The survivability of the Ebola Virus Disease is such a traumatic condition due to unfavorable physical and psychological consequences a person with EVD may endure during infection, treatment, and recovery. Several studies have shown that patients right after infection or after hospital discharge have compromised psychological health [4, 6, 9, 14, 30]. However, little is known, however, about the long term mental health implications of the EVD exposure. Our study is the first to investigate the psychological problem in Ebola survivors three years after the outbreak to address the question of whether exposure to EVD a risk factor for long term psychological problems in survivors.
Earlier studies on catastrophe survivors have shown that about one year after more than three-fourths of those with psychological problems shortly after the tragedy still have it [31, 32]. This study provides data on the psychological problems in EVD survivors, showing that they have higher odds of developing PTSD, depression, anxiety, and suicidality three years after recovery in comparison to non-survivors. Our results show a prevalence of PTSD (66%), depression (53%), anxiety (37%), and suicidality (34%) among EVD survivors three years after the outbreak. Such findings contribute to our understanding of Ebola survivors’ experience of persistent psychological symptoms. It is established that psychological symptoms that persist after an incident for more than six months are likely to persist over the long term [33, 34].
Our research findings indicate that most participants scored above the critical threshold with DTS, GAD-7, PHQ-7, and SBQ-R scores. In addition, the mean difference of depression, PTSD, anxiety, and suicidality scores were significantly higher in EVD survivors as compared to controls. The psychological consequences of EVD are often ignored in the acute setting but would be likely to persist into convalescing and may compound physical disabilities.
Earlier studies identified specific instances of major depression with suicide attempts after the EVD outbreak [35, 36]. Due to the shortage of therapists and social workers in the region, most survivors are still unable to receive adequate psychiatric care [17]. In order to offer medical and psychological services and the provision of appropriate medications, it is vital to have adequate skilled health professionals available. Currently, this is a significant limitation in Liberia. The availability of psychiatrists is rare in Liberia with just one psychiatrist [17]. Counseling of the Ebola survivors was performed by aid organizations and was done slowly [17].
Females account for most of our study participants. Other research studies have also reported more female survivors [37, 38]. It is due to the proportion of females admitted was more than males.
As in many traumatic events [6, 9], our study shows that psychological problems among Ebola survivors are common. Persons that have experienced severe trauma are at risk of increased psychological disorders [39]. The 1995 Kikwit, DR Congo Ebola outbreak, reported that 61% of the study participants presented issues related to mental/psychological consequences from the disease [4]. In Sierra Leone, a study of 74 survivors in Moyamba District, 2015 revealed that 48% of survivors show symptoms of psychological problems a few weeks after discharge from the ETC, placing them at risk of developing diverse levels of psychological disorders [40]. Similarly, 81 participants of another study in Kenema District, Sierra Leone, recorded around 35% had depression four months after discharge from the Ebola Treatment Unit [41]. Whereas in Liberia, the initial results of the ongoing research on neurological sequelae undertaken by Prevail III project showed a 49% prevalence of depression, for a cohort of 82 persons released from the treatment facility about six months earlier [36]. Another study performed by a Médecins Sans Frontières (MSF) team in Monrovia, reports a 40% prevalence of depression rate for a cohort of 136 persons discharged out of an Ebola Treatment Center for more than three months earlier and 12% for major PTSD-related depression [42]. The survivors of EVD are plagued by disease-related traumatic memories and associated death of relatives [43]. Our study also showed the survivors are struggling with extreme anxiety. This is due to fear of discrimination, as described by Reardon S. [43].
Contrary to assumptions, after three years of post-outbreak, psychological health levels did not subside, and depressed, nervous, suicidal, and posttraumatic symptoms are prevalent. It appears that instead of improving over time, EVD survivors’ psychological health in terms of PTSD, depression, anxiety, and suicidal symptoms is elevated; this may have been attributed to civil wars, constant human rights violations, economic hardships and fight against deadly diseases such as malaria, HIV/AIDS and diarrhea [44]. Another logical rationale was that many of the volunteers recruited by aid programs were students, social workers, and others without specialized psychology experience or advanced psychological counseling expertise. The following years also saw the rise of several economic hardships, unemployment, social shifts, health inequality, education, making it difficult for survivors and supporters to engage in long-term psychotherapy. Therefore, survivors who only once received the support for mental health remembered painful thoughts and re-experienced horrific scenarios without adequate assistance to relieve and resolve the negative feelings that may have contributed to secondary psychological issues. A significant contribution to the prevention and treatment of EVD survivors is the availability of long-lasting and effective mental health support after an epidemic.
The study revealed a significant association between EVD and later diagnosis of PTSD, depression, anxiety, and suicidality. The other relationship studied included marital status, age, region, education, gender, being a health care worker. In the secondary analysis, the variables of significance for the association predicting PTSD were marital status (separated), ages 30–34, and 35–39, low educational level, and religion – Christian. Our findings showed that the higher the level of education received, the less the psychological symptoms. It is necessary to combine local knowledge and understanding of the illness with a psychosocial approach, so, to help decrease the mental burdens surrounding the EVD epidemic. Training sessions can be structured classes regarding constructive mental health promotion or informal conversations between survivors and community members, peer support, education, and mental care services can be some methods shaping EVD survivors’ policy initiatives. Training sessions can be structured classes regarding constructive mental health promotion or informal conversations between survivors and community members, peer support, education, and mental care services can be some methods shaping EVD survivors’ policy initiatives [45]. The integration of local knowledge and understanding of the disease with psychosocial intervention is vital. Also, a marriage spilled is associated with poor mental health. A possible reason is due to the changes that occur after separation such as, poor sleep and appetite. The determinants of PTSD among Wenchuan earthquake survivors were also discussed by some recent articles [46–48]. During the post-earthquake period of the following the earthquake, Guo J. et al. [47] demonstrated that female gender, married, and low educational status were significantly associated with PTSD; and depression was significantly associated with PTSD 44 months after the earthquake. Additionally, Zhou X. et al. [48] further discovered that risk factors for PTSD were old age, female gender, and lonely living. While some of the causes as mentioned above are factors similar to our results, it is not fair to equate our findings with those of the above articles is not rational since our study was conducted three years after the outbreak and this is an epidemic of Ebola rather than an earthquake; all the above papers are cross-sectional studies, whereas this study was a retrospective cohort study.
Our research findings and that of other published reports have shown that many of the survivors have experienced psychological symptoms during and after the outbreak. It is, therefore, evident that a sensitive psychological trauma-informed care model is needed to meet the needs of the Ebola survivors, thus maximizing their mental and psychological health outcomes [49]. Such an approach enables health care providers, social workers, and policymakers to become aware of trauma, enhance screening and evaluation procedures, and implement evidence-based interventions that are tailored to the needs of EVD survivors [49].
We should also recognize existing efforts addressing the outbreak’s psychological effects, as evidenced by the award of approximately US$3 million in psychological assistance from the World Bank and Japan to address the necessities of physical and psychological and social care of EVD survivors [43]. Nonetheless, significant gaps exist in resolving the survivors’ psychological care, as shown by the findings of our study. Mental Health care has been inadequate due to the absence of proper planning, lack of resources, staff shortages, and weak health systems, and insufficient knowledge of policymakers that support mental health needs [43].
A significant limitation of the research is exploring psychological symptoms linked to different types of Ebola virus disease-related event exposures. Some other limitations existed in the interview and data collection process before analysis. Most of the survivors (cases) were illiterate; therefore, we have to explain the questions into simple English/ dialect for him/her to understand. Thus, the responses were subject to information bias. The self-reports of the study subjects, describing the effects encountered over the three years, were also subject to recall bias. The final major limitation in our study was the potential for participation bias. It is possible that, as with any cohort study, either cases or controls were differentially more likely to participate than the other if they somehow included in the results of the research.
Nevertheless, the results provide vital information about the psychological impact of an infectious disease epidemic for policymakers and mental health professionals globally, which can help brace the development of health systems and strategies to respond to possible future outbreaks of Ebola.