s time.

Participants completed the Covid-19 anxieties questionnaire, followed by the Crisis Support Scale (CSS), the DASS and the PTSD (PCL-5) measures. They were first invited to take part in the survey in April 2020 and the last participant completed the survey end of June 2020. Based on the UK government statistics (source https://coronavirus.data.gov.uk/details) the number of COVID-19 cases and deaths at the time that the first respondent completed the survey in the first week of April 2020 there were approximately 6,000 cases, and 1,000 deaths. The last participant responded in the last week of June 2020 when there were approximately 269, 687 cumulative cases, and 39,659 cumulative deaths at this timepoint.

At wave 2 participants completed the survey approximately a year later between April and May 2021, with the first responded completing the survey in the last week of April 2021 (approximately 4.3 million cases and 128,000 deaths), and the last completing the survey the last week of May 2021 (approximately 4.46 million cases, and 129,823 deaths).

We present the following analyses: (1) Comparison between Waves on Covid, CSS, DASS, and PTSD measures, (2) Wave 1 correlations, and (3) Wave 2 correlations.

1. Comparison between Wave 1 and Wave 2 data

Comparisons on the Covid-19 questionnaire

Mean scores on the Covid-19 scale for those participants who completed the measure in both data collection waves (N = 95), appear in Fig. 1A. There was a significant reduction of the overall mean Covid-19 scores at Wave 2 (M = 3.00, SD = .64) compared to Wave 1 [(M = 3.45, SD = .61), t(94) = 7.00, p < .001, 95% CI 0.32–0.57]. The same pattern for reduction of Covid-19 related worries was revealed when we examined the two Covid-19 subscales. Specifically, for factor 1 (health worries) Wave 2 scores were significantly lower than Wave 1 scores, t(94) = 6.58, p < .001, 95% CI 0.37–0.68. Similarly, for factor 2 (financial worries), Wave 2 scores were lower that Wave 1 scores, t(94) = 3.75, p < .001, 95% CI 0.14–0.46.

Comparisons on the Crisis Support Scale (CSS)

Mean scores on the CSS are shown in Fig. 1B. First, we report comparisons between CSS scores before the pandemic (CSS before scores) against CSS during the pandemic (CSS during scores). Examining Wave 1 data alone, CSS during scores (M = 26.43, SD = 7.19) were significantly higher CSS before (M = 25.50, SD = 7.74), t(94) = 2.00, p = .05, 95% CI 0.07–0.19. Examining the Wave 2 data alone, there was no difference between CSS before (M = 25.34, SD = 5.85) and CSS during (M = 24.9, SD = 6.12), t(91) = .97 p = .34.

Second, we report comparisons between Wave 1 and 2 on CSS before and CSS after. Pairwise comparisons showed that CSS before scores were not different between Waves 1 and 2, t(91) = .17, p = .86. However, CSS during scores were significantly lower at Wave 2 compared to Wave 1, t(91) = 2.17, p = .03, 95% CI 0.13–2.93, indicating that perceived levels of social and emotional support during the crisis were lower 15 months into the pandemic as compared to 2 months into the pandemic.

Comparisons on DASS

Mean percent of scores on the DASS-21 are shown in Fig. 2 for Wave 1 and 2, for participants who took part in both waves. Also shown is the percentage of participants who fell into the normal, mild, moderate, and severe categories. There was no difference between Waves 1 and 2 for either depression (t(84) = .04, p = 0.96), anxiety (t(84) = 1.68, p = .09), or stress (t(84) = .56, p = .58).

Comparisons on the PTSD (PCL-5)

Mean PTSD score across the sample in Wave 1 data was 22.67 (SD = 17.58). Of the 78 participants who completed the scale, 19 (24.3%) met the criteria for PTSD diagnosis, with a mean PTSD score 44.63 (SD = 10.34). The Wave 2 data from the same participants showed a mean PTSD score of 20.14 (SD = 15.85). Based on the Wave 1 data, 20 participants (25.6%) met the criteria for PTSD diagnosis with a mean PTSD score of 42.4 (SD = 12.79).

Comparing the mean PTSD scores at Wave 1 and 2, for the 78 participants who provided data at both times, there was no difference in PTSD scores between Wave 1 and Wave 2 (t(77) = 1.1, p = .27). There was also no difference in the percentage of participants with a PTSD diagnosis between the two waves (t(77) = .23, p = .82).

2. Wave 1 Correlations

Table 3 shows the correlations between measures based on the wave from Wave 1. Three sets of key observations arise. First, scores on depression, anxiety, and stress correlated positively with PTSD scores. Second, scores of the Covid-19 measure correlated positively with scores on depression, anxiety, stress and PTSD scores. Third, scores on the CSS correlated negatively and significantly with depression, anxiety, and stress.

Table 3

Correlations between measures at Wave 1. Asterisks denote significant correlations (*p < 0.01, ** p < 0.001.
	Covid-19 Worries about health (PCA1)	Covid-19 Worries about supporting others (PCA2)	CSS Before	CSS During	PTSD	Depression	Anxiety
Covid-19 (Worries about health)	-
Covid-19 (Worries about supporting others)	.36**	-
CSS Before	− .50	.02	-
CSS During	− .18**	− .12	.69**	-
PTSD	.45**	.28**	− .23**	− .28**	-
Depression	.35**	.29**	− .26**	− .31**	.73**	-
Anxiety	.44**	.37**	− .16*	− .19*	.65**	.60**	-
Stress	.42**	.32**	− .17*	− .17*	.69**	.70**	.76**

3. Wave 2 Correlations

Table 4 summarises the correlations between measures with the Wave 2 data. Those who scored highly on the COVID-19 finance worries scale (PCA2), also scored highly on levels of depression, anxiety, and stress. Those who scored highly on the health worries Covid-19 scale (PCA1) also scored highly on anxiety and stress, but not depression. Finally, unlike the data in Wave 1, in Wave 2 data there were no significant relationships between scores on the CSS and either of the two Covid-19 subscales.

Table 4

Correlations between measures at Wave 2. Note: Asterisks denote significant correlations - * p < .01, ** p < .001
	Covid-19 Worries about health (PCA1)	Covid-19 Worries about supporting others (PCA2)	CSS Before	CSS During	PTSD	Depression	Anxiety
Covid-19 PCA1	-
Covid-19 PCA2	.52**	-
CSS Before	− .05	− .13	-
CSS During	− .10	− .12	.79**	-
PTSD	.29**	.40**	− .16	− .37**	-
Depression	.12	.32**	− .46**	− .53**	.61**	-
Anxiety	.30**	.35**	− .22*	− .30**	.70**	.69**	-
Stress	.23**	.30**	− .38**	− .41**	.68**	.68**	.74**

The following key findings emerged. First, high levels of social support, especially during the pandemic predicted lower levels of depression, anxiety, stress, and PTSD scores. Second, high levels on the Covid-19 anxieties questionnaire predicted high levels of CMDs and PTSD scores. Third, strong social support led to lower Covid-19 anxiety, especially for the health worries subscale. Finally, comparing across time-points, although the scores on the Covid-19 anxieties questionnaire significantly reduced 12 months into the pandemic, the effects on mental health did not – there were no differences between time-points for any of the CMDs or PTSD symptoms.

There was a high prevalence of self-reported PTSD symptoms in both waves of data collection. Over 20% of our participants met the criteria of PTSD diagnosis. In a recent review of prevenance of PTSD consequences on healthcare workers, of the coronavirus-related pandemics (SARS and Covid-19), Falasi, Mazrouei, Ali, et al. (2021), reported a prevalence of acute PTSD symptoms among frontline medical staff ranged between ranged between 25.1% and 71.5% for China, and between 26.5% and 60.2% for USA. The current study corroborates the high prevalence – over 24% and 25% in Spring 2020 (Wave 1) and Spring 2021 (Wave 2) respectively – of self-reported PTSD symptoms among UK frontline healthcare professionals.

The prevalence of the other measured CMDs – stress, anxiety, and depression – was relatively high. Approximately 10% of our participants scored in the severe and 14% in the extremely severe range for depression, with approximately 20% reporting mild-to-moderate depression symptoms. Approximately 20% of our healthcare sample reported extremely severe anxiety, with over 50% reporting mild-to-moderate anxiety symptoms. Finally, over 50% reported mild stress symptoms. The data from depression and anxiety are comparable in terms of prevalence to those reported among a sample of German healthcare professionals (e.g., Weibelzahl, et al., 2021).

Implications of current findings for practice and research

The current findings demonstrate a need for further resources for psychological support and services for frontline medical staff following the outbreak. Specifically, the lack of difference in PTSD and CMDs scores between Wave 1 and Wave 2 of data collection, suggest a long-term deleterious effect on mental health difficulties that for some can become permanent if they are not addressed in time. Even with the danger of over-reporting symptoms (see Limitations and Strengths section), the perceived presence of mental health difficulties can lead to consolidation of some of those difficulties if not addressed sufficiently well and early.

Our work joins others in providing evidence to back a call to increased availability and access to mental health support for NHS staff, in the form of coping skills training, and reinforcing bonds with managers and co-workers (e.g., Cohen & Wills, 1985; Greenberg & Tracy, 2020; Ioannou, Kassianos, & Symeou, 2019). However, the data we present here demands that we go further, beyond the provisions for mental health support within the healthcare sector. Specifically, it appears that the provision and increased opportunity to use one’s own social support network, i.e., via extended leave, monetary compensation, recompense can be useful to build resilience.

Limitations and Strengths

A pandemic is an incident that presents itself suddenly and unexpectedly. Like other studies on pandemics and epidemics, which occur suddenly and without warning, we could not compare pre-pandemic scores on the same measures for our participants. Thus, it is impossible to separate those with chronic PTSD and CMDs symptoms from those whose symptoms emerged or worsened because of the pandemic. The current study is not alone in this limitation with some highly cited studies reporting the lack of baseline as an issue to be considered in the interpretation of the results (e.g., O'Connor, et al., 2021; Knowles, et al. 2022; Wang, et al., 2020) As in those studies, in the current study, to alleviate this limitation, we examined mental health (i.e., PTSD, depression, stress, and anxiety), social support and Covid anxieties in two separate waves of data collection over one year apart.

Second, the sample size was relatively small, preventing examination of risk factors in the development of symptoms. Another limitation is that we used self-administered tools to detect PTSD and CMDs, a practice that is vulnerable to over-reporting compared to clinical assessment (e.g., Bromet, et al., 2017). One methodological limitation and potential area for improvement, concerns the CSS measure. Specifically, asking people during the pandemic to report on their levels of social support during a crisis is susceptible to reporting bias. This could work in any direction – e.g., remembering pre-pandemic support as being better given that participants may feel insufficient support at the time of participation, or rating past support as similar to current support due to telescoping effects. In future studies, this limitation could be mitigated by including more concrete, behaviour-based items to supplement the CSS. E.g., the item “how often was there someone willing to listen” is somewhat vague compared with an alternative such as “how often did you meet with someone just to talk.”

The current study has some significant strengths. First, to our knowledge this is the first study using a measure of Covid-19 related worries in relation to the CMDs and PTSD in frontline NHS staff during the pandemic. The measure allowed us to capture some of the factors previously identified as predicting increases in psychological distress (e.g., Greene et al., 2021). This measure has the potential to be adapted for wider application, such as to other infectious diseases and other issues impacting NHS workers. Our Covid anxieties measure captures similar factors to those captured by other measures of Covid-19 fear, examined by Mertens, et al. (2021). They found several latent factors reflecting the multidimensionality of fear of COVID-19, including fear of health and fear about broad socio-economic consequences. In the current study, we examined how those aspects of fear of COVID-19 are related to common mental health difficulties, such as depression, anxiety and stress.

Second, the current study is one of the few longitudinal studies examining changes in reports of PTSD and CMDs. This allowed some key findings to emerge, showing that although worries about Covid-19 reduced after about a year into the pandemic, the mental health difficulties reported did not reduce, suggesting long-term effects of the pandemic on the mental health and psychological distress of frontline NHS staff.

In conclusion, the current study showed that (1) even when anxieties relating to the pandemic eased, the effects of the Covid-19 pandemic on CMDs and PTSD were long-lasting, and (2) social support during the crisis can reduce anxieties about the crisis as well as self-reported levels of CMDs and PTSD. To our knowledge, the current study is the only study so far to include a measure of emotional support received before and after the Covid-19 pandemic. This measure revealed important connections between levels of emotional support and the severity of Covid-19 anxieties questionnaire, especially during Wave 1 (Spring 2020). Critically, and consistent with previous work, our findings showed that high levels of social and emotional support from one’s support network is negatively correlated with all measured self-reported mental health difficulties – PTSD, depression, anxiety and stress. Our study joins others to underlie the need of the healthcare sector, and society as a whole, to make substantial provisions that allow to access and use one’s own social support network, i.e., via extended leave, monetary compensation, to help build resilience and moderate the detrimental long-term effects of pandemic-like situations on mental and psychological health.

Acknowledgments

The authors wish to gratefully acknowledge the help of the health boards and societies contacted and the staff that took part in the study. Author accepted manuscript document released under the terms of a Creative Commons CC-BY licence using the Swansea University Research Publications Policy (rights retention). CC-BY https://creativecommons.org/licenses/by/4.0/

Declaration of interest statement

The authors report no conflict of interest.

Data Availability

Should this manuscript be accepted, we will provide the data on an online data repository prior to publication and will provide a link to this is in the manuscript.

Author Contribution

FC and IR conceptualised the study, MC created the online questionnaires, JDT and IR analysed the data, JDT prepared the figures, and IR prepared the tables. IR wrote the first draft of the manuscript while FC, JDT, and MQ modified the manuscript.

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No competing interests reported.

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A longitudinal study examining PTSD and other mental health problems in NHS workers during the COVID-19 pandemic

Status:

Version 1

Abstract

Figures

INTRODUCTION

METHOD

Design and Recruitment

Participants

Measures

COVID-19 anxiety questionnaire

Crisis Support Scale

Procedure

RESULTS

1. Comparison between Wave 1 and Wave 2 data

Comparisons on the Covid-19 questionnaire

Comparisons on the Crisis Support Scale (CSS)

Comparisons on DASS

Comparisons on the PTSD (PCL-5)

2. Wave 1 Correlations

3. Wave 2 Correlations

DISCUSSION

Implications of current findings for practice and research

Limitations and Strengths

Conclusions

Declarations

References

Additional Declarations

Status:

Version 1