Prevalence and network structure of post-traumatic stress symptoms and their association with suicidality among Chinese mental health professionals immediately following the end of China's Dynamic Zero-COVID Policy: a national survey

The COVID-19 pandemic and China's Dynamic Zero-COVID policy presented unprecedented challenges, leading to unintended consequences like increased mental health issues. While effective in controlling transmission initially, the policy's strict measures—unpredictable lockdowns, constant testing, and travel restrictions—contributed to heightened risks of depression, anxiety, insomnia, and PTSD. Mental health professionals (MHPs) were particularly vulnerable due to factors such as historically marginalized psychiatric services, insufficient training for pandemic response, and increased exposure to infected patients. Existing research on PTSS among MHPs, especially following the lifting of restrictions, remains limited. This study aimed to address this gap by examining the prevalence, correlates, and network structure of PTSS and its association with suicidality among Chinese MHPs immediately after the termination of the Dynamic Zero-COVID Policy. Understanding these factors is crucial for developing effective preventative and therapeutic strategies to mitigate the lingering negative impacts of the pandemic on this vital workforce. The study employed a network analysis approach, which offers a dynamic perspective on the interconnectedness of symptoms, unlike traditional methods that treat symptoms as isolated entities. This approach helps identify key symptoms that may serve as targets for interventions.

Previous studies have documented the psychological burden of COVID-19 on healthcare workers (HCWs), with varying prevalence rates of PTSS reported. Studies on HCWs during previous outbreaks, such as SARS, also showed elevated PTSS levels in the years following the event. Research on the impact of COVID-19 on MHPs in China suggests that they face a high risk of PTSS due to factors such as the historically marginalized status of psychiatric services, insufficient training, and increased exposure to infected psychiatric inpatients. Risk factors like female gender, young age, less work experience, quarantine experience, economic burdens, and heavy workloads have also been associated with increased PTSS among MHPs. Traditional approaches to psychopathology often overlook the dynamic interrelationships between symptoms. Network analysis provides a novel approach to understand these interconnections, offering insights into the most influential symptoms in the network and identifying potential targets for intervention. While some network research on PTSS has been conducted, particularly focusing on the connections between PTSS and quality of life, further investigation is needed, especially in the context of post-policy impact on MHPs in China.

This cross-sectional, national survey was conducted between January 22 and February 10, 2023, immediately after the termination of China's Dynamic Zero-COVID Policy. A snowball convenience sampling method was used, recruiting MHPs (psychiatrists, nurses, technicians) through an online survey platform (WeChat-based Questionnaire Star) distributed nationwide to public psychiatric hospitals. Eligible participants were adults aged 18 years or older working in psychiatric settings in China during the pandemic and able to provide informed consent. Data collection included sociodemographic variables (age, gender, marital status, education, work experience, living situation, economic and health status, COVID-19 infection and quarantine experiences), PTSS (using the Chinese version of the Post-Traumatic Stress Disorder Checklist-Civilian version, PCL-C), depressive symptoms (using the PHQ-9), and suicidality (using standardized questions on ideation, plans, and attempts). Statistical analysis included univariate and multivariate analyses (SPSS version 26.0) to examine correlates of PTSS. Network analysis (R software, version 4.2.2) using a Graphical Gaussian Model (GGM) was employed to explore the structure of PTSS symptoms, focusing on centrality indices (expected influence, EI) and predictability to identify key symptoms. The stability and accuracy of the network were evaluated using bootstrapping methods. A Mixed Graphical Model (MGM) was used to examine the associations between PTSS and suicidality, employing the "flow" function to map specific symptom relationships. Network Comparison Tests (NCT) were used to compare the network structure of PTSS in quarantined versus non-quarantined groups.

A total of 10,647 MHPs participated (98% participation rate). The overall prevalence of PTSS (PCL-C score ≥ 38) was 6.7% (95% CI = 6.2-7.2%), with 2.9% having significant PTSS (PCL-C score ≥ 50). The overall prevalence of suicidality was 7.7% (95% CI = 7.2-8.2%). Compared to the non-PTSS group, the PTSS group was significantly older, more likely to be male and married, had longer work experience, reported poorer perceived economic and health status, had experienced quarantine, exhibited suicidality, and had higher PHQ-9 scores. Logistic regression showed that being married (OR = 1.523, P < 0.001), quarantine experience (OR = 1.288, P < 0.001), suicidality (OR = 3.750, P < 0.001), and more severe depressive symptoms (OR = 1.229, P < 0.001) were positively associated with PTSS, while better economic and health status were negatively associated. Network analysis revealed that "Avoiding thoughts" (PCL6), "Avoiding reminders" (PCL7), and "Feeling emotionally numb" (PCL11) were the most central PTSS symptoms. The network model showed strong positive associations between suicidality and "Negative belief" (PCL12), "Hypervigilance" (PCL16), and "Irritability" (PCL14). There were no significant differences in overall connectivity or network structure of PTSS between quarantined and non-quarantined groups. The network model showed a correlation stability coefficient (CS-C) of 0.75, indicating a stable network.

The findings reveal a substantial prevalence of PTSS among Chinese MHPs even after the end of the Dynamic Zero-COVID Policy. The prevalence rate is notable, highlighting the enduring psychological impact of the pandemic and its control measures on this population. The identified correlates of PTSS, including marital status, quarantine experience, economic status, and health status, underscore the interplay between social, economic, and physical factors in shaping mental health outcomes. The central role of avoidance and emotional numbing symptoms in the PTSS network highlights their importance in understanding and treating PTSS in this group. The strong association between specific PTSS symptoms (particularly negative beliefs and hyper-arousal) and suicidality emphasizes the need for targeted interventions. The absence of differences in PTSS network structure between quarantined and non-quarantined groups may suggest that the underlying mechanisms of PTSS are not significantly altered by quarantine experience. Further research is needed to explore these mechanisms, including the role of workplace stressors, societal support, and access to mental health services.

This study demonstrates a significant prevalence of lingering PTSS and suicidality among Chinese MHPs following the end of the Dynamic Zero-COVID Policy. Avoidance and hyper-arousal symptoms are central to the PTSS network and strongly associated with suicidality, suggesting they should be key targets for intervention. Future research should explore the longitudinal impact of the pandemic on MHPs, investigate effective interventions, and address the limitations of this cross-sectional study, such as reliance on self-report measures and convenience sampling.

This study's cross-sectional design limits the ability to establish causal relationships. The use of self-report measures may introduce recall bias and social desirability bias. The findings reflect PTSS rather than a formal PTSD diagnosis, as structured clinical interviews were not used. The convenience sampling method may have introduced selection bias. The overrepresentation of female participants may limit the generalizability of findings to male MHPs.