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. 2022 Dec 20;320:115012. doi: 10.1016/j.psychres.2022.115012

City-wide study of laboratory-confirmed COVID-19 cases in San Antonio: An investigation of stressful events accompanying infection and their relation to psychosocial functioning

Jack Tsai a,b,⁎, Abigail Grace a, Carol S North c, Robert H Pietrzak d,e, Marilu Vazquez a, Anita Kurian f
PMCID: PMC9762912  PMID: 36565515

Abstract

Little is known about how Coronavirus Disease-2019 (COVID-19) infection is associated with stressful events (SEs) and stress-related psychological symptoms. This study examined the prevalence of SEs and incidence of stress-related symptoms accompanying COVID-19 infection. The association between these stress-related symptoms and psychosocial functioning were also examined. A city-wide sample of 3,595 adults with lab-informed cases of COVID-19 infection in San Antonio, Texas completed an online assessment of their psychological health and well-being after completing contact tracing activities in 2021–2022. A total 88.3% of participants reported exposure to SEs related to COVID-19 infection and their “worst” SEs were related to physical symptoms, fear of infecting others, financial problems, being isolated/quarantined, and loss of a loved one. Based on these SEs, 14.8% of the sample screened positive for substantial stress-related psychological problems related to COVID-19 infection. These psychological symptoms were strongly associated with worse psychosocial functioning. Together, these findings suggest SEs were commonly experienced by adults infected with COVID-19. Only a relatively small proportion reported substantial psychological symptoms related to their infection, but those who did had a high likelihood of impaired psychosocial functioning. Targeted support for individuals at high-risk of psychological symptoms following COVID-19 infection may help mitigate long-term psychological effects.

Keywords: COVID-19 infection, Stressful events, Psychosocial functioning, Stress disorders

1. Introduction

The Coronavirus Disease-2019 (COVID-19) has infected over 560 million people around the world with over 6 million deaths reported related to COVID-19 as of July 2022 (Worldometer, 2022). The COVID-19 pandemic not only included disease outbreaks but involved city lockdowns, closing of businesses, and other events during this time. These events have disrupted the lives of many Americans, with a large body of studies documenting high levels of psychological distress experienced by frontline healthcare providers (Krishnamoorthy et al., 2020; Salari et al., 2020), as well as the general U.S. population during the COVID-19 pandemic (Abrams and Szefler, 2020; Blundell et al., 2020; Kickbusch et al., 2020; McKee and Stuckler, 2020; Torales et al., 2020).

A large growing body of studies have examined whether COVID-19 infection is associated with psychological symptoms. A systematic review of 43 studies found only two studies that have evaluated patients with confirmed COVID-infection; these two studies found high levels of post-traumatic stress symptoms and depressive symptoms in patients with COVID-19 (Vindegaard and Benros, 2020). Among the other studies in the review, patients with pre-existing psychiatric disorder have reported worsening psychiatric symptoms and increased mental health symptoms also been reported by health care workers and the general public during the COVID-19 pandemic. Thus, most studies have recruited patient samples with a lack of general population samples with lab-confirmed COVID-19.

One previous national study of middle and low-income U.S. adults with self-reported COVID-19 infection found that COVID-19 was not independently associated with symptoms of major depressive disorder, generalized anxiety disorder, alcohol use disorder, recent suicidal ideation, or posttraumatic stress symptoms; however, the combination of COVID-19 infection with symptoms of mental illness and alcohol use disorder additively predicted suicidal ideation (Tsai et al., 2021). Further, a meta-analysis has estimated the prevalence of depression and posttraumatic stress symptoms among patients with acute COVID-19 infection to be 42% for depression and 96% for posttraumatic stress disorder (PTSD) symptoms (Krishnamoorthy et al., 2020). Of note, the elevated prevalence of psychological symptoms is not unique to COVID-19 infection, as they have also been observed in previous severe coronavirus outbreaks, with 15% of survivors screening positive for depressive and 33% from posttraumatic stress symptoms after more than a year follow-up (Rogers et al., 2020).

PTSD is a particularly salient disorder in the public consciousness and among health care providers during the COVID-19 pandemic. A diagnosis of PTSD requires a precipitating event or situation in which a person is exposed to “death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence” according to Criterion A of the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5; American Psychiatric Association, 2013). This exposure may involve direct or indirect exposure such as witnessing the trauma or learning details about the trauma from somebody who experienced the event. There have been debates about whether COVID-19 infection, itself, is a Criterion A-qualifying traumatic event (Bridgland et al., 2021; Janiri et al., 2021; Norrholm et al., 2021; Van Overmeire, 2020). Some researchers have pointed out that “medical conditions from natural causes such as life-threatening viral infection do not meet the current criteria for trauma required for a diagnosis of PTSD” (Pfefferbaum and North, 2020), while others have noted that the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10; World Health Organization, 2004) does not contain this exclusionary clause (Shevlin et al., 2020). Because of this unresolved inconsistency, we chose to examine “stressful events” (SE) and corresponding stress-related psychological symptoms arising from COVID-19 infection rather than assuming COVID-19 represents trauma and results in posttraumatic stress symptoms. This seems particularly appropriate because there have been so many diverse experiences from both COVID-19 infection and the pandemic. A notable knowledge gap in understanding sequalae related to COVID-19 infection is examination of what SEs may be related to COVID-19 infection and how these specific SEs may result in psychological symptoms.

To examine these issues further, we analyzed data from more than 3500 adults with laboratory-confirmed COVID-19 infection in the city of San Antonio who were recruited at the time of contact tracing from early 2021 to 2022. Contact tracing has been an important infection prevention and control measure for over a century and was widely used during the COVID-19 pandemic. Through a citywide contact tracing effort in the city of San Antonio, the 7th most populous city in the U.S., we had a unique opportunity to study types of SEs related to COVID-19 infection that individuals experienced. This study contributes to the extant literature by evaluating a community sample with confirmed COVID-19 infection and not a patient sample; and specifically examines SEs in related to COVID-19 infection instead of the pandemic broadly.

We had three aims in this study: 1) characterize the nature and prevalence of SEs that accompanied COVID-19 infection; 2) examine the incidence of psychological symptoms related to COVID-19 related SEs; and 3) evaluate the association between psychological symptoms and psychosocial functioning.

2. Methods

From 2020–2022, the San Antonio campus for the University of Texas Health Science Center at Houston (UTHealth) School of Public Health led a city-wide call center for COVID-19 contact tracing in partnership with the City of San Antonio Metropolitan Health District. During that time, the UTHealth School of Public Health contact tracing team initiated over 80,000 calls in San Antonio to contact individuals infected with laboratory-confirmed cases of COVID-19 sent by hospitals and healthcare providers. The contact tracing team then works with infected individuals to gather personal information about places they visited and people they may have exposed.

From February 18, 2021 to March 28, 2022, the UTHealth School of Public Health contact tracing team deployed a research survey to study the health and psychosocial status of San Antonio residents with COVID-19 infection. The survey was hosted by the university's Qualtrics account and an invitation link to the survey was sent by text to every COVID-19 case that agreed to participate after they completing their contact tracing interview. The survey link was sent by the contact tracer team immediately after their interview and participants completed the survey the same day or at least within 5 days. Eligibility criteria for participation was that participants had to be 18 years or older; currently living in San Antonio; have a laboratory-confirmed case of COVID-19 as verified by the contact tracing team; and can read and write in English. Informed consent was obtained, and all study procedures were approved by the institutional review board at UTHealth School of Public Health. A total of 8807 individuals agreed to be sent a survey invitation, and 3595 (40.8%) participants completed the survey fully and were included in the study.

2.1. Measures

Sociodemographic information was assessed using a questionnaire that collected information about age, gender, race/ethnicity, education, marital status, employment status, income level, and veteran status.

Psychiatric history was assessed with a question that asked “Has a doctor or nurse ever told you that you have any of the following conditions” and participants responded to a list of 9 different mental and substance use disorder diagnoses.

Exposure to SEs at any time before 2020 (i.e., before the COVID-19 pandemic) was assessed with the standard self-report version of the Life-Events Checklist for DSM-5 (LEC-5; Weathers et al., 2018). The LEC-5 provides a list of 17 SEs and participants indicate whether the event happened to them directly, whether they witnessed it, whether they learned about it happening to someone else, and/or they were exposed to it as part of their job. For the current study, participants were instructed to only refer to the time before 2020 (i.e., before the COVID-19 pandemic), and after completing the list of 17 SEs, participants were asked to indicate which event was the “most recent” for them.

Exposure to SEs specifically related to COVID-19 infection was assessed with a measure created for this study based on review of the literature on COVID-19 infection (Dubey et al., 2020; Stavridou et al., 2020). Participants were instructed to: “Now thinking about any difficult or stressful things that may have happened with your COVID-19 infection this year, please check one or more of the boxes below to indicate if any of the events happened to you personally as a result of COVID-19 infection” and provided a list of 18 items, such as “needed hospitalization,” “put on a ventilator,” and “fear of infecting others.”

Psychological symptoms related to SEs were assessed with the PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2013). The PCL-5 is a 20-item self-report assessment that is typically used to determine posttraumatic stress symptoms but we used it in this study to assess stress-related symptoms more broadly given unresolved debates about whether the stress of COVID-19 infection constitutes a traumatic event (Bridgland et al., 2021; Janiri et al., 2021; Norrholm et al., 2021; Van Overmeire, 2020). For this study, the PCL-5 was administered twice. First, participants were asked to refer to their “most recent” SE endorsed on the LEC-5 before the year 2020 (i.e., before the COVID-19 pandemic) and then to rate the extent to which they were bothered by each of the PCL-5 symptoms from 0 (Not at all) to 4 (Extremely) before 2020 (Mota et al., 2016). The PCL-5 was then administered a second time by asking participants to refer to their “worst” SE specifically related to their COVID-19 infection and then to rate items on the same scale in reference to the past year. PCL-5 items were summed for a total score and scores ≥33 were considered a positive screen for substantial stress symptoms (Bovin et al., 2016). In this study, the PCL-5 showed excellent internal consistency (Cronbach's alpha= 0.97 in reference to period before 2020 and 0.97 in reference to after 2020).

Symptoms of major depression and generalized anxiety disorder were assessed with the 4-item Patient Health Questionnaire (PHQ-4) which consists of two items that assess depression (PHQ-2; Kroenke et al., 2003) and two items that assess for anxiety (GAD-2; Kroenke et al., 2007) with scores of ≥3 indicative of a positive screen for each respective disorder (Kroenke et al., 2001). In this study, there was good internal consistency for the PHQ-2 and GAD-2 (Cronbach's alpha= 0.82 and 0.80, respectively). Symptoms of alcohol use disorder were assessed with the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) with a score ≥4 indicative of a positive screen (Bush et al., 1998). In this study, the AUDIT-C had acceptable internal consistency (Cronbach's alpha= 0.71).

Psychosocial functioning was assessed with the Brief Inventory of Psychosocial Functioning (B-IPF; Bovin et al., 2018). The B-IPF is an abridged 7-item version of the Inventory of Psychosocial Functioning (IPF; Kleiman et al., 2020) that assesses past-month difficulties in seven functional domains including romantic relationships, family relationships, work, friendships and socializing, parenting, education, and self-care. Only those domains that were relevant to an individual were completed and scored.

2.2. Data analysis

Descriptive analyses were conducted to examine characteristics of the sample; prevalence of SEs prior to the COVID-19 pandemic, incidence of SEs related to COVID-19 infection, and associated stress-related psychological symptoms. Bivariate tests including a paired sample t-test and a McNemar's chi-square test were used to examine changes in psychological stress-related symptoms over time. Then, a series of multivariable models were analyzed, each including demographic characteristics, psychiatric history, current psychological symptoms, PCL score for the most recent past stressful event, PCL score for the worst COVID-related stressful event, and psychosocial functioning as measured by the B-IPF. Finally, relative importance analyses (Tonidandel and LeBreton, 2011) were conducted to identify which characteristics in the multiple regression were the most “important” (i.e., contributed the most variance) in relation to psychosocial functioning.

3. Results

Table 1 shows the background characteristics of participants and their exposure to SEs before the COVID-19 pandemic. The majority of participants were female, White Hispanic, in their late 30′s, with at least some college education, employed, married/living with a partner, and with an annual income below $60,000. About a quarter of the sample reported having been diagnosed with a psychiatric or substance use disorder before.

Table 1.

Sociodemographic characteristics, mental health history, and exposure to potentially traumatic events among adults with COVID-19 infection (n = 3595).

Sociodemographic characteristics Mean/N (SD/%)a
Age 37.04 (0.22)
Gender
▒Male 1238 (34.44%)
▒Female 2344 (65.20%)
▒Other 13 (0.36%)
Race/Ethnicity
▒White Non-Hispanic 951 (26.45%)
▒White Hispanic 2003 (55.72%)
▒Black Non-Hispanic 297 (8.26%)
▒Black Hispanic 78 (2.17%)
▒Asian/Pacific Islander 100 (2.78%)
▒Native American/Alaskan Native 30 (0.83%)
▒Other 136 (3.78%)
Education
▒Below high school 103 (2.87%)
▒High school or equivalent 907 (25.23%)
▒Some college 1100 (30.60%)
▒Associates/Bachelor's 1116 (31.04%)
▒Master's degree 305 (8.48%)
▒Doctoral degree 64 (1.78%)
Marital status
▒Single 1558 (43.34%)
▒Married/Living with partner 1607 (44.70%)
▒Divorced/Separated/Widowed 430 (11.96%)
Employment status
▒Employed full/half-time 2593 (72.13%)
▒Unemployed/Other 573 (15.94%)
▒Disabled/Retired 214 (5.95%)
▒Self-employed 215 (5.98%)
Personal annual income
▒No income 329 (9.15%)
▒$1-$19,999 814 (22.64%)
▒$20,000-$39,999 964 (26.82%)
▒$40,000-$59,999 728 (20.25%)
▒$60,000-$79,999 349 (9.71%)
▒$80,000-$99,999 175 (4.87%)
▒$100,000+ 236 (6.56%)
Psychological assessment
Psychiatric history 891 (24.78%)
▒Schizophrenia-spectrum disorder 12 (0.33%)
▒Bipolar disorder 139 (3.87%)
▒Major depressive disorder 263 (7.32%)
▒Anxiety disorder 590 (16.41%)
▒Alcohol use disorder 64 (1.78%)
▒Drug use disorder 41 (1.14%)
Current PHQ-2 score 1.26 (0.03)
Current GAD-2 score 1.31 (0.03)
Current AUDIT-C score 2.27 (0.04)
Exposure to stressful events before 2020 1866 (51.91%)
▒Transportation accident 943 (26.23%)
▒Physical assault 494 (13.74%)
▒Natural disaster 421 (11.71%)
▒Unwanted/uncomfortable sexual experience 402 (11.18%)
▒Sexual assault 320 (8.90%)
▒Any other stressful event/experience 271 (7.54%)
▒Life-threatening illness/injury 247 (6.87%)
▒Serious accident at work, home, or recreational activity 229 (6.37%)
▒Assault with a weapon 178 (4.95%)
▒Fire/explosion 157 (4.37%)
▒Sudden violent death 134 (3.73%)
▒Sudden accidental death 126 (3.50%)
▒Exposure to toxic substance (e.g., dangerous chemicals) 83 (2.31%)
▒Combat or exposure to war zone 78 (2.17%)
▒Serious injury, harm, or death you caused to someone else 33 (0.92%)
▒Captivity (e.g., kidnapped, abducted) 30 (0.83%)
PCL-5 score for participants’ most recent event before 2020 16.42 (0.33)
% of participants who screened positive for substantial mental health problems in reference to event before 2020b 687 (19.11%)
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a

Ranges for age were 18–89. Ranges for PHQ-2 scores were 0–6. Ranges for GAD-2 scores were 0–6. Ranges for AUDIT-C scores were 0–12.

b

Positive screen for substantial mental health problems was based on PCL-5 score ≥ 33.

The demographic composition of the study sample is roughly similar to that of the San Antonio adult population (U.S. Census Bureau, n.d.), except the study sample had a higher proportion of females (65% versus 51%) and high school graduates (97% versus 83%).

3.1. Exposure to stressful events

In the total sample, 52% reported exposure to SEs prior to the year 2020 (i.e., before the COVID-19 pandemic). Among SEs, the most prevalent, in descending order, were transportation accident, physical assault, natural disaster, unwanted/uncomfortable sexual experience, and sexual assault. Among participants who reported SEs, 19.1% screened positive for substantial psychological problems in reference to events prior to 2020.

Table 2 presents exposure to SEs related to COVID-19 infection. In the total sample, 3173 (88.3%) reported any SE exposure related to COVID-19 infection. Among the most common SEs, more than half of participants reported physical symptoms, being isolated/quarantined, fears of infecting others, social isolation, and financial problems. Among the “worst” SEs reported by participants, the most common were physical symptoms, fear of infecting others, financial problems, being isolated/quarantined, and loss of a loved one from COVID-19. Based on these SEs, 14.8% of participants screened positive for substantial psychological problems related to COVID-19 infection. Of the sample, 796 (22.14%) screened positive for substantial psychological problems in reference to the period before the COVID-19 pandemic and the period during COVID-19 infection.

Table 2.

Exposure to stressful events related to COVID-19 infection (n = 3595).

Events related to COVID-19 infection # of participants that endorsed these events (%) # of participants that rated the event as their worst experience (%)
Physical symptoms 2102 (58.47%) 823 (22.89%)
Isolated/quarantined 1853 (51.54%) 260 (7.23%)
Fear of infecting others 1700 (47.29%) 486 (13.52%)
Social isolation 1099 (30.57%) 102 (2.84%)
Financial problems 837 (23.28%) 267 (7.43%)
Personal fear of infection 817 (22.73%) 89 (2.48%)
Loss of meaningful activities 654 (18.19%) 61 (1.70%)
Psychological symptoms 586 (16.30%) 99 (2.75%)
Loss of loved one from COVID-19 386 (10.74%) 216 (6.01%)
Food insecurity 283 (7.87%) 16 (0.45%)
Loss of job 233 (6.48%) 60 (1.67%)
Needed hospitalization 144 (4.01%) 30 (0.83%)
Eviction/housing instability 142 (3.95%) 27 (0.75%)
Others’ actual serious illness/death linked to your COVID-19 infection 135 (3.76%) 23 (0.64)
Life-threatening illness/injury 104 (2.89%) 40 (1.11%)
Any other stressful event/experience 101 (2.81%) 45 (1.25%)
Other serious illness, injury, harm, or death you caused to someone else 62 (1.72%) 9 (0.25%)
Put on a ventilator 51 (1.42%) 13 (0.36%)
PCL-5 score for participants’ ‘worst’ event from COVID-19 infection 14.62 (0.33)
% of participants who screened positive for substantial mental health problemsa from events related to COVID-19 infection 534 (14.85%)
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a

Positive screen for substantial mental health problems was based on PCL-5 score ≥ 33.

3.2. Mental health symptoms and psychosocial functioning

A paired samples t-test of PCL-5 scores revealed significantly lower PCL-5 scores in association with participants’ “worst” SE related to their COVID-19 infection relative to their most recent SE before the COVID-19 pandemic (M = 16.2, SD=19.2 vs. M = 17.8, SD=19.5 t(3207)= 8.11, p<.001, d = 0.14). Additionally, a McNemar's chi-square test indicated that the proportion of participants who screened positive for substantial stress symptoms in reference to COVID-19 infection was significantly lower than those in reference to prior to the COVID-19 pandemic, χ2(1)= 56.65, p<.001.

Table 3 shows associations between psychiatric history, current psychiatric symptoms, and PCL-5 scores before the COVID-19 pandemic and in reference to COVID-19 infection. A history of schizophrenia-spectrum disorder, bipolar disorder, and major depressive disorder along with current PHQ-2, GAD-2, and AUDIT-C scores were all significantly positively associated with total B-IPF scores. After controlling for these psychological variables along with sociodemographic characteristics, PCL-5 scores in reference to SEs prior to 2020 and PCL-5 scores in reference to SEs related to COVID-19 infection were both significantly associated with the total B-IPF scores. Both sets of PCL-5 scores were also significantly associated with each of the separate functional domains of the B-IPF (e.g., trouble with romantic relationships, trouble with day-to-day activities, trouble at work) with the exception that PCL-5 scores related to COVID-19 infection, which were not significantly associated with difficulties with romantic relationships or with family relationships.

Table 3.

Multiple regression of psychological symptoms associated with psychosocial functioning.

Trouble with romantic relationship
 Trouble with family relationship
 Trouble with friendships
 Trouble at work
 Trouble with training and education
 Trouble with day-to-day activities
 Total B-IPF score
B p-value B p-value B p-value B p-value B p-value B p-value B p-value
Any history of schizophrenia-spectrum disorder −0.96 .10 −0.16 .75 −0.88 .07 −1.80 <0.001 −1.13 .01 −0.92 .06 −7.05 <0.01
Any history of bipolar disorder .41 .05 .09 .60 .37 .03 .17 .29 .13 .40 .58 <0.01 2.06 .01
Any history of major depressive disorder .19 .22 .05 .72 .26 .04 .18 .13 .13 .27 .69 <0.001 1.59 <0.01
Any history of anxiety disorder −0.15 .35 −0.13 .17 −0.02 .86 .08 .35 −0.05 .55 −0.07 .47 −0.53 .20
Any history of alcohol use disorder .16 .57 .24 .30 −0.19 .41 −0.25 .26 .03 .89 −0.07 .76 −0.06 .96
Any history of drug use disorder .16 .64 −0.11 .72 .36 .20 .62 .02 .64 .01 .10 .73 2.41 .05
Current PHQ-2 score .07 .05 .11 <0.001 .18 <0.001 .15 <0.001 .12 <0.001 .31 <0.001 .98 <0.001
Current GAD-2 score .20 <0.001 .11 <0.001 .08 <0.01 .10 <0.001 .05 .06 .07 .01 .66 <0.001
Current AUDIT-C score .07 <0.001 .04 <0.01 .01 .32 .04 <0.01 .02 .07 .01 .38 .24 <0.001
PCL-5 score in relation to events before the COVID-19 pandemic .02 <0.001 .02 <0.001 .01 <0.001 .01 <0.01 .01 <0.01 .01 <0.01 .08 <0.001
PCL-5 score in relation to events related to COVID-19 infection .01 .28 .01 .06 .02 <0.001 .02 <0.001 .02 <0.001 .02 <0.001 .10 <0.001
Total R2 .17 .18 .28 .29 .27 .37 .42
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Note: Multiple regression analyses were conducted controlling for age, gender, race/ethnicity, education, marital status, employment, and income. Coefficients shown are unstandardized beta coefficients. B-IPF= Brief Inventory of Psychosocial Functioning. Bolded values indicate statistical significance at <0.05 level.

Further, as shown in Fig. 1 , relative importance analyses revealed that PCL-5 scores in relation to COVID-19 infection, PCL-5 scores before the COVID-19 pandemic, and PHQ-2 scores explained the majority of variance in total B-IPF scores, collectively accounting for over 60% of the explained variance.

Fig. 1.

Fig. 1

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Relative importance analysis of characteristics associated with scores on the Brief Inventory of Psychosocial Functioning (BIP-F).

4. Discussion

In this population-based study of COVID-19 infected adults in San Antonio, our first aim was to investigate the type and prevalence of SEs and stress-related symptoms over the lifetime and specifically related to COVID-19 infection. We found that a little over half of the sample reported experiencing lifetime SEs prior to the pandemic and approximately 88% of the sample reported experiencing SEs specifically related to COVID-19 infection. The most prevalent COVID-19 infection-related SEs were not only about physical symptoms but were experiences that may have resulted from government mitigation strategies and social distancing measures (e.g., social isolation) as well as socioeconomic sequalae (e.g., financial problems) of the pandemic. It is important to acknowledge that we took liberties in using a broad definition of SEs and assessed a range of experiences under that definition relevant to the COVID-19 pandemic. Nonetheless, these findings provide insight on a comprehensive spectrum of SEs that were experienced by participants with COVID-19 infection and the proportion who reported these SEs were directly related to their COVID-19 infection.

Following our second study aim to examine the incidence of psychological symptoms related to COVID-19 infection, we found that 15% of our sample screened positive for substantial stress symptoms in reference to COVID-19 infection-related SEs. Because we used the PCL-5 as our main stress measure, which is typically used to assess for posttraumatic symptoms and there are active debates in the field about what events constitute a “traumatic event”(American Psychiatric Association, 2013; Norrholm et al., 2021), our results should be interpreted with caution. We likely did not capture the full range of SEs or stress symptoms participants may have experienced. However, many researchers agree that at least some of the SEs related to COVID-19 infection that participants reported would meet the definition of a traumatic event (Bridgland et al., 2021; Janiri et al., 2021; Norrholm et al., 2021; Van Overmeire, 2020), and we included a relatively lengthy list of SEs because no consistent standard exists. Importantly, we compared stress symptoms reported by our sample in reference to agreed-upon SEs before the COVID-19 pandemic and then in reference to specific SEs related to COVID-19 infection during the pandemic. We found significantly lower proportions of participants reported substantial stress symptoms related to COVID-19 infection than related to events before the pandemic (19.1% relative to 14.8% screened positive). The time frames of this comparison are different, but one could interpret this finding to indicate that despite many people reporting SEs related to COVID-19 infection, the majority did not report substantial stress symptoms. This finding would also accord with extant literature that most people have experienced SEs in their lives, but most people are also resilient and do not develop psychiatric disorders even after major SEs such as serious accidents and natural disasters (Pfefferbaum and North, 2020; Tsai et al., 2018, 2017). However, not to be dismissed, the 14.8% proportion who screened positive for substantial psychological symptoms related to COVID-19 infection may be higher than general population estimates, such as the 8.3–9.8% prevalence of PTSD in the general U.S. adult population (Kilpatrick et al., 2013) although it may be comparable to estimates of subsyndromal PTSD (Brancu et al., 2016). Nevertheless, our findings suggest that a considerable proportion of individuals—approximately 1 of 7—experienced high levels of psychological distress in response to COVID-19 infection-related SEs.

With regard to our third study aim, we found that both psychological symptoms reported by participants before and during the COVID-19 pandemic were independently and significantly associated with poorer psychosocial functioning, even after adjusting for sociodemographic and other mental health characteristics. While psychological symptoms experienced before the pandemic were significantly associated with poorer functioning across all psychosocial domains assessed, including greater problems with romantic relationships, family relationships, friendships, work, training and education, and day-to-day activities; psychological symptoms experienced during the pandemic were significantly associated with poorer functioning in fewer psychosocial domains, including problems with friendships, work, training and education, and day-to-day activities. These findings confirm what is already known about the impact of mental health on psychosocial functioning (Ogle et al., 2013; Pietrzak et al., 2010; Tsai et al., 2012), but they contribute to the knowledge base in the context of the COVID-19 pandemic. Specifically, the findings outline particular domains of psychosocial functioning that may be impacted by psychological symptoms related to COVID-19 infection. The clinical implications are the need to target these symptoms to prevent psychosocial impairment and to monitor these psychosocial domains among those with COVID-19. In addition, COVID-19 recovery efforts as well as future pandemic and disaster preparedness should plan for intervention pathways to address these issues early to prevent these negative psychosocial sequalae.

Several limitations of this study are worth noting. First, this study was based on cross-sectional data and so no casual inferences can be made. Second, there are several potential biases that may have influenced results. Some participants who initially agreed to participate did not participate so there may have been participant bias; unfortunately, we did not have background information about those who did not participate to compare to those who did. Since participants were asked to recall SE exposures before 2020, there may have been recall bias. Third, the sample was limited to one major U.S. city and the generalizability of the results need to be replicated using other samples. Our sample was roughly similar to the San Antonio population although there were a few demographic differences. Lastly, in assessing SEs and related stress symptoms, we included many reference events that may not typically be considered and were created specifically for this study.

Nevertheless, these limitations are counterbalanced by the strengths of the study including a large, city-wide sample of laboratory-confirmed COVID-19 participants, assessment of a range of SEs, and multivariable analyses that controlled for other mental health variables. Together, results of this study contribute to the literature about SEs that may result in substantial stress symptoms, as well as the psychosocial impact of COVID-19 infection on the population at large as the world works to recover and learn from the COVID-19 pandemic.

Author statement

J. Tsai conceptualized the study, supervised project staff, and wrote the paper. A. Grace helped with data collection and data curation. C. North and R. Pietrzak helped conceptualize and write the paper. M. Vazquez helped with project administration. A. Kurian provided project administration support and resources for the study. All authors approved the submitted paper.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

None of the authors report any conflicts of interest with this work.

Acknowledgements

The authors thank the UTHealth COVID-19 contact tracing team and the City of San Antonio Metropolitan Health District for their support of this work.

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