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. 2023 Feb 9:1–10. Online ahead of print. doi: 10.1007/s12144-023-04291-z

PTSS in COVID-19 survivors peritraumatic stress symptoms among COVID-19 survivors in Iraq

Parzheen J Mohammad 1, Dyari S Hama amin 2,✉, Pshtiwan F Mohammed 3, Hawkar A Hussein 4, Omiad S Abdullah 5
PMCID: PMC9909637  PMID: 36785743

Abstract

The COVID-19 pandemic became a source of psychological distress worldwide. People infected with the disease faced the possibility of losing their lives, and due to the high number of people with the disease, hospitals were overburdened. Therefore, the situation had characteristics of a traumatic event; this is especially true in Iraq since the healthcare system is on the brink of failure, and the hospitals are a place of low-quality service. Consequently, the current study aims to explore peritraumatic stress symptoms among survivors of COVID-19 in Iraq. Moreover, group differences based on several variables and the associated factors with peritraumatic stress are also investigated. The post-traumatic stress disorder checklist for DSM-5 was used as a measurement tool. A total of 370 survivors of COVID-19 from the different governorates of Iraq participated in this study; 148 females and 22 males. 51, 70, 165, and 84 participants were aged 18–25, 26–30, 31–40, and above 40, respectively. The results revealed that 31.1% of the participants had probable PTSD since they scored above the cut-off of the score of 23. Significant differences between males and females were not found. Regarding associated factors, education level was a significant predictor (i.e., no education, primary school, secondary school, diploma, bachelor’s degree, and postgraduate degree). Compared to primary school education and no education, postgraduate education was significantly associated with probable PTSD. Furthermore, the longer duration of being infected with COVID-19 was associated with higher odds of having probable PTSD. This was one of the first studies in Iraq to explore peritraumatic stress symptoms following COVID-19 infection using standardized instruments and investigate the associated factors. The results have various implications for developing the healthcare system of Iraq and the need to have social workers and psychologists trained in psychological first aid available in the hospital to manage the patients’ distress.

Keywords: PTSS, Trauma, COVID-19, Iraq, Pandemic

Background

The initial outbreak of Coronavirus Disease of 2019 (COVID-19) dates back to December 2019, when cases of pneumonia with no clear etiology were identified. Soon it was discovered that the disease was caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), and a novel coronavirus was recognized (World Health Organization, 2020). As of July 30, 2021, around the world, more than 196 million cases of COVID-19 have been recorded, with approximately 4.2 million deaths; in Iraq, the number of confirmed cases of COVID-19 is more than 1.6 million, and 18,595 people have lost their lives (Dong et al., 2020). It has been reported in previous studies (e.g., Jalloh et al., 2018; Zürcher et al., 2020) that after the outbreak of infectious diseases, survivors, families of survivors, medical practitioners, and community individuals may experience elevated rates of mental health issues. Epidemics such as Ebola, SARS, MERS, H1N1, and flu lead to higher rates in the prevalence of mental health problems. However, after the epidemic, most of these problems disappear, except the symptoms of Post-Traumatic Stress Disorder (PTSD), which may last for a prolonged period (Xiao et al., 2020). In a systematic review by Luo et al. (2020), the psychological impacts of viral respiratory epidemics were explored in particular. This review reported that depression, anxiety, and PTSD symptoms were the most common mental health outcomes. Additionally, it was revealed that certain subgroups, such as females, elderlies, people with chronic illnesses, students, and migrant workers are more vulnerable to negative mental health outcomes.

According to the American Psychiatric Association (APA), PTSD is characterized by an extreme response to a stressor that is severe. The symptoms category of the disorder includes intrusive symptoms (i.e., flashbacks and nightmares), negative alterations in cognition and mood, alterations in arousal and reactivity, and avoidance of stimuli, all of which are associated with the traumatic event or events. The symptoms have to be present for more than one month for PTSD to be diagnosed (American Psychiatric Association, 2013). Furthermore, the disorder’s diagnosis is only considered in the context of serious traumas. Serious traumas entail the individual experiencing or witnessing an event that has led to actual or threatened death, severe injuries, or violations that are sexual in nature (Kring et al., 2014). Concerning the prevalence of PSTD among survivors of infectious diseases, one study explored the long-term psychiatric issues among survivors of SARS in Hong Kong. 90 patients participated in the study, which was conducted 30 months after the outbreak of the disease. The results showed that at the time of assessment, 33.3% of the SARS survivors had psychiatric disorders. Furthermore, 25.5% of the participants had PTSD (Mak et al., 2009). Another study by Hong et al. (2009), which was a 4-year longitudinal study, explored the incidence of PTSD among a sample consisting of 70 patients with SARS. The first assessment, done two months after hospital discharge, showed that 40% of the participants had PTSD. In the last assessment that was performed 46 months after discharge from the hospital, the prevalence rate of PTSD was 42.1% among the 57 patients that had remained in the study. As for the Ebola virus, a cross-sectional study was performed on 114 Ebola virus survivors to assess the mental health impacts of the disease. The authors reported that the prevalence rate of PTSD among the sample was 24.3%, and that male gender and being young (i.e., 18–24 years old) were associated with the PTSD diagnosis (Kaputu-Kalala-Malu et al., 2021). Regarding MERS, a prospective study in South Korea was conducted 12 months after the disease outbreak, in which 73 survivors participated. It was reported that the prevalence of PTSD among the participants was 42.9% (Park et al., 2020).

Exposure to COVID-19 can be a traumatic experience when the patient is suffering from severe symptoms associated with the disease, such as shortness of breath, difficulty breathing, respiratory failure, change in the conscious state, and being close to death (Xiao et al., 2020). The prevalence of PTSD among survivors of COVID-19 has been investigated in a number of studies. One such study in South Korea recruited 64 patients with COVID-19 that were hospitalized and discharged after treatment. The authors, Chang and Park (2020), used Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5); a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. It was revealed in the results of the study that 20.3% of the COVID-19 survivors were experiencing PTSD. Although, significant differences between the group of participants with PTSD and the group of participants with no PTSD were not based on the duration of stay in the hospital, duration prior to discharge, gender, and age. In Italy, a cross-sectional study by Janiri et al. (2021) explored the prevalence of PTSD among 381 patients who had experienced severe COVID-19. Clinician-Administered PTSD Scale (CAPS-5) for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), was used for assessing PTSD. The results of this study revealed that 30.2% of the sample were experiencing PTSD. In addition, individuals with PTSD were more likely to be female, had a history of mental disorders, and experienced more medical symptoms post-illness stage. It was also found that gender and persistent medical symptoms were associated with PTSD. In Norway, a study by Einvik et al. (2021) investigated the prevalence of PTSD and the associated risk factors among COVID-19 patients that have been hospitalized and those who have not been hospitalized 1.5–6 months after the onset of the disease. In total, 538 patients participated in the study; 125 were hospitalized, while 458 were not hospitalized. The results revealed that PTSD, based on DSM-5 criteria, was more prevalent among hospitalized patients (9.5%) than non-hospitalized patients (7%). Furthermore, PTSD was more prevalent among female patients (8.6%) compared to male patients (6.3%). It was also reported that experiencing dyspnea during the course of COVID-19 and female sex were associated with PTSD. However, the time since the onset of the disease did not show any significant association with PCL-5 scores in the full data analysis and a stratified analysis. In the United Kingdom, a study examined PTSD among a sample of 13,049 suspected or confirmed cases of COVID-19. The results showed the prevalence of the PTSD symptoms increased with the severity of the COVID-19 symptoms (Chamberlain et al., 2021).

As for the Middle Eastern countries, the prevalence of PTSD symptoms and sociodemographic and clinical correlates of the disorder were investigated among an Egyptian sample in a cross-sectional study by Abdelghani et al. (2021). The sample of the study was composed of 85 survivors of COVID-19 and 85 control participants. The results of this study showed that the COVID-19 survivor’s group experienced higher levels of moderate to severe PTSD symptoms (72%) as compared to the control group (53%). In addition, the COVID-19 group experienced more intrusive, avoidance, and hyper-arousal symptoms compared to the control group. The logistic regression analysis results showed that moderate to severe COVID-19 symptoms were associated with moderate to severe PTSD symptoms. In a meta-analytic study conducted by Yuan et al. (2021), the level of PTSD after the outbreak of infectious diseases was investigated. The authors searched for any study conducted on the prevalence of PTSD from the inception of the databases to 2020. Regarding prevalence information, 77 studies were included. It was reported that the pooled prevalence of PTSD among these studies was 22.6%. Healthcare workers experienced the highest levels of PTSD (26.9%), followed by infected individuals (23.8%) and the public (19.3%). This meta-analysis also reported female gender, young age, low annual income, and low education level as personal risk factors for post-pandemic PTSD. Xiong et al. (2020) conducted a systematic review of 19 studies from eight countries. Relatively high rates of depression, anxiety, distress, and PTSD symptoms were reported. Three studies in this review stated that female gender was associated with a higher likelihood of developing PTSD, whereas one study found no association.

The existing literature on the prevalence of PTSD symptoms shows that after infectious diseases, generally, and after COVID-19 specifically, the level of PTSD increases. A previous study by the first two authors, which aimed to explore the negative psychological impact of the COVID-19 pandemic among 182 healthcare workers, revealed that 53.3% of the participants screened positive for PTSD (Mohammad, Amine, Sabir, Saeed, Hama amin, 2021). Therefore, the treatment of survivors of infectious diseases does not end with the remission of their medical symptoms; additionally, the mental health of the survivors is an important aspect that may require psychiatric and therapeutic interventions. After the initial wave of COVID-19 last year, the mental health influences of the pandemic in Iraq remain uninvestigated for the most part. Specifically, studies using standardized questionnaires to explore the prevalence of PTSD among Iraqi survivors of COVID-19 are lacking. The need for such investigation becomes more relevant when considering the recent and previous history of the Iraqi people, including the Kurdish population, who have experienced violence and traumatic events on a daily basis for the past decades. This is in tangent with an evident shortage of mental health services and the population’s tendency to believe supernatural explanations concerning mental health issues, as discussed by Younis et al. (2019). Furthermore, the war against ISIS led to a deep economic crisis in the country that influenced the health sector negatively. These factors highlight the need for systematic studies regarding mental health topics. Consequently, the current study aims to find the prevalence of PTSD among survivors of COVID-19 in Iraq. In addition, differences in PTSD based on age, gender, marital status, education level, and time since remission of the symptoms, as well as the factors that are associated with PTSD are addressed.

Methods

Participants and design

The Institutional Review Board of Charmo University, Kurdistan Region, Iraq approved the study protocol. This study followed a cross-sectional design to assess the psychological impact of COVID-19 on survivors who recently or just recovered from the infection in Iraq. The only criterion for participation in this study was to be a COVID-19 survivor. To ensure this, the participants were asked whether they had been infected and recovered from COVID-19 and whether their infection and recovery had been confirmed through a test; if the answer was yes, they could start the questionnaires.

Procedure

We employed several styles of data collection, including online, in-person, and telephone structured interviews from August 17, 2020, to January 23, 2021. A Snowball sampling technique was used. Most of the participants (150) were telephone interviewed by the fourth author, the director of one of the COVID-19 hospitals in the region, using the mobile number recorded for hospitalization during their infectious time. Another group of participants (50 participants) included friends, friends of friends, and acquaintances diagnosed with COVID-19 by physicians and had recently recovered. They were handed a copy of the survey, which was collected later. The survey was also created using a common platform, google survey, in both Kurdish and Arabic. The online questionnaire was distributed through social media applications like Facebook, Messenger, and WhatsApp. Participants were encouraged to distribute the survey too. The survey was published through personal accounts, groups specific to recovered individuals, and pages on Facebook. Some participants also received the survey through private messages on Messenger and WhatsApp. All the participants were given a description of the study and asked to provide informed consent before answering the questionnaires. The participants were also asked to confirm they are above 18 years old and have recovered from COVID-19. Then they were able to click on start the survey. Data were kept confidential and were not disclosed unless for study purposes. A total of N = 370 individuals completed the questionnaires.

Measurement tools

Participants completed the following self-administrative questionnaires:

Sociodemographic measures to collect sociodemographic characteristics included age, gender, level of education, marital status, occupation, residency, number of times infected, and infection duration.

PTSD checklist for DSM-5 (PCL-5) (Ibrahim et al., 2014). The Kurdish and Arabic versions of PCL-5, which showed suitable psychometric properties for evaluating PTSD in a previous validation study (Ibrahim et al., 2018), were used to determine the PTSD symptoms among survivors of COVID-19. These versions of PCL-5 are exactly as the original English version. Respondents were asked to fill up the 20 items scale about their feelings and thoughts during the last month. It includes four subscales; i: Re-experience (5 symptoms), ii: Avoidance (2 symptoms), iii: Negative alterations in cognition and mood (7 symptoms), and iv: Alterations in arousal and reactivity (6 symptoms). The answers to each question are on a 5-rate scale, ranging from 0 to 4: 0 “Not at all,” 1 “A little bit,” 2 “Moderately,” 3 “Quite a bit,” and 4 “Extremely.” Scores range from 0 to 80. The cut-off point > 23 on the PCL-5 total score was used as an indication of probable PTSD, as it is recommended by a previous validation study with a high internal consistency of (alpha = 0.85) (Ibrahim et al., 2018).

Data analysis

All data analyses were performed by the Statistical Package for Social Science (SPSS) software Version 23. Demographic data were analyzed using descriptive statistics. The authors calculated the total scores (mean ± SD) of PTSD and determined the percentage of clinically significant PTSD according to the PTSD guidelines. To analyze the distribution of the scores, explanatory data analysis was conducted. Visual inspection of histograms and normal Q-Q plots, and the results from the Shapiro-Wilk test (P > .05), showed that scores of the continuous variable of PTSD do not follow a normal distribution. Therefore, group differences were compared using Mann-Whitney U and Kruskal-Wallis tests for two and three groups, respectively. Moreover, A forward stepwise binary logistic regression analysis was used to determine the factors associated with probable PTSD.

Results

Characteristics of the participants

As depicted in Table 1, the sample of this study was mainly composed of individuals from the Kurdistan Region of Iraq N = 346. The majority of the participants reported their gender as male (222), and 148 participants were female. Most participants were aged 31–40 (44.6%), and only 13.8% were aged 18–25. Furthermore, only 20 individuals had no educational background, which constitutes 5.4% of the whole sample. 36.5% had primary or secondary education, 48.1% had undergraduate education, and 10% had a postgraduate degree. In addition, the mean duration of the infection among the sample was 18.79 days. Of the total sample, only two participants reported their marital status as divorced. The overwhelming majority of the participants were infected with COVID-19 once (96.5%), whereas only 13 participants were infected twice (3.5%).

Table 1.

participant’s demographic characteristics and group differences in PTSD.

Variables Categories Frequency Percentage (%) Mean Rank (MR) Sig.
Gender Female 148 40.0 195.32 0.149
Male 222 60.0 178.95
Marital Status Single 85 23.0 211.18 0.012
Married 285 77.0 177.84
Age 18–25 51 13.8 199.76 0.260
26–30 70 18.9 195.34
31–40 165 44.6 186.31
Above 40 84 22.7 167.04
Education No education 20 5.4 141.85 ≤ 0.001
Primary School Education 102 27.6 147.55
Secondary School Education 33 8.9 183.11
Diploma 58 15.7 196.04
Bachelor’s degree 120 32.4 222.10
Postgraduate degree 37 10.0 190.62
Residence Kurdistan Region 346 93.5 182.75 0.211
Rest of Iraq 22 5.9 211.98
Infection times Once 357 96.5 183.33 0.041
Twice 13 3.5 245.04
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Prevalence of PTSD

The results showed that 31.1% of the participants scored above the cut-off score of 23 and had probable PTSD. The mean PTSD score was 20.39, with a standard deviation of 13.82. Criterion B (M = 5.52, SD = 3.98), criterion C (M = 2.76, SD = 2.05), criterion D (M = 6.05, SD = 5.7), and criterion E (M = 6.05, SD = 4.48) were present among the participants 88.6%, 71.4%, 55.9%, and 66.8% respectively (See Table 2).

Table 2.

mean and standard deviation scores of PTSD and symptom clusters

Variables N Mean SD
PTSD 370 20.39 13.82
Cluster B 370 5.52 3.98
Cluster C 370 2.76 2.05
Cluster D 370 6.05 5.70
Cluster E 370 6.05 4.48
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Group differences in PTSD

The Mann-Whitney U test results revealed a statistically significant difference between the group that had COVID-19 only once and the group that got infected twice (U = 1546.5, p = .041). The individuals who were infected twice scored higher on PTSD, with a median score of 27, compared to individuals who were infected only once (mdn = 16). Moreover, a significant difference was found in PTSD based on marital status (i.e., single or married) (U = 9929.5, p = .012). The participants who reported their marital status as single exhibited a higher median score of PTSD (mdn = 21) than those who reported their marital status as married (mdn = 15). However, the Mann-Whitney U test did not show statistically significant differences in PTSD based on gender and region.

A Kruskal-Wallis test showed a significant effect of education level on PTSD score, H (5) = 30.91, p ≤ .001, indicating evidence for a difference in the mean rank of at least one group pair. Dunn’s pairwise test was performed for 15 group pairs. There was evidence of a difference (p = .028, adjusted using the Bonferroni correction) between the group that had no education with the group that had an undergraduate degree (i.e., bachelor’s degree). The median score of PTSD for the group with no education was 13, whereas the median score of the group with an undergraduate degree was 23. Furthermore, Dunn’s pairwise test showed evidence of a difference (p ≤ .001, adjusted using the Bonferroni correction) between the group that had a primary school education and the group that had an undergraduate degree. Compared to the group with an undergraduate degree (mdn = 23), the group with no educational background showed a median score of 14. There was no evidence of a difference between the other group pairs (see Table 1).

Factors associated with PTSD

A forward stepwise binary logistic regression was used to determine the factors associated with probable PTSD. Overall, four predictors (i.e., age groups, region, education, and infection duration) were included as predictors in the final general model. A total of 362 cases were analyzed, and since a forward stepwise logistic regression was utilized, all four models significantly predicted probable PTSD. The reference category for the predictors was set at last. The first model, which used education level as a predictor of probable PTSD and had the other demographic variables controlled, accounted for 15.3% (Cox & Snell R2) to 21.5% (Nagelkerke R2) of the variance in the presence of probable PTSD. The model successfully predicted 77.1% of the no probable PTSD group compared to 54% of the group with probable PTSD. Overall, 69.9% of the predictions were accurate. As opposed to the participants that had a postgraduate degree (35.1%), individuals with only primary school education were less likely (8.8%) to be in the probable PTSD group, χ2 (1, N = 362) = 12.33, p < .001. Similar results were found between the participants that had no formal education compared to the participants that had postgraduate education (i.e., participants that had no education were less likely than the participants that had postgraduate education to be in the probable PTSD group) χ2 (1, N = 362) = 4.64, p < .05 (see Table 3).

Table 3.

Forward stepwise (likelihood ratio) models predicting probable PTSD

Predictors Model 1 Model 2 Model 3 Model 4
B SE (B) OR B SE (B) OR B SE (B) OR B SE (B) OR
Education
 No education -2.331* 1.082 0.097 -2.427* 1.086 0.088 -2.270* 1.092 0.103 -2.170* 1.108 0.114
 Primary School Education -1.722*** 0.490 0.179 -1.929*** 0.504 0.145 -1.818*** 0.510 0.162 -1.874*** 0.523 0.153
 Secondary School Education 0.015 0.509 1.015 0.038 0.517 1.039 0.008 0.521 1.008 − 0.050 0.545 0.951
 Diploma − 0.080 0.449 0.923 − 0.123 0.455 0.885 − 0.189 0.460 0.828 − 0.321 0.486 0.725
 Undergraduate degree 0.681 0.391 1.976 0.627 0.397 1.871 0.401 0.401 1.618 − 0.324 0.433 1.382
Infection duration 0.045** 0.015 1.046 0.048** 0.015 1.049 0.054** 0.016 1.055
Region 0.703** 0.264 2.019 0.819** 0.274 0.2.269
Age groups
 18–25 1.083* 0.483 2.953
 26–30 0.137 0.451 1.147
 31–40 0.734 0.377 2.083
Constant − 0.613 0.344 0.542 -1.399 0.438 0.247 -1.671 0.452 0.188 -2.270 0.550 0.103
X 2 3.170 10.192 13.672 17.040
df 5 5 5 5
% of probable PTSD 54.0 32.7 41.6 44.2
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Note: Controls are gender and frequency of infection. OR = Odds Ration. Predicted probability is of membership for probable PTSD. Postgraduate degree, rest of Iraq, and age above 40 are the reference category for the predictor variables of education, region, and age respectively

*p < .05. **p < .01. ***p < .001

The second model adds infection duration as the next predictor variable. Thus, model 2 has two predictor variables: education and infection duration, as shown in Table 3. With other demographic variables controlled, model 2 explained 17.5% (Cox & Snell R2) to 24.7% (Nagelkerke R2) of the variance, which marks an increase from the previous model. Furthermore, model 2 successfully predicted 90.4% of the no probable PTSD group, whereas the percentage of successful prediction for the probable PTSD group was 32.7%. The overall percentage of accurate prediction has also increased, as it was 72.4%. Duration of COVID-19 duration reliably predicted the presence of PTSD. The values of the coefficient showed that an increase in infection duration by one day is associated with an increase in the odds of having probable PTSD by a factor of 1.046, χ2 (1, N = 362) = 9.022, p < .01.

The region was added as the predictor variable in the third model (see Table 3). Therefore, in this model, three predictor variables existed (i.e., education, infection duration, and region). Having controlled other demographic variables, model 3 accounted for an increased 19.1% (Cox & Snell R2) to 26.9% (Nagelkerke R2) of the variance. Moreover, the model was successful in predicting the no probable PTSD category and the probable PTSD category by a rate of 87.1% and 41.6%, respectively. There was a slight increase in the overall percentage of successful predictions (72.9%). Individuals in the Kurdistan region were twice more likely to be in the probable PTSD group than those in the rest of Iraq χ2 (1, N = 362) = 12.33, p < .01.

In the final model, age groups were added as a new predictor variable and controlled for marital status, infection times, and gender. The model successfully predicted 88% of the no probable PTSD group and 44.2% of the probable PTSD group, with an overall percentage of 74.3% that has increased from model 3. Of the total variance, the model accounted for 21.1% (Cox & Snell R2) to 29.6% (Nagelkerke R2). The results revealed that, when compared to individuals aged above 40 (17.9%), individuals aged 18–25 (45.1%) were almost three times more likely to be in the probable PTSD group, χ2 (1, N = 362) = 5.02, p < .05.

Discussion

The present study findings show that post-traumatic stress disorder is prevalent in survivors of the COVID-19 pandemic. The result may be best understood in the context of the continuing traumatic history in Iraq’s last four decades. Wars, political and religious violence & oppression, forced displacement and migration, human rights abuses, unemployment, and poverty have scourged Iraqi society, creating major public mental health crises. Moreover, since the ISIS war in 2014, Iraq has been significantly impacted economically. The public health system has experienced serious challenges, e.g., lack of workforce, drug shortage, and lack of medical supplies. Hospitals have minimal healthcare capacity and, as a result, patients encounter difficulties in receiving adequate care, especially adequate service during the pandemic. However, different kinds of survivors present a distinct prevalence of PTSD. Possible risk factors associated with PTSD were further identified, including age groups, region, education, and infection duration. The findings help in designing interventions for the survivors of the pandemic in Iraq and other cultures.

Almost one-third of the participants have probable PTSD. This finding is in line with another study conducted in Italy, in which they found PTSD in (30.2%) of the participants (Janiri et al., 2021) and findings of previous coronavirus illnesses. In a meta-analysis, the prevalence of PTSD in the post-illness stage was 32·2% (121 of 402 cases from four studies) (Rogers et al., 2020). This may highlight the importance of making mental health a global priority for all. However, our findings are much higher compared to the findings of research conducted on even more severe COVID-19 patients (Nagarajan et al., 2022; Yuan et al., 2021; Einvik et al., 2021; Liu et al., 2020; Chang & Park 2020). One study in Norway reported the prevalence of PTSD to be 9.5% in hospitalized and 7.0% in non-hospitalized subjects (Einvik et al., 2021). Some of the previous studies in Iran reported the rate of PTSD as low as 2.3–5.3% among the survivors of COVID-19 (Khademi et al., 2021). Moreover, in their systematic review, Nagarajan et al. (2022) analyzed 13 articles from 10 different countries, including Switzerland, Netherlands, Italy, Iran, China, USA, France, UK, Turkey, and Austria, with 1,093 participants, the prevalence of PTSD among survivors of COVID-19 was estimated to be 16%. Similarly, another systematic review conducted by Salehi et al. (2021) included 35 studies in their meta-analysis. They estimated the prevalence of PTSD symptoms to be about 18%. Such findings may be best explained by accumulated stress and repeated complex traumatic events in conflicted countries, which may leave the individuals vulnerable to developing pathological symptoms when facing other new stressors. For example, one study conducted in Egypt reported that 72% of COVID-19 survivors experienced moderate-to-severe PTSS (Abdelghani et al., 2021). This emphasizes the need for prioritizing mental health and interventions in countries where the population is vulnerable and already has a high rate of psychological needs.

One interesting finding of this study was that high education level was associated with PTSD. This may be mediated by higher stress levels and responsibility people may have when they have a high educational degree compared to those with little or no education. Moreover, infection duration also added more risk of developing PTSD symptoms among survivors. This is consistent with the findings of Janiri et al. (2021), who found persistent medical symptoms as a factor associated with PTSD. This could be because more days with infection may increase the patient’s fear and traumatic experiences.

Other associated characteristics included region and age. People in the Kurdistan Region were more likely to be in the PTSD group than the individuals in south Iraq. Likewise, Nagarajan et al., 2022 indicated significant differences in the prevalence of PTSD between regions. This may be because COVID-19 hit Kurdistan Region first and more firmly than Iraq (Abdullah et al., 2020). Furthermore, participants aged 18–25 were more likely to have PTSD symptoms than those aged above 40. This finding aligns with other studies conducted in Iran and China, indicating a higher rate of psychological symptoms among younger individuals (Khademi et al., 2021; Shi et al., 2020; Kong et al., 2020). People who have older age in such countries may have more experience and developed skills to cope with adversities. Thus, they may have less proneness to develop PTSD after 40 years. Accordingly, professional and effective psychological interventions should be designed to aid the mental health and well-being of the population in affected areas, especially those with longer infection duration, higher education levels, hard-hit infected areas, and people aged 18–25. Government and non-governmental organizations should be aware of the high possibility of PTSD among COVID-19 survivors, particularly in conflict regions such as Iraq, where people have already experienced complex traumas and large-scale stressors, e.g., multiple wars during Saddam Hussain’s regime, ISIS war, and other crimes against the minorities in Iraq.

Regarding treatment approaches, the most evidence-based treatment is Cognitive Behavior Therapy (CBT) which has been tested during Covid-19 and found to be very effective (Ferrario et al., 2021; Sun et al., 2021; D’Onofrio et al., 2022), especially technology-assisted CBT (Fathi Ashtiani et al., 2020) that can prevent the spread of infection during the pandemic. Perhaps considering a one-to-one model not be a reasonable option to the already overwhelmed capacity Iraq and the Kurdistan Region have in terms of qualified mental health professionals. Such a model may not reach the number of people who need mental health services, and with the increased demands, mental health providers, who are already limited in numbers, may be at risk of experiencing burnout.

The present study had several limitations. First, a larger sample selected through random sampling techniques would have contributed more conclusive results. Second, most of the participants were from the Kurdistan Region, whereas a lower number were from the central and southern parts of Iraq; this limits the generalizability of results to the country as a whole. Third, the severity of the COVID-19 infection was not considered in the data analysis as a factor.

Conclusion

The present study showed that a significant number of survivors of COVID-19 experience peritraumatic stress symptoms in the form of probable PTSD as measured by the PCL-5. It was also revealed that individuals infected twice with the disease had higher scores of probable PTSD compared to individuals infected only once. The four models of prediction used in the data analysis showed factors such as postgraduate education, longer infection duration, age (18–25), and region (i.e., individuals in the Kurdistan Region) were associated with higher instances of peritraumatic stress symptoms. This study’s results highlight the problems with the country’s healthcare system; the working model is not patient-centered. They also highlight that patients’ mental health is not considered an essential factor, which results in a significant rate of peritraumatic stress symptoms among the survivors. The study implies the importance of having trained social workers and psychologists in the hospitals and considering mental health as a crucial factor in future instances of epidemics and pandemics. The presence of agents trained in psychological first aid who can provide psychosocial support to the infected individuals contributes to reducing the negative mental health consequences of epidemics and serves as a prevention mechanism.

Abbreviations

COVID-19

Coronavirus Disease of 2019

SARS-CoV-2

Severe Acute Respiratory Syndrome Coronavirus 2

PTSD

Post-Traumatic Stress Disorder

PCL-5

Post-Traumatic Stress Disorder Checklist for DSM-5

CAPS-5

Clinician-Administered PTSD Scale

DSM-5

Diagnostic and Statistical Manual, fifth edition

SPSS

Statistical Package for Social Science

CBT

Cognitive Behavior Therapy

Author contribution

All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.

Funding

This research received no external funding.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author, on Figshare, upon reasonable request.

Declarations

Statement of ethics

This study was carried out following the recommendations of the Code of Ethics of the American Psychological Association. The Ethics Committee approved the protocol for Research at Charmo University. In accordance with the Declaration of Helsinki, all the participants gave written informed consent for their participation in the study.

Conflict of interest disclosures

The authors declare no conflict of interest.

Footnotes

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References

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author, on Figshare, upon reasonable request.

Articles from Current Psychology (New Brunswick, N.j.) are provided here courtesy of Nature Publishing Group

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