Psychological Trauma:

Theory, Research, Practice, and Policy

© 2020 American Psychological Association 2020, Vol. 12, No. 7, 812– 819
ISSN: 1942-9681 http://dx.doi.org/10.1037/tra0000914

COVID-19: PTSD Symptoms in Greek Health Care Professionals

Apostolos Blekas, Panteleimon Voitsidis, Maria Athanasiadou, Eleni Parlapani, Aliki F. Chatzigeorgiou,
Marina Skoupra, Markos Syngelakis, Vasiliki Holeva, and Ioannis Diakogiannis
Aristotle University of Thessaloniki

Objective: The objective of this study was to assess the emergence of posttraumatic stress symptoms
(PTSS) in Greek health care professionals during the COVID-19 pandemic. Method: A cross-sectional
study was conducted via an online survey from April 10 until April 13, 2020. The survey included
sociodemographic questions and the following psychometric tools: the Peritraumatic Distress Inventory,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

the Posttraumatic Stress Disorder– 8 questionnaire, the Brief Patient Health Questionnaire Depression
This document is copyrighted by the American Psychological Association or one of its allied publishers.

scale, the Athens Insomnia Scale, and 3 questions about negative perceptions of COVID-19. The survey
was distributed through social media and comprises part of a larger survey targeting the general
population. Altogether, 270 health care professionals responded to the survey. Results: Health care
professionals appeared to be moderately stressed from the COVID-19 crisis, with women scoring higher
on all clinical scales and the difference between women and men being statistically significant. Criteria
for a probable posttraumatic stress disorder diagnosis were met by a total of 16.7% (21.7% of women;
5.1% of men). Negative emotion and threatened or physical tension are positive significant predictors of
PTSS. Those suffering with higher levels of PTSS scored positively for insomnia and exhibited
significantly higher peritraumatic distress. Conclusion: Health care professionals could benefit by being
screened for PTSS and insomnia.

Clinical Impact Statement

As COVID-19 delivers a devastating blow worldwide, health care professionals (HCPs) face
enormous stressors within their everyday clinical practice, such as increased workload; adaptation to
multiple roles; decreased time spent with significant others; and emotional issues like stress, guilt,
and fear about personal safety. Therefore, screening HCPs is crucial, because this specific population
is particularly vulnerable not only to COVID-19 but also to its psychological impact. This study, in
accordance with research during previous pandemics, dispelled the myth that HCPs are immune to
psychological distress. Early detection and targeted interventions may protect HCPs and contribute
to sustaining a functioning health care system.

Keywords: COVID-19, health care professionals, Greece, PTSD, insomnia

We are at war. These were the words chosen by the Greek Prime
Minister Kyriakos Mitsotakis when addressing the COVID-19
Editor’s Note. This article received rapid review due to the time-sensitive
nature of the content. It was reviewed by the special section Guest Editors
and the Journal Editor.—KKT
This article was published Online First August 27, 2020.
X Apostolos Blekas, X Panteleimon Voitsidis, Maria Athanasia-
dou, X Eleni Parlapani, Aliki F. Chatzigeorgiou, Marina Skoupra,
Markos Syngelakis, X Vasiliki Holeva, and Ioannis Diakogiannis, 1st
Department of Psychiatry, General Hospital “Papageorgiou”, School of
Medicine, Aristotle University of Thessaloniki.
The authors have no conflicts of interest to disclose.
Correspondence concerning this article should be addressed to Eleni
Parlapani, 1st Department of Psychiatry, General Hospital “Papageorgiou”,
School of Medicine, Aristotle University of Thessaloniki, Ring Road Thessa-
loniki, Nea Efkarpia, 54603 Thessaloniki, Greece. E-mail: eparlapa@
auth.gr
812
issue to the public. Regarding this ambiguous war metaphor, one
may contend that the pandemic’s casualties may not be limited to
its direct victims.
From ancient times, a variety of symptoms have been described
concerning those surviving a battle. Gilgamesh (2100 BC; Epic of
Gilgamesh) suffered from repetitive and intrusive flashbacks and
nightmares after witnessing his best friend’s death. Herodotus,
Hippocrates, Lucretius, and many more described persistent men-
tal symptoms in those fighting on the front line. Leaping forward,
there was the account of “the soldier’s heart” and “shell shock”
(Crocq & Crocq, 2000, p. 47) before the formulation of the
diagnostic category of posttraumatic stress disorder (PTSD) in the
third edition of the Diagnostic and Statistical Manual of Mental
Disorders (American Psychiatric Association, 1980).
Is a pandemic such a traumatic experience? Is it like war? It is
well established that pandemics have shaped human history
throughout the ages. To name a few, the Athenian Plague (430 BC)
killed at least one quarter of the population in Athens, among them
the significant statesman Pericles, determining the Peloponnesian
War outcome. The Antonine Plague (AD 165–180) wiped out the
 COVID-19 AND PTSD SYMPTOMS
Roman army and signaled the decline of the Roman Empire. The
Black Death conquered Europe, reigning for 40 years and claiming
the lives of millions. Many physicians among those who were not
too afraid to perform their duties died. As a result, the “plague
doctor” (medico della peste; Earnest, 2020, p. 1) was born.
Coming to the modern age, the “Spanish flu” pandemic (1918 –
1920) during World War I killed more than 50 million people
worldwide, according to some estimates (e.g., Taubenberger &
Morens, 2006), whereas others put it around 100 million (e.g.,
Hobday & Cason, 2009). Apart from the death toll, its long-term
impact was described by a study published in 2006 (Almond,
2006). Cohorts in utero during the pandemic displayed “reduced
educational attainment, increased rates of physical disability,
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lower income, lower socioeconomic status, and higher welfare
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payments compared with other birth cohorts” (p. 672). Since then,
the HIV outbreak during the 20th century and the pandemics of the
following century—among which are SARS (2003), H1N1 (2009),
MERS (2012), the Ebola epidemic in Africa (2014 –2015), and the
Zika virus (2015–2016)— have all taken their toll on humankind,
shaping the social landscape.
Taking the pandemics’ severity into account, vigilance is re-
quired for the mental health of those fighting on the front line, the
health care professionals (HCPs). Studies have revealed that HCPs
are exposed to trauma while caring for patients in their everyday
practice. According to a study of preclinical and in-hospital pro-
viders in the United States, 33% of the participants scored posi-
tively in PTSD screening (Luftman et al., 2017). Taking into
account the circadian rhythm disruption due to the night shifts,
together with many other work stressors, such as great patient
number, severe treatment decisions, and paper work, HCPs are
exposed to a lot of work-related stress. Emergency physicians in
particular have a substantial burden of PTSD’s posing a potential
threat to their own well-being (DeLucia et al., 2019). Specifically,
a study in the United States reported that 22% of surgical residents
screened positive for PTSD, whereas another 35% was at risk for
developing PTSD. Altogether, 21% of these residents cited care
provision to the critically injured as a traumatic stressor (Jackson
et al., 2017).
When caring for patients during a pandemic, HCPs are exposed
to repeated and prolonged stressors, while their own health is
endangered due to direct exposure to an infectious disease. It is
therefore expected that these stressors have an impact on mental
health. Indeed, data from previous infectious disease outbreaks
validate concern about the mental health of HCPs. Providing
health care during a pandemic is far more than “business as usual.”
During the SARS outbreak in 2003, a survey from Toronto in
Canada concluded that 29% of HCPs were probably in emotional
distress, with the rate among nurses being 45% (Nickell et al.,
2004). During the same period, health care workers in two acute
care general hospitals in Hong Kong showed elevated stress levels.
When reassessed 1 year later, the high-risk health care workers
appeared to suffer from chronic stress and higher levels of depres-
sion and anxiety (McAlonan et al., 2007). Another study of hos-
pital staff in Singapore revealed a PTSD diagnosis in approxi-
mately 20% of participants (Chan & Huak, 2004). Even 3 years
after the SARS outbreak, in 2006, some 10% of the hospital staff
in Beijing showed high levels of posttraumatic stress (Wu et al.,
2009). Last, a survey from South Korea during the MERS outbreak
showed that 57.1% of the nurses involved in the care of suspected
813
cases or infected patients experienced PTSD symptoms, and
25.1% experienced full PTSD (Huang, Han, Luo, Ren, & Zhou,
2020).
Regarding the current pandemic, a study in a tertiary infectious
disease hospital for COVID-19 in China investigated 230 members
of the medical staff. According to the results, the incidence of
anxiety was as high as 23.04%, and the incidence of PTSD was
estimated at 27.39% (Huang et al., 2020). All this evidence be-
comes far more alarming combined with the outcome of a study
conducted in an Australian hospital in 2009. This study revealed
that 53% of HCPs would arbitrarily be absent from work if a
significant number of influenza outbreak victims were admitted to
their hospital (Martinese, Keijzers, Grant, & Lind, 2009). If some-
thing like this happened during a pandemic outbreak, the health
care system would be seriously jeopardized and could even face
collapse.
To the best of our current knowledge, there has been only one
study of HCPs in Greece, during the H1N1 pandemic, which
reported moderately high anxiety levels (Goulia, Mantas, Dim-
itroula, Mantis, & Hyphantis, 2010). The aim of the present study
was to explore the prevalence of posttraumatic stress symptoms
(PTSS) among Greek HCPs during the COVID-19 pandemic, 3
weeks after a national lockdown had been imposed in Greece.
Method
Participants
This study comprised part of a larger survey, conducted from
April 10 until April 13, 2020. The study was conducted via an
online survey due to the restriction measures imposed on March
23, 2020, in Greece, and it was distributed through social media. 〈
detailed information sheet was presented to the participants before
they gave informed consent. Ethical approval was received from
the Scientific Committee of the General Hospital “Papageorgiou”
Review Board prior to data collection. Participation was voluntary
and anonymous, and subjects could stop completing the survey
whenever they decided.
The initial study targeted the Greek general population, whereas
this study focused exclusively on HCPs. These HCPs were distin-
guished from the other participants based on the answer to the
question “Are you currently working in a hospital, healthcare
center, private practice, or any other healthcare providing facil-
ity?” The health care professionals category comprised a wide
range of professionals, including different medical specialties and
nursing staff, without any further categorical distinction among
them. Inclusion criteria were age 18 and over and completion of
96% of the survey questions.
Measures
In addition to the basic sociodemographic questions, partici-
pants completed the following self-administered tools:
Peritraumatic Distress Inventory (PDI; Bunnell, Davidson,
& Ruggiero, 2018). The PDI is a 13-item self-report question-
naire that measures the level of distress experienced during a
traumatic event or immediately thereafter. Items are rated on the
following 5-point Likert-type scale: 0 (not true at all), 1 (slightly
true), 2 (somewhat true), 3 (very true), and 4 (absolutely true).
 814 BLEKAS ET AL.

Total scores range between 0 and 52. Higher scores indicate higher Table 1
levels of peritraumatic distress. The inventory contains two sub- Sociodemographic Characteristics
scales: Negative Emotions, a seven-item subscale describing neg-
ative emotions, and Feeling Threatened/Physical Tension, a six- Sociodemographic
characteristics n %
item subscale assessing perceived threat and arousal.
Posttraumatic Stress Disorder– 8 inventory (PTSD-8; Han- Gender
sen et al., 2010). The PTSD-8 is an eight-item self-administered Valid
questionnaire for probable PTSD originating from the first 16 Male 59 21.9
items of the Harvard Trauma Questionnaire and targeting a trauma Female 199 73.7
Total 258 95.6
population (Mollica et al., 1992). The best threshold is obtained Missing 12 4.4
from a combination of at least one symptom with an item score of Total 270 100
3 or higher from each of the three PTSD symptom clusters; that is,
intrusion, avoidance, and hypervigilance. Age
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Brief Patient Health Questionnaire (PHQ-9) Depression Valid

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scale (Kroenke, Spitzer, & Williams, 2001). The PHQ-9 is a 18–30 1,334 55
31–45 558 23
useful tool to assess both major depression and subthreshold 46–60 429 17.7
depressive disorder in the general population (Martin, Rief, 61–75 88 3.6
Klaiberg, & Braehler, 2006). The scale assesses depressive symp- ⬎75 11 0.5
toms’ severity over the past 2 weeks on this 4-point severity scale: Total 2,420 99.7
Missing 7 0.3
0 (not at all), 1 (several days), 2 (more than half the days), and 3 Total 2,427 100
(nearly every day). Total scores range between 0 and 27.
Athens Insomnia Scale (AIS; Soldatos, Dikeos, & Paparri- Educational level
gopoulos, 2000). The AIS is a self-administered psychometric Valid
tool designed to assess sleep problems. The eight-item question- Elementary school 0 0
naire evaluates sleep onset, unwanted waking, sleep duration, sleep Middle school 2 0.7
High school 36 13.3
quality, frequency and duration of complaints, distress caused by University 120 44.4
insomnia, and interference with daily functioning. A cutoff score MS 84 31.1
of 10 was used to distinguish insomniacs from noninsomniacs. PhD 25 9.3
Questions about COVID-19-related negative perceptions. Total 267 98.9
Missing 3 1.1
To explore participants’ COVID-19-related fear, we used three
Total 270 100
questions: “I worry a lot about coronavirus-19” (COVID-19
worry), “Coronavirus-19 is an unpredictable disease” (COVID-19 Residential area
unpredictability), and “Coronavirus-19 is almost always terminal” Valid
(COVID-19 lethality). These questions were omitted from the Fear Urban 226 83.7
of COVID-19 Scale after failing to load significantly in the factor Smaller city 19 7.0
Rural 24 8.9
analysis (Ahorsu et al., 2020). These items were selected instead of Total 269 99.6
the whole scale, because several items were similar to the items Missing 1 0.4
included in the other utilized clinical measures and because those Total 270 100
three questions seem to address negative perceptions instead of
clear fear. The questions were scored on a 10-point Likert Scale.
The higher the score, the higher the negativity toward COVID-19. The measures used in this study explored common symptoms
related with extreme stress. According to the scales’ scores, HCPs
Statistical Analyses appeared to be moderately stressed from the COVID-19 pandemic,
suffering from insomnia and depressive symptomatology. Female
All analyses were performed by IBM Statistical Package of
participants scored significantly higher in all clinical scales, a
Social Science software Version 26. Demographic and clinical
result indicating a higher psychological burden compared to male
data were compared using analyses of variance and t tests for
participants (see Table 2).
continuous variables and chi-square for categorical variables. Bi-
Based on the PTSD-8 scores, subjects were classified as prob-
nary logistic regression analysis was used to compare those with
able or nonprobable cases of PTSD. Rankings in the four criteria
high PTSD symptomatology with those without.
are presented in Table 3. Again, women met the criteria to a
significantly larger extent than did men. Classification in the
Results
criteria of avoidance and hypervigilance may reflect the distancing
A total of 270 HCPs met inclusion criteria and entered the study rules and points out the radical changes HCPs had to adjust to,
(Mage ⫽ 37.61 years, SD ⫽ 11.93; female ⫽ 199 [77.1%], male ⫽ after the level of awareness in their work environment changed
59 [21.9%], did not report gender ⫽ 12 [4.4%]). Women’s age dramatically (see Table 3).
(M ⫽ 38.25, SD ⫽ 11.24) was slightly higher than men’s (M ⫽ Age did not differ significantly among the probable PTSD
37.16, SD ⫽ 12.08), with no statistical significance, t(258) ⫽ category (p ⬎ .001). Probable PTSD sufferers reported symptoms
617, p ⬎ .001. Detailed sociodemographic data are presented in of insomnia and depression as well; 73.3% of the probable PTSD
Table 1. sufferers scored positively for insomnia, whereas only 28% of the
 COVID-19 AND PTSD SYMPTOMS 815

Table 2
Data for Clinical Measures

Male Female
Variables n (male/female) M SD M SD t(df)

PTSD-8 score 58/191 15.81 4.77 18.32 5.39 ⫺3.19ⴱ (104)

PDI score 59/199 18.86 5.44 22.47 7.08 ⫺4.14ⴱⴱ (123)
AIS score 59/199 11.46 3.59 12.93 3.88 ⫺2.61ⴱ (256)
PHQ-9 score 59/199 12.49 2.82 14.74 4.31 ⫺3.77ⴱⴱ (268)
COVID-19
Worry score 56/188 4.55 2.15 6.02 2.32 ⫺4.70ⴱⴱ (67)
Unpredictability score 57/188 6.16 2.31 7.23 2.32 ⫺3.04ⴱⴱ (73)
Lethality score 57/185 4.14 2.36 5.38 2.50 ⫺3.32ⴱⴱ (250)
Note. PTSD-8 ⫽ Posttraumatic Stress Disorder– 8 inventory; PDI ⫽ Peritraumatic Distress Inventory; AIS ⫽
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Athens Insomnia Scale; PHQ-9 ⫽ Brief Patient Health Questionnaire.

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ⴱ
p ⬍ .05. ⴱⴱ p ⬍ .001.

non-PTSD sufferers reported sleeping difficulties. Almost half
(48.4%) of those who reported PTSS also reported moderate to
moderately severe depressive symptomatology, compared to the
11.1% of those who did not meet the criteria for probable PTSD.
Exploring further the associations of the probable PTSD category
and peritraumatic distress, subjects who scored positively for prob-
able PTSD showed significantly higher peritraumatic distress (see
Table 4), negative emotions, and feelings of threatened or physical
tension. The same pattern was repeated in the questions exploring
negative perceptions toward COVID-19. Again, subjects with high
PTSS had elevated levels of worry and a sense of unpredictability
compared with those without PTSD symptoms. They also believed
to a greater extent that COVID-19 is a terminal disease (see Table
4).
Multiple logistic regression was utilized to examine the inde-
pendent effects of COVID-19 negative perceptions, depression
measured by the PHQ-9, insomnia measured by the AIS, and
peritraumatic distress measured by the PDI on PTSD. The omnibus
test, ␹2(8, N ⫽ 234) ⫽ 94.35, p ⬍ .001, and the Hosmer–
Lemeshow test, ␹2(8, N ⫽ 234) ⫽ 3.47, p ⫽ .901, were used to
assess model fit in the regression analysis.
Results of the multivariate logistic regression model adjusting
for other covariates are presented in Table 5. Negative emotion
was a positive significant predictor of PTSD (b ⫽ 282, SE ⫽ 0.09,
p ⫽ .002), with the odds ratio (OR) indicating that for every unit
increase on this factor, the odds of PTSD changed by a factor of
1.326. Threatened or physical tension was a positive significant
predictor of PTSD (b ⫽ 266, SE ⫽ 13, p ⬍ .001), with the OR
indicating that for every unit increase on this factor, the odds of
PTSD changed by a factor of 1.305. Gender, PHQ-9, AIS,
COVID-19 worry, COVID-19 unpredictability, and COVID-19
lethality failed to show significance (p ⬎ .05).
Discussion
The present study results may be best considered in the context
of the current socioeconomic status in Greece. The COVID-19
pandemic launched itself in the Greek society after more than a
decade of austerity. Since 2008, the Great Recession has signifi-
cantly impacted the Greek economy. The public health system has
suffered profound cutbacks in the years that followed. Serious
challenges were experienced in the whole spectrum of health care,

Table 3
Rankings on PTSD-8 Criteria

Criterion n (%) Male: n (%) Female: n (%) ␹2(1, N ⫽ 270) p

Intrusion 8.48 .002

Doesn’t meet criterion 221 (81.9) 56 (94.9) 156 (78.3)
⌴eets criterion 49 (18.1) 3 (5.1) 43 (21.7)
Total 270 59 199
Avoidance 2.24 .093
Doesn’t meet criterion 78 (28.9) 21 (35.6) 51 (25)
⌴eets criterion 192 (71.1) 38 (64.4) 148 (74.3)
Total 270 59 199
Hypervigilance 2.77 .068
Doesn’t meet criterion 81 (30) 23 (38.9) 55 (27.6)
⌴eets criterion 189 (70) 36 (61.0) 144 (72.4)
Total 270 59 199
Probable Diagnosis 7.38 .003
Doesn’t meet criterion 225 (83.3) 56 (94.9) 156 (78.3)
⌴eets criterion 45 (16.7) 2 (5.1) 43 (21.7)
Total 270 59 199
Note. PTSD-8 ⫽ Posttraumatic Stress Disorder– 8 inventory.
 816 BLEKAS ET AL.

Table 4
Characteristics of Subjects Meeting Criteria for Probable PTSD

Probable non-PTSD Probable PTSD

(n ⫽ 223) (n ⫽ 45)
Characteristics n (%) M (SD) n (%) M (SD) ␹2(df, N) p t (df, N) p

Age (years) 2.17 (3, N ⫽ 268) ⬎.001

18–30 (n ⫽ 92) 80 (87) 12 (13)
31–45 (n ⫽ 102) 85 (83.3) 17 (16.7)
46–60 (n ⫽ 69) 54 (78.3) 15 (21.7)
61–75 (n ⫽ 5) 4 (80) 1 (20)
AIS 33.66 (1, N ⫽ 258) ⬍.001
Noninsomniacs (n ⫽ 174) 162 (93.1) 12 (6.9)
Insomniacs (n ⫽ 96) 63 (28) 33 (73.3)
51.92 (3, N ⫽ 270) ⬍.001
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PHQ-9
No depression (n ⫽ 104)
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101 (44.9) 3 (6.7)

Mild (n ⫽ 117) 99 (44.0) 18 (40.4)
Moderate (n ⫽ 39) 19 (8.4) 20 (44.4)
Moderately severe (n ⫽ 10) 6 (2.7) 4 (8.9)
Severe (n ⫽ 0) 0 (0) 0 (0)
PDI 19.87 (5.19) 30.95 (6.59) ⫺10.09 (54, N ⫽ 270) ⬍.001
Negative Emotions 10.53 (3.18) 16.98 (4.44) ⫺9.27 (53, N ⫽ 270) ⬍.001
Feeling Threatened/Physical Tension 9.34 (2.54) 13.98 (3.20) ⫺10.64 (268, N ⫽ 270) ⬍.001
COVID-19
Worry 5.57 (2.1) 7.80 (1.37) ⫺8.17 (67, N ⫽ 253) ⬍.001
Unpredictability 6.67 (2.37) 8.54 (1.07) ⫺4.79 (73, N ⫽ 256) ⬍.001
Lethality 4.75 (2.48) 6.85 (2.00) ⫺5.03 (250, N ⫽ 252) ⬍.001
Note. PTSD ⫽ posttraumatic stress disorder; AIS ⫽ Athens Insomnia Scale; PHQ-9 ⫽ Brief Patient Health Questionnaire; PDI ⫽ Peritraumatic Distress
Inventory.

from workforce shortages in primary care facilities lacking every-
day materials to the intensive care units, where a total of 605
intensive care beds existed in the National Health care System,
among which, only 557 were in operation in the beginning of the
pandemic. As a result, patients, moreover disadvantaged ones,
encountered difficulties to receive adequate care.
In addition, the rise in migration to Greece since the beginning
of the Syrian Civil War and the subsequent management of the
refugee crisis led to the creation of large overpopulated Reception
and Identification Centers for asylum seekers and migrants, prac-
tically serving as migrant camps. The larger centers can be found
on certain Greek islands (Lesbos, Chios), which have minimal
health care capacity. As of March 2020, some 37,427 asylum
seekers and migrants have been accommodated in Greek island
facilities, which were originally planned to house only 6,095
people (General Secretariat for Information and Communication,
2020). These facts have raised questions about the capacity to
provide adequate living conditions, let alone the ability to imple-
ment adequate health care strategies during a pandemic, especially
for vulnerable social groups.

Table 5
Binary Logistic Regression to Identify Significant Predictors of PTSD

95% CI for Exp(b)

Predictors ␤ SE Wald df Sig. Exp(b) Lower Upper

Gender
Female ⫺.433 .858 0.254 1 .614 0.649 0.121 3.488

Step 1
PHQ-9 ⫺.042 .099 0.179 1 .672 0.959 0.790 1.164
AIS .135 .090 2.224 1 .136 1.144 0.959 1.366
COVID-19
Worry .249 .168 2.207 1 .137 1.283 0.923 1.784
Unpredictability ⫺.126 .158 0.639 1 .424 0.881 0.647 1.201
Lethality ⫺.024 .124 0.039 1 .844 0.976 0.766 1.244
PDI
Negative Emotions .282 .092 9.364 1 .002 1.326 1.107 1.590
Feeling Threatened/Physical Tension .266 .132 4.052 1 .044 1.305 1.007 1.692
Constant ⫺10.280 1.538 44.662 1 .000 0.000
Note. PTSD ⫽ posttraumatic stress disorder; Sig. ⫽ significance; Exp ⫽ exponentiation of the B coefficient; CI ⫽ confidence interval; PHQ-9 ⫽ Brief
Patient Health Questionnaire; AIS ⫽ Athens Insomnia Scale; PDI ⫽ Peritraumatic Distress Inventory.
 COVID-19 AND PTSD SYMPTOMS
The COVID-19 pandemic has been an unprecedented experi-
ence for the vast majority of the Greek HCPs. This is especially
true because Greece was not affected by the most recent pandem-
ics (SARS, MERS) with the exception of the West Nile virus
(which was geographically limited) and HIV. As a result, despite
the adequate scientific background, the field experience was lack-
ing. The novelty of COVID-19, the information overload with
many contradicting views, the media coverage focusing on certain
tragic deaths, and the lack of similar prior experience caused a
confusing mixture possibly leading to a sense of not having control
over the situation. Prior research has indicated that the feeling of
losing control over stressors was considered the most important
predictor of physician burnout (Freeborn, 2001), as well as a factor
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increasing anxiety (Maier & Seligman, 2016) and decreasing work
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competency (Arnsten, 2015). In this way, one may gain a better
understanding of the HCPs’ special concern over COVID-19 un-
predictability and lethality and search for ways of increasing the
sense of control to avoid negative outcomes (Southwick & South-
wick, 2018).
Because this survey was conducted during the pandemic, the
PDI was probably one of the most useful tools to assess
the psychological state of HCPs. Despite a dispute concerning the
perfect cutoff point score (Bunnell et al., 2018; Rybojad, Aftyka,
& Milanowska, 2019), it became clear that male HCPs experi-
enced at least moderate distress, whereas their female counterparts
experienced severe distress. Peritraumatic distress is associated
with PTSS (Gandubert et al., 2016), an observation supported by
the present study. Threatened or physical tension and negative
perceptions may be useful predictors of PTSS, in accordance with
previous surveys indicating that the strongest predictors of PTSD
were several peritraumatic psychological processes. Threatened or
physical tension corresponds to the “perceived life threat,” a strong
predictor of PTSD according to a meta-analysis published in 2003,
whereas the emotional responses here described as “negative per-
ception” are more indicative of acute stress symptomatology
(Ozer, Best, Lipsey, & Weiss, 2003, p. 52). Negative perceptions
of COVID-19 as a generalized state of an individual coping with
an adverse event may predispose a person to a negative outcome in
the sense of a self-fulfilling prophecy. A study in China stated that
negative attitudes toward COVID-19 may result in application of
incorrect and dangerous safety precautions posing a potential
threat (Zhong et al., 2020). Of course, a negative attitude alone
does not simultaneously translate into a specific action (Clayton &
Myers, 2009). Still, detecting negative perceptions may enhance
focus on groups requiring better and more accurate information.
The emotional state of HCPs appears to be at stake. Even
without an emergency situation, HCPs and especially physicians
suffer from emotional distress. Resident physicians have been
reported to have an estimated 20.9% prevalence of depressive
symptoms when screened using PHQ-9 (Kroenke, Spitzer, & Wil-
liams, 2001). In the current study, male HCPs reported moderate
depressive symptomatology, whereas female HCPs’ scores were
consistent with moderately severe symptomatology. This is in
agreement with the findings of a survey that reported depressive
symptoms in 34.6% of doctors and nurses in 31 different provinces
of China during the COVID-19 pandemic. Approximately half of
them were experiencing symptoms of moderate severity (Liu et al.,
2020). Keeping in mind that depressive symptoms do not neces-
sarily correlate with the diagnosis of depressive disorder, HCPs
817
reporting more severe depressive symptoms should be further
clinically evaluated.
Another finding that demands clinical focus is that of insomnia.
Studies focusing on the impact of the COVID-19 pandemic have
reported that HCPs were at high risk of poor sleep quality (Huang
& Zhao, 2020). According to this study, insomnia was not a
positive predictor of PTSD. Still, it was definitely alarming that
both male and female HCPs reported overall worsening of sleep, a
finding in accordance with the results reported by a survey in
Wuhan’s HCPs during the COVID-19 outbreak (Lai et al., 2020).
Sleep–wake cycle disturbances may reflect extended work shifts
due to hospitals’ being short-handed. They may also be the result
of anxious rumination, reflecting distress over possible patient
outcomes, getting sick after caring for someone with COVID-19,
or even anxiety over the possibility of bringing home the virus and
infecting someone they love. Either way, sleep challenges should
be addressed, because studies have indicated that insomnia may
result in more work-related accidents, as well as ineffective im-
plementation of safety strategies (Brossoit et al., 2019). The latter
could be especially detrimental in the current pandemic, because
failure to protect oneself from COVID-19 could result in further
spreading the disease.
Altogether, the aim of the present study was to explore the
psychological impact of COVID-19 on Greek HCPs. To the best of
our knowledge, there have not been any other published studies
focusing on HCPs during the COVID-19 pandemic in Greece. This
study, in accordance with previous research during other pandem-
ics, dispelled the myth that HCPs are immune to psychological
distress. HCPs are vulnerable not only to COVID-19 but also to its
psychological impact. Screening frontline HCPs for the aforemen-
tioned symptoms could be helpful in assessing and improving their
well-being. Early detection and targeted intervention may protect
HCPs and help to sustain functioning of the health care system.
Still, the present study had some limitations. The online survey
limited by default its scope to those having access to the Internet.
The survey was distributed through social media; therefore, the
majority of respondents were of a younger age. Although HCPs
tend to adapt to technological advances, it should be kept in mind
that some HCPs have limited technological literacy and do not
utilize social media. Furthermore, the study was based on a cross-
sectional design. According to the literature, it is generally stated
that PTSD symptoms tend to recede over time and most people
affected by a traumatizing event or experience develop resilience
(Riggs, Rothbaum, & Foa, 1995). Another limitation was that the
survey did not distinguish among the variety of HCPs. As a result,
further analysis of professionals from different disciplines was not
possible. Last, there was no comparison with another group, either
working during the pandemic or staying at home. Thus, the relative
psychological burden of being an HCP cannot be fully evaluated.
In conclusion, the present study results should be considered in
the context of the fact that the trajectory of the epidemic curve has
been—for now—successfully flattened in Greece. As a result of
Greek government policies, including a nationwide lockdown less
than a month after the first COVID-19 case in Greece, most HCPs
outside the special COVID-19 units did not have contact with
significant numbers of COVID-19 patients. This study revealed
that working in health care facilities comes with a moderate
psychological burden, which is significantly higher for female
HCPs and is not affected by age. According to the literature, the
 818 BLEKAS ET AL.
great majority of those exposed to traumatic events do not develop
posttraumatic psychopathology and acute stress symptoms remit
(Bryant, 2003). Among those at greater risk of experiencing psy-
chological consequences are individuals involved in caring (or
other forms of services) for the victims (Wright & Bartone, 1994).
It is no surprise that HCPs experience greater levels of peritrau-
matic distress and that addressing issues of insomnia and depres-
sive symptoms among HCPs in the next stages of the pandemic
could efficiently promote health care.
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Received May 7, 2020
Revision received July 2, 2020
Accepted July 6, 2020 䡲