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The relationship among posttraumatic stress
disorder, posttraumatic growth, and suicidal
ideation among Italian healthcare workers
during the first wave of COVID-19 pandemic
Camilla Gesi
1,2
, Rita Cafaro
1,2
, Francesco Achilli
1,2
, Maria Boscacci
1,2
,
Matteo Cerioli
1,2
, Giovanna Cirnigliaro
1,2
, Fotios Loupakis
3
, Massimo Di Maio
4
and
Bernardo Dell’Osso
1,2,5,6
1
Department of Mental Health and Addiction, ASST Fatebenefratelli-Sacco, Milan, Italy,
2
Department of Biomedical
and Clinical Sciences “Luigi Sacco”, University of Milan, Milan, Italy,
3
KISS –No-Profit Association, Pisa, Italy,
4
Department of Oncology, University of Turin, A.O. Ordine Mauriziano, Turin, Italy,
5
Department of Psychiatry and
Behavioral Sciences, Stanford University, Stanford, CA, USA and
6
CRC “Aldo Ravelli”for Neurotechnology and
Experimental Brain Therapeutics, University of Milan, Milan, Italy
Abstract
Objective. The COVID-19 pandemic impacted mental health across different groups, including
healthcare workers (HWs). To date, few studies focused on potential positive aspects that may
follow the exposure to the pandemic. We investigated the prevalence of posttraumatic stress
disorder (PTSD) in Italian HWs and whether posttraumatic growth (PTG) dimensions affected
the risk of suicidal ideation (SI) during the first COVID-19 wave.
Methods. An online self-report survey was conducted between April and May 2020. Socio-
demographic data, information about COVID-19-related stressful events, Impact of the Event
Scale-revised, and Post-Traumatic Growth Inventory-Short Form (PTGI-SF) scores were
collected and compared between participants. Patient Health Questionnaire-9 scores were also
collected to assess SI through item 9. Multivariate logistic regression was used to assess the
relationship between PTGI and SI.
Results. Among 948 HWs, 257 (27.0%) reported a provisional PTSD diagnosis. The median
PTGI-SF score was 24. Participants reporting PTSD symptoms had higher scores in the Spiritual
change,Appreciation of life, and New possibilities domains, and in the total PTG scale. A total of
100 HWs (10.8%) screened positive for SI. Improvements in Relating to others domain of PTGI-
SF (odds ratioOR: .46; 95% confidence interval: .25–.85) were associated with lower odds of SI.
Conclusions. COVID-19 pandemic has been indicated as a risk factor for SI, also among HWs.
PTG may have a protective role on suicide risk. Improvements in Relating to others domain
reduced odds of SI, consistently with the role of loneliness and lack of connectedness with others
in enhancing suicidal risk.
Introduction
Extensive research has focused on the negative consequences of the COVID-19 pandemic on
mental well-being. A number of studies have been especially investigating depressive, anxiety,
and posttraumatic stress disorder (PTSD) symptoms arising in the wake of the pandemic and
social distancing restrictions.
1
However, only little attention has been devoted to positive
psychological changes that may develop in the aftermath of a stressful event. Beyond increasing
the risk for psychiatric illness, traumatic events may also promote post-traumatic growth (PTG),
which refers to thriving on traumatic circumstances while achieving greater appreciation of life
and relationships, enhanced spirituality, increased awareness of personal strength, and identi-
fication of new possibilities in one’s life. As PTG is experienced by a large number of trauma
survivors and associated with a beneficial effect on functioning,
2
addressing the correlates of PTG
might be as crucial as addressing those of PTSD.
Healthcare workers (HWs) have been shown to be at elevated risk for COVID-19-associated
mental health issues, such as PTSD, depression, anxiety, and suicidal ideation (SI).
3
While several
sociodemographic and work-related factors were found to be associated with the propensity to
develop mental health problems among HWs, a more comprehensive understanding still lacks
the assessment of possible positive factors. A recent study, conducted during COVID-19
pandemic in a sample of US veterans, found that moderate to high levels of PTG were present
in slightly less than a half of veterans, with markedly higher percentage among those with
COVID-19-associated PTSD symptoms and a significant effect of some PTG dimensions in
CNS Spectrums
www.cambridge.org/cns
Original Research
Cite this article: Gesi C, Cafaro R, Achilli F,
Boscacci M, Cerioli M, Cirnigliaro G, Loupakis
F, Di Maio M, and Dell’Osso B (2023). The
relationship among posttraumatic stress
disorder, posttraumatic growth, and suicidal
ideation among Italian healthcare workers
during the first wave of COVID-19 pandemic.
CNS Spectrums
https://doi.org/10.1017/S1092852923002493
Received: 01 July 2023
Accepted: 05 September 2023
Keywords:
PTSD; post-traumatic growth; COVID-19;
suicidal ideation; healthcare workers
Corresponding author:
Rita Cafaro;
Email: rita.cafaro@unimi.it
© The Author(s), 2023. Published by Cambridge
University Press. This is an Open Access article,
distributed under the terms of the Creative
Commons Attribution licence (http://
creativecommons.org/licenses/by/4.0), which
permits unrestricted re-use, distribution and
reproduction, provided the original article is
properly cited.
https://doi.org/10.1017/S1092852923002493 Published online by Cambridge University Press
reducing the odd for SI.
4
In light of these findings, the present study
analyzed data from a national sample of HWs gathered during the
first wave of COVID-19 in Italy, aiming to evaluate (a) the prev-
alence of COVID-19-associated PTG among HW with and without
COVID19-associated PTSD symptoms and (b) the association
between PTG and SI during the first wave of the pandemic.
Methods
This is a cross-sectional, web-based survey study, conducted during
the first wave of COVID-19 in Italy. Study procedures are exten-
sively elucidated elsewhere.
5
Briefly, answers were collected
between April 4 and May 13, 2020, the late phase of the first
stay-at-home order in Italy. An invitation letter presenting the
research and containing the link to the survey was sent to health-
care institutions, physicians’, and nurses’associations and circu-
lated through groups of health professionals on social networks and
researchers’direct contacts. Participants gave their informed con-
sent to participate in this study and to have their personal, clinical,
and demographic data used for research purposes. Their answers
were collected anonymously. The study was conducted in accor-
dance with the Declaration of Helsinki and all participants pro-
vided informed consent. The study protocol was approved by the
Department of Psychiatry of the ASST Fatebenefratelli-Sacco of
Milan as relevant institutional review board for low-risk studies
(code: dsm 12–20).
Participants
The inclusion criterion was being an HW actively working in Italy
during the pandemic. Any professionals involved in rehabilitation,
diagnostic, and administrative activities were invited to participate.
Assessments
Post-traumatic growth
COVID-19-related PTG was assessed using the Posttraumatic
Growth Inventory-Short Form (PTGI-SF)
6
. One total score and
5 subscores including Appreciation of life, Relating to others, Per-
sonal strength,Spiritual change, and New possibilities were calcu-
lated. In proceeding with previous studies using the PTGI-SF,
2,4
item responses were also dichotomized based on moderate or
greater endorsement. Endorsement at a moderate or greater level
of both items composing each PTGI-SF domain was indicative of
endorsement of the whole domain. Additional details regarding the
Italian-validated version of PTGI-SF and chosen cut-offs are pro-
vided in the Supplementary Material.
COVID-19-related PTSD symptoms
Participants were invited to fill the Impact of Event Scale-Revised
(IES-R) if they answered positively to a screening question (In the
past month, did you significantly felt on guard/easily startled or
detached from others/surrounding or disturbed by repeated/
unwanted memories of the COVID-19 epidemic (or something
you experienced because of it) or avoidant of situations that
reminded you of it (or something you experienced because of it)?
While the IES-R is not meant to be a diagnostic tool, a total score
of 33 has been indicated as having good diagnostic sensitivity
(0.91) and specificity (0.82) compared to a clinical diagnosis.
7
The
Italian version has also shown optimal psychometric properties
and validity.
8
Suicidal ideation
SI was assessed using the Patient Health Questionnaire-9 (PHQ-9).
A positive screen for SI was indicated by a response of “several
days,”“more than half the days,”or “nearly every day”to the Item
9(thoughts that you would be better off dead, or of hurting yourself
in some way).
Statistical analysis
Descriptive statistics were used to assess frequencies of socio-
demographic and clinical characteristics. A multivariable logistic
regression analysis was used to examine the association between
PTGI and SI, after adjustment for background characteristics
and clinical features. Data were analyzed using the SPSS software
program, version 27.0 (IBM Corp). All P-values are two-sided,
and statistical significance was set at P< .05. Additional details
regarding the PTGI-SF are provided in the Supplementary
Material.
Results
Of the 948 participants, 931 completed both IES-R and PTGI,
and were therefore included in the final sample. As the survey
was circulated with the assistance of healthcare institutions,
associations, and social networks, the response rate could not
be calculated. The mean (SD) age was 45.1 (11.8) years,
592 (63.7%) were females, 441 (47.4%) were from Lombardy,
and the remaining 489 (52.6%) were from other Italian regions.
In total, 723 (77.7%) were physicians, 104 (11.2%) were nurses,
and 103 (11.1%) were a mixed group mostly composed by mid-
wives, rehabilitation personnel, and laboratory technicians.
Table 1 shows the sociodemographic and clinical characteristics
of all included participants. Regarding IES-R, 553 (58.3%) HWs
reported a particularly stressful event. A total of 257 (27.6%)
screened positive for COVID-19-associated PTSD symptoms.
The median PTGI-SF score was 24.
The most endorsed domain of PTGI-SF at a moderate or greater
level was Appreciation of life (79.6%), the least endorsed was
Spiritual change (41.7%) (Table 1). HWs who screened positive
to COVID-19-associated PTSD symptoms scored higher than
those who screened negative on the total and Spiritual change,
Appreciation of life, and New possibilities domain scores of PTGI-
SF (Figure 1).
A total of 100 HWs (10.8%) screened positive for SI as assessed
through item 9 of the PHQ-9. After adjusting for background and
pandemic-associated risk factors, COVID-19-associated improve-
ments in Relating to others domain of PTGI-SF (odds ratio [OR]:
.46; 95% confidence interval [CI], .25–.85) was independently
associated with lower odds of SI (Table 1).
Discussion
The majority of HWs, mostly females and physicians, participating
in this study in the wake of the first outbreak of COVID-19 in Italy,
endorsed several dimensions of PTG at a moderate or greater level,
the most prevalent being the domains of Appreciation of life
(79.6%) and Personal strength (76.9%). This is consistent with
2 small studies reporting about PTG in samples of nurses facing
COVID-19 pandemic, where the highest item mean scores were in
the domains of Appreciation of life and Personal strength.
9,10
On the
other hand, spiritual growth was found to be the PTGI-SF
2 C. Gesi et al.
https://doi.org/10.1017/S1092852923002493 Published online by Cambridge University Press
dimension with the lowest mean score, accordingly to recent data
from literature.
11
Albeit concerns have been raised about the contribution of
COVID-19 in suicide risk among HWs,
12,13
no studies evaluated
whether PTG stemming from COVID-19 pandemic may exert a
protective effect against SI. Greater improvement in Relating to
others significantly reduced the odd of SI in our sample. This is
consistent with the role of loneliness and lack of connectedness
with others in enhancing the risk of suicide
14
and provides support
to the implementation of interventions targeting PTG-driven relat-
edness with others to prevent and address SI among HWs. Notably,
having a provisional PTSD diagnosis was not related to increased
odds of SI, suggesting that such interventions could profitably be
addressed to the whole population of HWs, independently from the
presence of clinically significant PTSD symptoms. Somewhat in
parallel, higher scores in Relating to others domain were not
influenced by having a provisional PTSD diagnosis in the compar-
ative analysis. This latter seems to confirm that PTG and PTSD
does not develop one from another, nor are mutually exclusive, as
they both represent different outcomes that may occur after expo-
sure to a traumatic event.
15
From this perspective, PTG may
represent an independent target of intervention to promote post-
traumatic adjustment and psychological well-being in populations
exposed to traumas.
Conclusions
PTG may have a protective role against SI among HWs facing a
global pandemic, especially when the dimension of relatedness to
others is enhanced in the process of adjustment. Limitations of the
study include the lack of information about the response rate of the
survey, the use of self-report instruments, and the cross-sectional
study design. Moreover, even though the presence of previous
mental disorders was assessed as possible confounding factor
(25.2% in our sample), the occurrence of psychopharmacological/
Table 1. Sociodemographic, Pandemic, and Clinical Characteristics of the
Sample and Results of Multivariate Regression Model Examining Their
Association with Current Suicidal Ideation
Sample
characteristics, N(%)
(n= 931)
Current suicidal
ideation OR
(95% CI)
Background characteristics
Age
Younger than 40 375 (40.3) 1
40 or older 556 (59.7) 1.62 (0.78–3.41)
Sex
Female 593 (63.7) 1
Male 338 (36.3) 1.60 (0.89–2.86)
Region
Lombardy 441 (47.4) 1.93 (1.03–3.62)
a
Other regions 490 (52.6) 1
Date of completion
Before May 4, 2020 697 (74.9) 1
May 4, 2020 or later 234 (25.1) 0.85 (0.43–1.68)
Minor children 336 (36.1) 0.55 (0.32–0.97)
a
Adult children 239 (25.7) 2.05 (0.91–4.60)
Living parents 716 (76.9) 1.38 (0.65–2.90)
Profession
Physician 724 (77.8) 1
Nurse 104 (11.2) 1.04 (0.45–2.41)
Other 103 (11.1) 1.40 (0.48–4.13)
Length of service
Up to 15 years 490 (52.6) 1
More than 15 years 428 (46.0) 0.34 (0.13–0.90)
a
Pandemic-associated factors
Workplace
Frontline 88 (9.5) 1
Inpatient no frontline 144 (15.5) 5.18 (0.98–27.38)
Outpatient/territorial
medicine
283 (30.4) 6.59 (1.26–34.39)
a
Services/other 416 (44.7) 5.94 (1.16–230.268)
a
Adequate PPE 421 (45.2) 0.75 (0.43–1.31)
Change in usual tasks 261 (28.0) 0.95 (0.47–1.90)
Relocation to other units 179 (19.2) 1.23 (0.55–2.79)
Relocation to COVID-
19 units
286 (30.7) 0.94 (0.43–2.03)
Unusual exposure to
suffering/death
420 (45.1) 1.24 (0.68–2.26)
Infection, self 82 (8.8) 1.17 (0.45–3.08)
Infection, relatives/close
friends
296 (31.8) 1.00 (0.53–1.90)
Death following infection,
relatives/close friends
261 (28.0) 1.13 (0.50–2.53)
Death following infection,
colleagues
112 (12.0) 0.62 (0.21–1.84)
Table 1. Continued
Sample
characteristics, N(%)
(n= 931)
Current suicidal
ideation OR
(95% CI)
Separation from
cohabiting relatives
115 (12.4) 0.91 (0.45–1.83)
Separation from
noncohabiting
relatives
862 (92.6) 0.70 (0.29–1.72)
Clinical factors
Previous mental disorders 235 (25.2) 1.79 (1.04–3.07)
a
Positive IES-R screen for
PTSD
258 (27.7) 1.53 (0.84–2.78)
PTGI-SF dimensions
Appreciation of life 741 (79.6) 1.67 (0.81–3.45)
Relating to others 642 (69.0) 0.46 (0.25–0.85)
a
Personal strength 716 (76.9) 0.79 (0.43–1.45)
Spiritual change 382 (41.0) 1.70 (0.96–3.03)
New possibilities 610 (65.5) 0.54 (0.29–1.01)
Note: The table shows sociodemographic, pandemic, and clinical characteristics and ORs of
suicidal ideation of each factor.
a
P-values < 0.05.
CNS Spectrums 3
https://doi.org/10.1017/S1092852923002493 Published online by Cambridge University Press
psychological treatments was not assessed and might have biased the
results. Lastly, sinceour data were collected in a relatively precocious
phase of COVID-19, follow-up data on the long-lasting effects of the
pandemic and the longitudinal course of PTG among HWs are
needed. Studies replicating these findings and assessing changes in
PTG and SI over time are warranted, as well as developing evidence-
based interventions enhancing PTG and helping HWs to manage
stressors during and beyond COVID-19 pandemic.
Supplementary material. The supplementary material for this article can be
found at https://doi.org/10.1017/S1092852923002493.
Acknowledgements. Fondazione Romeo ed Enrica Invernizzi.
Author contribution. Supervision: B.D.; Writing –original draft: G.C., F.L.,
F.A., C.G., M.B., M.D.M., M.C., R.C.; Conceptualization: F.L., C.G., M.D.M.;
Data curation: F.L., C.G., M.D.M.; Formal analysis: F.L., C.G., M.D.M.; Writing
–review & editing: R.C.
Financial support. No specific funding was received for this article.
Disclosure. The authors declare that they have no known competing financial
or nonfinancial interests to disclose in relation to the present article.
References
1. Cénat JM, Blais-Rochette C, Kokou-Kpolou CK, et al. Prevalence
of symptoms of depression, anxiety, insomnia, posttraumatic stress
disorder, and psychological distress among populations affected by
the COVID-19 pandemic: a systematic review and meta-analysis.
Psychiatry Res. 2021;295:113599. doi:10.1016/J.PSYCHRES.2020.1
13599.
2. Wu X, Kaminga AC, Dai W, et al. The prevalence of moderate-to-high
posttraumatic growth: a systematic review and meta-analysis. J Affect
Disord. 2019;243:408–415. doi:10.1016/J.JAD.2018.09.023.
3. Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P.
Prevalence of depression, anxiety, and insomnia among healthcare workers
during the COVID-19 pandemic: a systematic review and meta-analysis. Brain
Behav Immun. 2020;88:901–907. doi:10.1016/J.BBI.2020.05.026.
4. Pietrzak RH, Tsai J, Southwick SM. Association of symptoms of posttrau-
matic stress disorder with posttraumatic psychological growth among US
veterans during the COVID-19 pandemic. JAMA Netw Open. 2021;4(4):
e214972. doi:10.1001/JAMANETWORKOPEN.2021.4972.
5. Gesi C, Cirnigliaro G, Achilli F, et al. The impact of COVID-19 pandemic
first wave on healthcare workers: a new perspective from qualifying PTSD
criterion A to assessing post-traumatic growth. J Clin Med. 2023;12(5):
1862. doi:10.3390/JCM12051862.
6. Cann A, Calhoun LG, Tedeschi RG, et al. A short form of the Posttraumatic
Growth Inventory. Anxiety Stress Coping. 2010;23(2):127–137. doi:
10.1080/10615800903094273.
7. Creamer M, Bell R, Failla S. Psychometric properties of the impact of event
scale - revised. Behaviour Res Ther. 2003;41(12):1489–1496. doi:10.1016/J.
BRAT.2003.07.010.
8. Craparo G, Faraci P, Rotondo G, Gori A. The impact of event scale - revised:
psychometric properties of the Italian version in a sample of flood victims.
Neuropsychiatr Dis Treat. 2013;9:1427–1432. doi:10.2147/NDT.S51793.
9. Cui PP, Wang PP, Wang K, Ping Z, Wang P, Chen C. Post-traumatic
growth and influencing factors among frontline nurses fighting against
Figure 1. Comparison between scores at the PTGI of subject with versus without PTSD. The figure shows the comparison between the mean scores in each PTGI-SF domain and
subdomain of participants reporting COVID-19-related PTSD symptoms and those not showing PTSD symptoms.
4 C. Gesi et al.
https://doi.org/10.1017/S1092852923002493 Published online by Cambridge University Press
COVID-19. Occup Environ Med. 2021;78(2):129–135. doi:10.1136/
OEMED-2020-106540.
10. Peng X, Zi ZH, Yang Y, Li RZ, Ying HD, He Q. Post-traumatic growth
level and its influencing factors among frontline nurses during the COVID-
19 pandemic. Front Psychiatry. 2021;12:632360. doi:10.3389/
FPSYT.2021.632360.
11. Feingold JH, Hurtado A, Feder A, et al. Posttraumatic growth among health
care workers on the frontlines of the COVID-19 pandemic. J Affect Disord.
2022;296:35–40. doi:10.1016/j.jad.2021.09.032.
12. Rahman A. A scoping review of COVID-19-related stress coping resources
among nurses. Int J Nurs Sci. 2022;9(2):259–267. doi:10.1016/J.
IJNSS.2022.02.008.
13. Awan S, Diwan MN, Aamir A, et al. Suicide in healthcare workers: deter-
minants, challenges, and the impact of COVID-19. Front Psychiatry. 2022;
12:792925. doi:10.3389/FPSYT.2021.792925.
14. McClelland H, Evans JJ, Nowland R, Ferguson E, O’Connor RC. Loneli-
ness as a predictor of suicidal ideation and behaviour: a systematic review
and meta-analysis of prospective studies. J Affect Disord. 2020;274:
880–896. doi:10.1016/J.JAD.2020.05.004.
15. Wu K, Zhang Y, Liu Z, Zhou P, Wei C. Coexistence and different
determinants of posttraumatic stress disorder and posttraumatic
growth among Chinese survivors after earthquake: role of resilience
and rumination. Front Psychol. 2015;6:1043. doi:10.3389/fpsyg.2015.
01043.
CNS Spectrums 5
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