Sars Survivors

Canadian Psychology/Psychologie
canadienne
Psychological Impact on SARS Survivors: Critical Review
of the English Language Literature
Paula J. Gardner and Parvaneh Moallef
Online First Publication, October 13, 2014. http://dx.doi.org/10.1037/a0037973
CITATION
Gardner, P. J., & Moallef, P. (2014, October 13). Psychological Impact on SARS Survivors:
Critical Review of the English Language Literature. Canadian Psychology/Psychologie
canadienne. Advance online publication. http://dx.doi.org/10.1037/a0037973
Canadian Psychology / Psychologie canadienne

2014, Vol. 55, No. 4, 000
2014 Canadian Psychological Association

0708-5591/14/$12.00 http://dx.doi.org/10.1037/a0037973
Psychological Impact on SARS Survivors: Critical Review of the English

Language Literature
Paula J. Gardner
Parvaneh Moallef
Sunnybrook Health Sciences Centre, St. Johns Rehab, Toronto,

Ontario, Canada
St. Johns Rehab Hospital, Toronto, Ontario, Canada and

York University
Severe acute respiratory syndrome (SARS) has been labelled a mental health catastrophe, an infectious
atypical pneumonia condition that spread to 29 countries in 2002/2003, infecting over 8,000 people, 774
of whom died. A literature search on electronic databases, including MEDLINE, PsycINFO, CINAHL,
and Cochrane Library was used to conduct a critical review of the English language literature on the
psychological impact of SARS for survivors. Twenty original studies pertaining to the psychological
experience of patients revealed prominent symptoms: in the acute and early recovery stages, psychotic
symptomatology, fear for survival, and fear of infecting others; across all timeframes, stigmatization,
reduced quality of life, and psychological distress; posttraumatic stress symptoms were prevalent across
all stages post-SARS. Health care workers with SARS were found to be at increased risk. Limitations
within many studies restrict the optimal usefulness of the findings. Studies included in our review
consistently reported high rates of emotional distress among survivors, persisting for years postinfection.
Recommendations to enhance comparability across studies for future outbreaks were proposed.
Keywords: SARS, psychological, posttraumatic stress disorder, health care workers, infectious diseases
research into the impact of this viral epidemic reveals many

weaknesses, indicating a lack of preparedness on the part of
researchers. This lack of research preparedness appeared to mirror
a lack of preparedness of public health systems to intervene by
providing mental health support for survivors in an effective and
timely way, and to help prevent mental health difficulties from
developing, particularly for frontline health care workers
(Maunder et al., 2006; Xing, Hejblum, Leung, & Valleron, 2010).
Although there is a considerable body of research on the effects of
the SARS epidemic on the community in general, and health care
workers in particular, the focus of the current review presents only
the available research on psychological sequelae reported by survivors of SARS, both in the early acute recovery stages of the
illness, and in the later recovery periods, highlighting some problematic aspects of these studies.
After its first emergence in Asia in November 2002, severe

acute respiratory syndrome (SARS) spread throughout several
parts of the world and was finally contained by July 2003. This
epidemic, with its rapid spread and high mortality rate, generated
considerable panic and anxiety around the globe (Campbell, 2006).
The origin of SARS was traced to a novel strain of the coronavirus that causes flu-like symptoms, which for many sufferers
escalated into clinical pneumonia. In 29 countries, 8,096 individuals were infected, and a wide range of severity was reported, from
asymptomatic infection to severe illness and death. Between 20%
and 25% of SARS patients became critically ill, requiring intensive
care, and 10%, or 774 individuals, died worldwide (World
Health Organization, 2004). In the few studies reviewed to date
that pertain to the psychological impact on SARS survivors, high
rates of emotional distress were reported, including anxiety, depression, fearfulness, and stigmatization (Chan et al., 2003; Cheng
& Wong, 2005; Tsang, Scudds, & Chan, 2004; Zhang, Liu, & He,
2004). However, because most of these studies looked at the
period covering the acute phase of the illness and up to 6 months
postinfection, we know very little about the longer-term psychological effects of SARS, and we know even less about how the
psychological effects of SARS changed over time. Furthermore,
Method
A systematic search of the peer-reviewed literature was carried
out to identify all original research studies that assessed the psychological or psychosocial functioning and mood status of SARS
survivors, from the beginning of the epidemic in 2002 until November 2011. The MEDLINE, Cumulative Index of Nursing and
Allied Health (CINAHL), Psychological Abstracts (PsycINFO),
and the Cochrane Library catalogue were searched using the
keywords SARS and psychology, psychological, psychosocial, social, psychiatric, psychosis, neuropsychiatric, mood, depression,
anxiety, trauma, posttraumatic stress disorder, PTSD, distress,
stress, coping, emotion, emotional, adjustment, stigma, and quality
of life. Initial inclusion criteria consisted of English language
peer-reviewed research articles that measured some aspect of psychological or psychosocial functioning or mood status in adults
Paula J. Gardner, Sunnybrook Health Sciences Centre, St. Johns Rehab,

Toronto, Ontario, Canada; Parvaneh Moallef, St. Johns Rehab Hospital,
Toronto, Ontario, Canada, and Department of Psychology, York University.
Correspondence concerning this article should be addressed to Paula J. Gardner,
Sunnybrook Health Sciences Centre, St. Johns Rehab, 285 Cummer Avenue,
Toronto, Ontario, Canada M2M 2G1. E-mail: paula.gardner@sunnybrook.ca
1
GARDNER AND MOALLEF
who had been infected with SARS. Next, the studies were considered for a specific quality of methodology; that is, only those
studies were included that used either standardized measures
and/or an internationally accepted diagnostic classification system
such as the Structured Clinical Interview for DSM Disorders
(SCID). Overall, 27 studies met the initial inclusion criteria; from
these, 7 studies did not fulfil the subsequent specific quality of
methodology for inclusion noted above; that is, results reported in
these 7 rejected studies were based on symptom lists only, or
nonstandardized measures of mood. In the end, 20 studies were
included for the formal review. For the next step, rank ordering of
their level of evidence was performed (i.e., scientific rigour in
terms of research design), based on the classification similar to that
published by the American Academy of Neurology (Edlund,
Gronseth, So, & Franklin, 2004). Because none of the studies
available for the current review qualified for the highest ranking
level of evidence, that is, randomization or double-blind techniques, and none involved the lowest ranking, that is, expert
opinion, the classification system was collapsed from four categories to two mutually exclusive categories (A or B) as follows:
Level A, included studies with a higher level of scientific rigour
(prospective design, two-group or multiple timeframe, inclusion of a
matched control, or cohort); Level B, included studies with a lower
level of scientific rigour (retrospective and/or cross-sectional design
with no matched control or cohort). Both authors rank-ordered the 20
studies independently and, where there were differences of opinion,
interrater agreement was reached through discussion.
Figure 1.
Results
In the tables, described below, major findings, as well as the
limitations of each study, are outlined. Inconsistencies in study design
or use of standardized measures were notable features. The prominence of specific psychological factors identified varied across time
postinfection: psychotic symptomatology, fear for survival, fear of
infecting others, perceived stigmatization, reduced quality of life,
psychological/emotional distress, and PTSD. Figure 1 illustrates the
presence of psychological factors across three timeframes post-SARS:
the acute stage (up to 1 month postinfection), the early recovery from
SARS stage (1 month to 6 months postinfection) and the later recovery from SARS stage (6 months to 51 months postinfection). Next,
the reviewed studies are presented in the tables that follow the three
timeframes noted above: Table 1, presents the Acute Stage of Recovery from SARS for Survivors (1 month); Table 2, Early Recovery
Period from SARS for Survivors (1 to 6 months); Table 3, Later
Recovery Period from SARS for Survivors (6 to 36 months); and
Table 4 lists studies that had a prospective multiple timeframe design
(from 6 weeks to 51 months postinfection).
Within each table, studies are categorized in terms of their level of
evidence, as described in the Method section: 12 studies were designated as Level A, and 8 as Level B. A number of studies utilized
multiple designs: 13 used a cross-sectional and/or retrospective design, 9 used a prospective design, and 7 included comparison with
either matched controls, cohort, or community samples. Thirteen
studies included health care workers (HCWs) as part of their sample.
Psychological factors across three time-frames post-SARS.
A: Cross-sectional
Matched control
B: Retrospective
B: Retrospective
Cross-sectional
Chua et al. (2004)
Lau et al. (2005)
Wu et al. (2005)
Journal of
Traumatic
Stress
Acute phase, 1 month

postdischarge
Early acute phase
2 weeks postdischarge
1 month postdischarge
(acute stage)
n 79 SARS patients Age

range 1860 M/F
34:66 HCWs 39%
n 145 community
Age range 1860
M/F 41:59
n 171 Mean age 37.4

(SD 12.65) M/F
35:65
n 195 Age range 18

88 M/F 43:57
Timeframe
n 180 Mean age 36.9

(SD 11.1) M/F
33:67 HCWs 20%
n 649 community
Mean age 32.1
(SD 8.63) n 189
psychiatric patients
Mean age 42.7
(SD 12.82)
Sample and study

population
Survey questionnaire
Self-report questionnaires:
Perceived life threat:
new
IES-R
HADS
Medical record review

6 min walk test
Musculoskeletal fitness
tests
Self-report questionnaire:
SF-36, HRQoL

PSS-10
Current symptom list:
new
SARS database in Hong

Kong
BAI
BDI
SARS impact scale:
new
Methods/measures
10 to 18% reported PTSD,

anxiety and depression
symptoms
Symptom severity was
associated with high
perceived life threat, low
emotional support, and
knowing other SARS
patients
66% had mild or more
prominent psychological
distress
Both SARS survivors and

community residents
reported increased stress
levels
SARS survivors were
significantly more affected
20% had psychological
symptoms
HCWs (SARS) had
significantly more positive
as well as negative
psychological effects
SARS survivors had deficits in
cardiorespiratory and
musculoskeletal
performance
Health related quality of life
significantly impaired
35% reported severe or moderate

to severe anxiety and
depression symptoms
Two factors, being a HCW or
having a family member
killed by SARS significantly
contributed to high levels of
psychological distress
Major findings
Criterion A of DSM-IV
PTSD not assessed
limiting
determination of
PTSD prevalence
Low response rate
(41%)
Respondents were
somewhat younger
than nonrespondents
Small sample for certain
groups
Some selection bias

possible because of
exclusion criteria
Submaximal exercise
testing selected for
cardiorespiratory
fitness of patients
Low response rate (42.4%)

Respondents were
younger than
nonrespondents
Community sample data
collected before
epidemic
One measure was newly
developed for study
and not standardized
Because of risks of
infection as well as
patient fatigue,
questionnaires had
to be brief and selfadministered
Psychometric properties
of new measure not
evaluated
Limits of study
Despite moderate
impairment in early
physical fitness,
quality of life ratings
were low suggesting
early initiation of
physical intervention
program
The significant risk factors
identified found may
help to identify the
at-risk survivors for
timely intervention
New measure demonstrated

satisfactory internal
consistency (SARS
Impact Scale)
Negative appraisals of
the illness
experience were
related to
psychological
symptom distress
Increased stress levels and
negative
psychological effects
for SARS patients
led to the
recommendation to
track these patients
for psychiatric needs
after discharge
Implications of study
Note. BAI Beck Anxiety Inventory; BDI Beck Depression Inventory; DSM-IV Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition; HADS Hospital Anxiety and
Depression Scale; HCWs health care workers; IES-R Impact of Events Scale-Revised; PSS-10 Perceived Stress Scale; PTSD posttraumatic stress disorder; SF-36 Short-Form 36 Health
Survey; HRQoL Health Related Quality of Life.
A: Prospective
Matched control
Level of evidence
and design
Cheng, Wong et al.

(2004)
Reference
Table 1
Acute Stage of Recovery From SARS for Survivors, 1 Month Postinfection (n 4)
PSYCHOLOGICAL IMPACT ON SARS SURVIVORS
A: Retrospective
Cross-sectional
Cohort
B: Retrospective
Cross-sectional
B: Cross-sectional
Cheng, Sheng et al.

(2004)
Sheng et al. (2005)
Cheng et al. (2006)
11 months
postdischarge
Mean time since

discharge 42
days Range 26
86 days
26 months
postdischarge
n 100 SARS patients

Mean age 37.1
(SD 12.09) M/F
34:66 HCWs 18%
n 184 community
Mean age 34.5
(SD 8.71) M/F
40:60 HCWs 11%
n 102 Mean age 37.6

(SD 12.4) M/F
34:66 HCWs 17.5%
n 57 Mean age 38.1

(SD 10.4) M/F
33:67 HCWs 38.6%
Those referred for
psychological Ax and
Rx
Timeframe
2 months postdischarge
n 41 Mean age 35.9

(SD 11.15) M/F
46:54
Sample and study

population
Methods/measures

BDI
BAI
Perceived health
SARS appraisal inventory
Thriving Scale
Posttraumatic growth

Self-report questionnaires
(family and friends also
completed):
GHQ28
NPSC-SARS version: new

GHQ28
Rosenberg Self-Esteem Scale
WHOQOL-BREF
SARS Symptom Checklist:
new
Social support questionnaire:
new
Medical record review,

interview
Disruption Scale
SSQR
HADS
Major findings
High proportion of suspected

cases of psychiatric
and psychological
morbidity in SARS
patients in early phase
of recovery
HCWs demonstrated a
worse adjustment
outcome than nonHCWs
Dose effects of steroids
and severity of SARS
symptoms accounted
for a substantial
portion of variance in
distress
Social support impacted
self-esteem
65% had strong symptoms on
GHQ28
Use of corticosteroids were
predictive of
psychological
symptoms (anxiety,
depression, psychosis,
behavioural symptoms)
Disease severity correlated
with neuropsychiatric
symptoms
Severity of distress, high
doses of corticosteroids
and being HCW
predicted
neuropsychiatric
complaints
Risk factors for poor
adjustment identified
such as being HCW,
ICU admission and
being female
Perceived impact, coping
efficacy and
relationship growth
accounted for
significant variance in
outcome measures of
psychological
functioning
Physical functioning and lack

of satisfaction with
social supports
significantly correlated
with psychological
distress
Limits of study
Causal relationships remain

tentative because of
cross-sectional
design
Select sample, only those
referred for
psychological Ax
and Rx may impact
generalizability
Some measures
nonstandardized
Low response rate (33%)

Male gender
underrepresented
NPSC-SARS new,
nonstandardized
questionnaire

Symptom severity
ratings were
dependent on
patients recall
Small sample size

No cause and effect can
be discerned based
on study design
Because perceived impact and

coping efficacy tended to
influence psychological
outcomes, suggestions are
offered for strategies for
interventions
Factors surrounding both illness

and Rx contributed
significantly to mental
health in both the acute and
convalescent stages
Because HCWs were
significantly affected
psychologically, consultation
services were recommended
Assists in understanding the nature

of events contributing to
distress in discharged SARS
patients; this can assist staff
to identify patients in need
of psychosocial support and
to tailor interventions
Indicates vulnerability of HCWs
and suggests early screening
for psychological distress
Also indicates early intervention
for isolation patients,
emphasizing importance of
social support
Note. BAI Beck Anxiety Inventory; BDI Beck Depression Inventory; GHQ28 General Health Questionnaire; HADS Hospital Anxiety and Depression Scale; HCWs Health Care Workers;
ICU intensive care unit; NPSC Neuropsychiatric Symptom Checklist-SARS; Rx treatment; SSQR Revised Social Support Questionnaire; WHOQOL-BREF World Health Organization
Quality of Life-Brief Version.
B: Retrospective
Cross-sectional
Level of evidence
and design
Au et al. (2004)
Reference
Table 2
Early Recovery Period From SARS for Survivors, 1 Month to 6 Months Postinfection (n 4)
4
GARDNER AND MOALLEF
B: Cross-sectional
A: Retrospective
Matched
control
Cohort
Mak, Law et al. (2009)
Moldofsky & Patcai

(2011)
30 months post-SARS
outbreak
18 months post-SARS
outbreak
1336 months
postinfection
n 143 Mean age 38.4

(SD 12.4) M/F 37:63
HCWs 32.9%
n 22 Mean age 46.3

(SD 11.02) M/F 3:19
HCWs 95% n 7
community Mean age 30
(SD 6.7) n 21 FMS
patients, all female Mean
age 42.4 (SD 11.8)
Timeframe
n 90 Mean age 41.1

(SD 12.1) M/F 38:62
HCWs 30%
Sample and study population
Self-report measures:
WPSI
BDI
PCL-C
SAQ
Semi-structured Interview
Self-report
questionnaires:
MHSIP survey:
adapted
MOS-SSS
SUPPH
SF-36, HRQoL
subscales
IES-R
HADS
SF-36, HRQoL
DSM-IV categories
SCID structured
interview
Methods/measures
Chronic post-SARS is
characterized by
persistent fatigue, diffuse
myalgia, weakness,
depression, and
nonrestorative sleep
patterns similar to
patients with FMS and
chronic fatigue syndrome
10% of SARS patients reached
clinical significance for
symptoms of PTSD
Social support and self-efficacy

were associated with
better psychological
adjustment, particularly
support by HCWs
Self efficacy was a
significant mediator
between social support
and psychological
adjustment
Post-SARS cumulative
incidence of psychiatric
disorders was 58.9%,
with prevalence at 30
months at 33.3%
PTSD prevalence was 25.6%
A significantly higher
prevalence of PTSD was
found among HCWs
Major findings
Pre-SARS data subject to
subjects recollections
Concerns regarding
stigmatization may
have led to
underreporting of
psychiatric symptoms,
though litigation and
compensation may
have led to overexaggeration of
symptoms
No control group included
Cause and effect relationships
cannot be made based
on design
Specific trauma or
psychological factors
were not examined
Premorbid psychological
functioning was not
included
Oversampling of younger
subjects and HCWs
Sleep findings could be a
result of adverse effects
of first night effect of
the sleep laboratory, or
from the traumatic
effects of the acute
infectious illness
Difficult to establish
connection among
depression, pain, and
sleep difficulties
Limits of study
Sleep features as well as mood

difficulties can be longterm consequences of
SARS, similar to
findings of patients with
FMS
Support from family, friends

and HCWs can promote
SARS survivors mental
health by enhancing
their perceived efficacy
in coping with stress
Highlights the need to enhance

preparedness and
competence of HCWs in
detecting and managing
psychological sequelae
for future infectious
disease outbreaks
May help to make decisions
in manpower forecasting
for future outbreaks
Note. BDI Beck Depression Inventory; DSM-IV Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition; FMS Fibromyalgia Syndrome; HADS Hospital Anxiety and
Depression Scale; HCWs health care workers; IES-R Impact of Events Scale-Revised; MHSIP Mental Health Statistics Improvement Program Survey; MOS-SSS Medical Outcomes Study
Social Support Survey; PCL-C Posttraumatic Stress Disorder Checklist-Civilian Version; PTSD posttraumatic stress disorder; SAQ Sleep Assessment Questionnaire; SCID Structured Clinical
Interview for DSM-IV Diagnostic categories; SF-36, HRQoL Short-Form 36 Health Survey, Health Related Quality of Life; SUPPH strategies used by patients to promote health; WPSI Wahler
Physical Symptom Inventory.
B: Retrospective
Cross-sectional
Level of evidence
and design
Mak, Chu et al. (2009)
Reference
Table 3
Later Recovery Period From SARS for Survivors, 6 Months to 36 Months Postinfection (n 3)
A: Prospective
Cohort
A: Prospective
Repeated
measures
within subject
A: Prospective
A: Prospective
Cross-sectional
A: Prospective
Matched
control
Wu et al. (2005)
Emerging Infectious
Diseases
Li et al. (2006)
Kwek et al. (2006)
Lee et al. (2007)
Level of evidence
and design
Hui et al. (2005)
Reference
3, 6, and 12 months
postdisease onset
1 and 3 months
postdischarge
3, 6, and 12 months
postdisease onset
6 weeks and 3 months

postdischarge
2003 April to May

2004 April to May
n 131 Mean age

41.8 (SD 14.01)
M/F 44:56
HCWs 11%
n 59 SARS survivors
with ARDS only
Mean age 47
(SD 15.7) M/F
58:42
n 63 Mean age 34.8

(SD 10.49) M/F
21:79 HCWs 54%
n 79 in 2003 M/F
34:66 HCWs 38%
in 2003 n 96 in
2004 M/F 37:63
HCWs 34.4% in
2004 Healthy matched
controls
n not provided
Timeframe
n 97 Mean age 36.9

(SD 9.5) M/F
40:60 HCWs 70%
Sample and study

population

In 2003:
PSS-10
In 2004:
PSS-10
DASS-21
IES-R
GHQ-12
IES
HADS
SF-36, HRQoL

Physical assessment
SF-36, HRQoL

IES-R
HADS
DSM-IV categories

Physical assessment
SF-36, HRQoL
Methods/measures
No significant differences were found

between those who had
mechanical ventilation versus
those who did not
Patients over age 40 had impaired
HRQoL on multiple domains at
all time frames including at 12
months postillness
41.7% had scores indicative of PTSD
27% likely had anxiety and 33%
depression
ICU patients compared similarly with
rest of SARS patients
All rates of psychological disturbance
were higher than the national
prevalence of minor psychiatric
disorders of 17%
Some improvement noted over time
Higher stress levels for SARS survivors
vs. healthy controls persisted from
2003 to 2004
1 year after SARS, survivors showed
worrying levels of depression,
anxiety and posttraumatic
symptoms, with possible
deteriorating condition over time
64% scored with potential psychiatric
morbidity
Being a woman and being HCW were
predictive of poor psychological
adjustment
Significant decrease in psychological

symptom severity from 1 to 3
months postdischarge
Risk factors identified for psychological
distress included being a HCW,
knowing someone who had SARS
and history of psychiatric
consultation
Health related quality of life lower than

scale norms at 3 months
postinfection, specifically mental
health ratings
Significant physical and health status
impairment found at 12 months
postdisease
Still, functional disability appeared to
be out of proportion to lung
function impairment
Major findings
Table 4
Prospective, Multiple Time-Frame Studies Post-SARS for Survivors, 6 Weeks to 51 Months Postinfection (n 9)
Reliance on self-report of
symptoms
Unable to compare subjects over
time
No information on past psychiatric

history
Low response rate (40%)
Causal relationships remain
tentative because of crosssectional design
IES scale used to detect PTSD,
not optimal use of measure
Small sample size did not permit

multivariate analyses
Premorbid HRQoL was not
available
More sensitive measures to assess
exercise and lung capacity were
not used
Certain physical/medical testing

not performed/measured
97 of 123 (79%) survivors
completed all phases of the
study
Difficult to determine the
psychological contribution and
motivational factors to reduced
physical functioning, since
compensation was being sought
for occupation-related SARS
Small sample size of certain
groups within study
Criterion A of DSM-IV PTSD not
assessed limiting
determination of PTSD
prevalence
Limits of study
(table continues)
Instead of abating over time,

long-term psychological
effects of infectious disease
persisted, more pronounced
for women and HCWs
Suggests psychological services
important in rehabilitation
phase, looking ahead at future
potential outbreaks (H5N1)
Recovery in quality of life found

to trail behind recovery from
acute illness
Psychological follow-up after
discharge should be part of
the management plan
Quality of life for younger

patients reached near-normal
levels at 6 months whereas
for older adults it remained
low
Findings are similar to quality of
life ratings for ARDS patients
Early and focused support

services and resources for
emotional support to enhance
resilience following the
illness are warranted
Degree of physical impairment

found after 12 months
Reduced ratings of quality of life
noted even at all stages of
recovery
Psychological concerns warrant
further follow-up to assess if
deficits are persistent
6
GARDNER AND MOALLEF
A: Prospective
A: Retrospective
Prospective
A: Prospective
Cohort
Bonanno et al.
(2008)
Hong et al. (2009)
Ngai et al. (2010)
Timeframe
6, 12, and 18
months
postdischarge
2, 7, 10, 20,
and 46 months
postdischarge
3, 6, 12, 18,
and 24 months
n 68 Mean age 38.5

(SD 12.3) M/F
33:67
n 55 Mean age 44.4

(SD 13.2) M/F
34.5:65.5 HCWs
49%
M 41.3 months
postdischarge
Range 3151
months
postdischarge
n 997 Mean age 42

(SD 14) M/F
39:61
n 233 Mean age

43.3 M/F 30:70
HCWs 36.9%
Sample and study

population
Methods/measures

Physical assessment
SF-36, HRQoL

Interview
IES
SDS
SAS
SCL-90
SF-36, HRQoL
SDSS
CCMD-III categories
Interviews
MOS, SF-12
SARS-related worries: new
Perceived social support
questions

Clinical interview
SCID for DSM-IV
Diagnosis
Interview for CFS
HADS
CIES-R
Perceived Impairment: new
Perceived Stigmatization:
new
Chalder Fatigue
Questionnaire
Major findings
Prevalence of chronic psychological

dysfunction was higher than
typically observed personal threat
experiences (42%)
High proportion of hospitalized SARS
survivors exhibited delayed
psychological dysfunction (13%)
Resilient and recovered subjects had
greater social support and less
SARS-related worry
44.1% developed PTSD
The occurrence of PTSD predicted
persistent psychological distress
in a number of areas as well as
diminished social functioning in
the 4 years after SARS illness
and treatment
The impact of PTSD was severe and
persistent, adversely affecting
both mental and physical health
Psychological findings are similar to
those reported in ARDS and ICU
survivors
Significant impairment of lung function,
exercise capacity and health status
persisted at 24 months postillness
29.6% of HCWs and 7.1% non-HCWs
had not returned to work in same
time frame
Greater impairment was found in HCWs
42.5% had psychiatric illness and most

common diagnoses were PTSD,
depression, somatoform pain
disorder and panic disorder with
impairment for return to work in
these groups
Being a HCW, unemployed, perceiving
stigmatization, having applied to
the SARS survivors fund were
associated with risk of psychiatric
morbidities in the long-term
Rates of psychiatric morbidities, chronic
fatigue, and resultant disabilities
were persistently high
CFS symptom rates were elevated and
interacted with psychiatric
disorders
Limits of study

27% patients had medical comorbidities, which may have
influenced results
More sensitive measures to assess
exercise and lung capacity were
not used
Limited sample size

CCMD-III is a more conservative
measure of PTSD than the
DSM-IV and may have
underestimated PTSD
prevalence
Females overrepresented in sample
Data regarding severity of SARS,
treatment method and drug
dose were unavailable
Data was limited to self-report

Predictors in study were limited
and did not include personality
factors
Prior history of emotional
difficulties was not available
Some participants did not

complete all parts of study
Response bias is possible because
of higher female ratios
No concurrent physical assessment
included
SARS can lead to persistent

physical and mental
difficulties, with a greater
adverse impact on HCWs
Health authorities need to
provide support and followup for these patients
The prevalence and endurance of

PTSD and related symptoms
suggest that attention to
psychological aftermath of
severe infectious disease is
warranted
Demonstrated outcome
trajectories following a major
health-threat event, in an
Asian sample, resembled
trajectories in trauma studies
using Western samples
Support appeared as an
important factor for recovery
Highlights the mental impact of

SARS was significant and
persisted up to 4 years later
CFS symptoms and syndrome
were also prevalent
Optimization of treatment in
rehabilitation is
recommended, targeting
mental health morbidities, as
well as symptoms of fatigue
Note. ARDS Acute Respiratory Distress Syndrome; CCMD-III Chinese Classification and Diagnostic Criteria of Mental Disorders-Version III; CEIS-R Chinese Impact of Events
Scale-Revised; CFS Chronic Fatigue Syndrome; DASS-21 Depression and Anxiety Stress Scale; DSM-IV Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition; GHQ12
General Health Questionnaire; ICD-10 International Statistical Classification of Diseases and Related Health Problems-10th Revision; HADS Hospital Anxiety and Depression Scale; H5N1
Influenza A Virus; HCWs health care workers; ICU intensive care unit; IES, IES-R Impact of Events Scale, original and revised version; MOSSF-12 Medical Outcomes Study Health Status,
Short Form 12; PSS-10 Perceived Stress Scale; PTSD posttraumatic stress disorder; SAS Zung Self-Rating Anxiety Scale; SCID Semi-Structured Clinical Interview for the DSM-IV; SCL-90
Symptom Checklist; SDS Zung Self-Rating Depression Scale; SDSS Social Disability Screening Schedule; SF-36, HRQoL Short-Form 36 Health Survey, Health Related Quality of Life.
B: Cross-sectional
Level of evidence
and design
Lam et al. (2009)
Reference
Table 4 (continued)
GARDNER AND MOALLEF
Psychotic Symptomatology
At both the early acute phase of the illness as well as in the
convalescent phase, Sheng and colleagues (2005) found that corticosteroid treatment tended to predict subsequent neuropsychiatric
symptoms, some of which included psychotic symptoms such as
hallucinations and persecutory ideas (steroid administration accounting for 3.1% of variance in psychotic symptomatology during
the acute phase; Sheng, Cheng, Lau, Li, & Chan, 2005). However,
because of the absence of a control group, the findings from this
study were interpreted with caution. This was the only study on
this topic that was included in the formal review (see Table 2).
Although two other studies found a link between the dosage of
steroid treatment and psychotic symptomatology, they did not use
standardized diagnostic criteria and as such they were not included
in our formal review (Cheng, Tsang, Ku, Wong, & Ng, 2004; Lee
et al., 2004). These findings are consistent with the existing literature on the psychiatric reactions to corticosteroid treatment (specifically psychosis) occurring in a proportion of patients; such
links have been documented in the literature since the 1950s, with
the risk appearing to increase with higher doses (Sirois, 2003).
It is still not clear from the reviewed literature whether the
coronavirus itself was one of the main contributors to the psychotic
reaction. For example, Severance and colleagues (2011) have
documented a comorbid risk for serious mental disorder, specifically psychotic symptoms, in individuals exposed to the coronavirus (Severance et al., 2011). In other studies, the use of steroid
medication for treatment in conditions such as SARS has been
questioned, because of its uncertain benefits as well as evidence of
avascular necrosis and steroid-induced psychosis (Stockman,
Bellamy, & Garner, 2006). Indeed, psychotic symptoms, including
full-blown mania, are not only highly distressing for the individual, the behaviours associated with them can lead to serious
concerns for health care workers trying to manage an infectious
disease outbreak. Research has shown that when these behaviours
conflict with cooperation with essential infection control measures,
effective containment of the virus can be compromised (Lee et al.,
2004). Certainly, in the few studies described here with SARS
survivors, there appears to be a correlative relationship between
corticosteroid treatment and psychotic symptoms.
Fear for Survival and of Infecting Others

When compared with other types of illness conditions, the
unique psychosocial aspects of SARS included not only its lifethreatening nature, but also the deep concern with becoming the
agent of infecting others. Cheng and colleagues (2004) found a
prominent concern of patients in the acute phase of SARS to be
passing the virus on to their family (Cheng, Wong, Tsang, &
Wong, 2004). In this study, their findings were based on a newly
developed SARS Impact Scale (SIS), which demonstrated high
internal consistencies based on a large sample (n 180). In
another study, Wu and colleagues (2005 JTS) found that, at 1
month postdischarge, 61% of survivors rated their perceived life
threat to be between moderately and extremely serious, and that
this rating tended to predict the presence of trauma and anxiety
symptomatology, as measured by the Impact of Events ScaleRevised (IES-R) (Weiss & Marmar, 1997), and by the Hospital
Anxiety and Depression Scale (HADS) (Wu, Chan, & Ma, 2005;
Zigmond & Snaith, 1983). In addition, vivid fears were recorded in
a qualitative study that was not included in our formal review

because of its small number of participants and methodological
limitations. Still, nurses in this study described experiencing the
fear of death, feelings of isolation, loneliness and need for support,
and fearing they had exposed family members to the disease (Mok,
Chung, Chung, & Wong, 2005). Overall, psychosocial features
associated with the SARS illness that likely contributed to a
negative impact on mood included both fear for ones own mortality, and fear of being an agent of infecting others.
Perceived Stigmatization
The perception of stigmatization can be imposed from without,
or originate from within, when patients worry about infecting
others. Cheng and colleagues (2004) suggested that survivors
isolation during the acute phase of infection and treatment put
them at a higher risk for developing a negative self-perception,
which contributed to their emotional distress: that is, I am contagious, bad, and causing harm to others (p. 870) (Cheng, Sheng
et al., 2004). Researchers also found that worry regarding being
discriminated against was ranked higher by patients at 1 month
postinfection, compared with the earlier acute phase of recovery
(Cheng, Wong, Tsang, & Wong, 2004). Perceived stigmatization,
as reported by SARS patients in a large longitudinal study, was
also found to predict higher risk of psychiatric morbidity in the
long term (Lam et al., 2009). Persuasive examples of stigmatization were reported up to 16 months post-SARS in a study by Siu
(2008); experiences included feeling polluted (p. 733), and contaminated and dirty (p. 735). However, this study was not included in our formal review, again because of a lack of rigour in
study design. Overall, based on the small number of studies in this
area, a substantial number of survivors experienced being stigmatized as a consequence of their contagion, which appeared to
further contribute to their emotional distress.
Reduced Quality of Life

Research shows that in survivors of other infectious diseases,
such as Legionnaires Disease, many aspects of quality of life are
negatively impacted up to 17 months postinfection (Lettinga,
Nieuwkerk, Jonkers, Gersons, Prins, & Speelman, 2002). In the
studies included in our review, this concept was most frequently
measured using the Short Form 36 Health Survey, Health Related
Quality of Life (SF-36 HRQoL) (Ware, Snow, Kosinski, &
Gandek, 2000), a measure that is commonly used in diseaserelated research. For SARS survivors, a few of the reviewed
studies showed that quality of life ratings for survivors were
significantly lower than those of either a specific community
sample or the established norms, often across all domains, including bodily pain, general health, physical functioning, vitality,
social functioning, and mental health (Hui, Wong, Ko, Tam, Chan,
Woo, & Sung, 2005; Lau, Lee, Wong, Ng, Jones, & Hui, 2005;
Ngai, Ko, Ng, To, Tong, & Hui, 2010). Other studies found
significantly lower health status ratings among SARS survivors at
12 months postinfection, compared with a control group, with
worsening of physical health ratings over time, and no noted
differences between ICU and non-ICU patients (Hui, Wong, Ko,
Tam, Chan, Woo, & Sung, 2005). Similarly, Ngai and colleagues
(2010) found reduced quality of life ratings at 24 months postin-
fection, in addition to poorer scores among HCWs, with fewer

HCWs being able to return to work.
Using the WHOQOL-BREF (WHOQOL Group, 1998), Cheng
and colleagues (2004) compared ratings from SARS patients to
that of a community sample and found that, at 1-month recovery,
the scores for physical, psychological, and environment quality of
life were lower in the SARS sample than in the community sample
(Cheng, Sheng et al., 2004). Again, being a HCW tended to predict
significantly lower quality of life ratings, and the authors related
this to the anticipatory anxiety of returning to a workplace that was
the scene of their traumatic experience. In another study comparing SARS survivors to matched community control subjects, levels
of stress were reported to be significantly higher in SARS patients
at the peak of the outbreak in 2003, with stress scores remaining
elevated 1 year later, and were higher for females (Lee et al.,
2007). In yet another study involving a group of critically ill (24%
mortality rate) SARS patients, Li and colleagues (2006) found that
the age of patients influenced ratings of quality of life; with those
over 40 years of age reporting impaired quality of life ratings up to
12 months postinfection, whereas younger patients had reached
near normal levels by the 6-month timeframe (Li, Gomersall,
Joynt, Chan, Leung, & Hui, 2006). This latter finding is consistent
with that of other studies reporting persistent impaired ratings of
quality of life in older individuals long after a disaster, even when
survivors did not sustain direct physical injuries (Wen, Shi, Li,
Yuan, & Wang, 2012). Consistently, a robust finding in the existing literature has been poor quality of life ratings in SARS survivors across recovery stages postinfection, with being older and
being a female as important contributing factors to the likelihood
of impairment.
Psychological/Emotional Distress
Among SARS survivors, high rates of distress (well above
norms) were consistently reported across all timeframes in Asia
Pacific regions, where the majority of studies were conducted
(Chiu, 2004; Kwek et al., 2006). For example, Cheng and colleagues (2004) found that 65% of SARS patients, at 1-month
recovery, scored in the mild, moderate, or severe range of
depression and anxiety on the Beck Depression Inventory (BDI;
Beck & Steer, 1987) and Beck Anxiety Inventory (BAI; Beck,
Epstein, Brown, & Steer, 1988; Cheng, Wong, Tsang, & Wong,
2004). Longer-term studies continued to show considerably elevated rates of psychological morbidity among SARS survivors. In
a 1-year follow-up study, Lee and colleagues (2007) found elevated levels of distress on the Depression Anxiety Stress Scale
(DASS) (Lee et al., 2007; Lovibond & Lovibond, 1995). The
authors concluded that 64% of the survivors in their study were
potential psychiatric cases (p. 237). In another study, based on
structured diagnostic interviews, and two self-report questionnaires, a cumulative incidence (total number of diagnostic categories) of 58.9% for psychiatric disorders was found at 30 months
post-SARS (Mak, Chu, Pan, Yiu, & Chan, 2009). Lam and colleagues (2009), using a thorough methodology, also reported a
high rate (42.5%) of psychiatric morbidity in their large sample up
to 4 years postinfection (Lam et al., 2009).
With differing trajectories of distress noted across time,
Bonanno and colleagues (2008) found a high prevalence of overall
chronic psychological dysfunction at 6, 12, and 18 months postin-
fection (Bonnano et al., 2008). Within their very large sample (n

997), the four trajectories for recovery were identified as follows:
35% had high levels of psychological functioning that were maintained over time; 42% reported a low level of functioning, a level
that was maintained over time; 10% began with a high level of
functioning and subsequently evidenced a steep positive slope; and
13% began with a high level of functioning but subsequently
showed a steep negative slope. This finding, that psychological
dysfunction can occur at any point along the continuum of recovery post-SARS, clearly indicates a need for ongoing follow-up of
psychological status.
To investigate the psychological impact of SARS on survivors,
Cheng and colleagues (2006), devised a SARS Appraisal Inventory (SAI), from which they derived a factor called perceived
impact of SARS, which they defined as worries of either a physical
or social nature (e.g., SARS will permanently damage my health,
or my family will be destroyed by SARS; Cheng et al., 2006).
They found that, in the early phase of recovery, higher levels of
depression and anxiety among post-SARS patients were correlated
with levels of perceived impact and negative appraisals of SARS.
Furthermore, not only were rates of anxiety and depression
found to be elevated in all studies on SARS survivors, many
studies found that being a HCW with SARS was predictive of
worse psychological outcomes (Cheng et al., 2006; Cheng, Wong,
Tsang, & Wong, 2004; Lee et al., 2007). In particular, HCW SARS
survivors, who either knew someone who also had SARS or who
had a pre-existing history of psychiatric consultation, were found
to be at a higher risk for experiencing psychological distress (Wu,
Chan, & Ma, 2005 EID). This was a notably strong study with a
multivariate design, and one of the few available studies examining pre-existing factors that are known to be predictive of psychological distress, such as previous psychiatric history. In contrast,
Chua and colleagues (2004) found that, in the early acute phase of
the disease, relative to non-HCWs, HCW SARS survivors presented with significantly more positive as well as negative psychological concerns, which led the authors to conclude that HCWs
were more resilient in the face of adversity than non-HCWs.
Examples of positive psychological effects included civicmindedness, caring for others, and being fortunate (p. 387) (Chua
et al., 2004).
Understandably, among the predictors of psychological distress
post-SARS, having a family member die from SARS was a significant factor (Wu, Chan, & Ma, 2005 JTS).
On the whole, there is substantial evidence to support the
presence of psychological disturbance among SARS survivors at
all phases of recovery and, for the most part, being a HCW has
been predictive of worse emotional outcome.
Posttraumatic Stress Disorder

Lifetime prevalence rates of PTSD in the general population
have been reported to be 10.1% in the United States (Kessler,
Petukhova, Sampson, Zaslavdky, & Wittchen, 2012), and 5.6% in
Europe (Frans, Rimmo, Aberg, & Fredrikson, 2005), considerably
lower than rates of PTSD reported for survivors of SARS. Within
the studies presented here, PTSD symptoms were measured either
through self-report questionnaires, or through a formal diagnostic
process. Three studies determined levels of PTSD symptom severity based on only one self-report measure and found significant
GARDNER AND MOALLEF
10
elevations of trauma symptoms at different time frames postinfection: at 1 month (Wu, Chan, & Ma, 2005 JTS), 3 months (Kwek et
al., 2006), and 1 year (Lee et al., 2007). For example, Lee and
colleagues (2007) found that, at 1 year post-SARS, the higher the
perceived life threat the greater the PTSD symptom severity, with
ratings exceeding reported norms for accident-related and emergency care patients. However, because a formal diagnosis of PTSD
cannot be confirmed based on a self-report measure alone, there
are limitations to the validity of the findings in the three studies
noted above.
Using a more rigorous method of establishing a PTSD diagnosis
(i.e., psychiatric interviews), in a longitudinal study that followed
SARS patients across five time periods from 2 to 46 months, Hong
and colleagues (2009) found that 44.1% of patients had developed
PTSD across the course of the study (Hong, Currier, Zhao, Jiang,
Zhou, & Wei, 2009). In their sample, a diagnosis of PTSD was
also associated with greater distress in a number of other domains,
such as depressed mood, anxiety, and diminished social functioning; in addition, it appeared to adversely affect physical functioning. Other studies have reported similar rates of PTSD prevalence
among survivors at 2 years (25.6%) and 3.5 years (54.5%)
post-SARS (Lam et al., 2009; Mak, Chu, Pan, Yiu, & Chan, 2009).
Furthermore, in the study by Mak and colleagues (2009), HCWs
had significantly higher rates of PTSD than non-HCWs infected
with SARS. In general, studies show that, for many SARS patients,
PTSD symptomatology had become chronic, was associated with
poor emotional adjustment, and had a higher prevalence among
HCWs.
Discussion
The studies included here have identified a significant number
of psychological and psychosocial concerns affecting SARS survivors throughout their recovery process. Overall, findings showed
that in the early stages of recovery, psychotic symptoms, fear for
survival, and fear of infecting others predominated, whereas other
factors including perceived stigmatization, reduced quality of life,
and psychological/emotional distress were prominent across all
stages of recovery. Posttraumatic stress symptoms were also present from the early recovery stage onward, and found in high
proportions of survivors even as late as 51 months postinfection. In
addition, for some patients, psychological symptomatology appeared to worsen over time.
Originally understood to be a severe pneumonia condition,
SARS produced physical effects in sufferers that for many continued to linger, with accompanying reports of reduced quality of
health and quality of life (Ngai et al., 2010). Over time, the
post-SARS condition, with its chronic impairment of lung function
and exercise capacity, has come to be known as a chronic illness
(Ngai et al., 2010). The relationship between illnesses such as
chronic obstructive pulmonary disease (COPD) (Patten &
Williams, 2007; van den Bemt et al., 2009), chronic fatigue syndrome (CFS) (Lowry & Pakenham, 2008), and acute respiratory
distress syndrome (ARDS) (Weinert & Meller, 2006), and the
presence of emotional disturbance has been well-documented.
Similar to SARS patients, elevated rates of depressed and anxious
mood have been found in patients with these somewhat comparable respiratory or chronic illnesses. Reduced quality of life has also
been reported in both COPD (Cully et al., 2006) and ARDS
patients (Hough, 2006), and PTSD has been reported in patients

with ARDS (Kapfhammer, Rothenhausler, Krauseneck, Stoll, &
Schelling, 2004). However, an added feature for survivors of
infectious diseases, such as SARS, has been the experience of
being contagious, because of its attendant infection control measures, extensive isolation, and public fearfulness of the disease.
Legionnaires Disease, a well-documented infectious disease,
shares many features related to contagion (Lettinga et al., 2002).
For both conditions, Legionnaires and SARS, quality of life ratings
have been found to be low long after the acute phase of the illness,
and PTSD symptoms have been noted to be present and to remain
elevated. In such cases, aspects of the stigmatization could be
considered to contribute to the traumatic reactions for survivors.
Rates of PTSD and depression, comparable to SARS survivors,
have also been documented in patients ill with other infectious
diseases such as HIV, where the depression rate has been found to
be 14%, whereas the PTSD was found to be 5% in HIV patients
(Myer et al., 2008). For individuals who have contracted tuberculosis, rates of probable depression and anxiety have been reported
to be as high as 50% (Husain, Dearman, Chaudhry, Rizvi, &
Waheed, 2008).
While the present review offers some insight into the substantial
psychological complications that accompany infectious diseases
such as SARS, and their long-lasting impact for survivors (i.e.,
psychiatric morbidity, poor psychological adjustment, or chronic
PTSD), and highlights the vulnerability of HCWs in particular to
elevated rates of psychological distress, limitations within these
studies, because of variability in their methodology and quality,
restrict the optimal usefulness of the findings. As is often the case
with research in the early aftermath of a disaster or epidemic, there
were a number of inconsistencies with respect to study design,
research methods, and the use of standardized measures in the
SARS literature. Only four studies, for example, considered the
pre-existing psychiatric history of subjects, a factor well known to
predict the occurrence of psychological problems later in life
(Karsten et al., 2011; Ozer, Best, Lipsey, & Weiss, 2003). These
noted limitations highlight the importance of the use of common,
predefined protocols and ready-to-use instruments in research
postinfection/postdisaster, which would enhance comparability of
findings across studies, as well as improve the timeliness of
available results (Xing, Hejblum, Leung, & Valleron, 2010).
Research into the psychological aftermath for survivors of viral
disease outbreaks that follows sound design methods would provide valuable insights that might guide both prevention as well as
effective intervention, despite the challenging nature of providing
intervention to patients because of strict infection control measures. Many authors of the studies reviewed called for public
health measures that ensure adequate early screening of psychological symptoms for patients, preventive measures to mitigate
psychological disturbance, and early treatment intervention protocols as some of the critical elements needed to minimize the
harmful impact. Because a greater adverse effect has been found
for front line health care personnel during a viral outbreak, specific
attention to and support for their psychological adjustment and
recovery is essential. Maunder (2009) posited that a number of
unique aspects of SARS, as compared with other disasters or
outbreaks, have likely contributed to higher rates of stress in
HCWs generally. Factors he identified included that SARS was a
novel illness and the treatment course unknown, exposure to the
contagion was associated with social isolation, and HCWs feared

not only for their own safety, but of exposing others to the virus,
especially their loved ones. Many HCWs were also required to
work in high-risk, high-intensity units, for some an unfamiliar area
of care, and this might have further contributed to their elevated
levels of emotional distress. HCW SARS survivors were found, in
some studies, to present with lower return to work rates than
non-HCWs. To assist with mitigating the adverse psychological
impact of future pandemics, for HCWs in particular, some researchers have suggested engaging HCWs in collaborative pandemic planning and organizational preparedness training, increasing emotional resilience by promoting adaptive coping, providing
greater support via mentoring and peer support, identifying those
at high risk and providing intervention, and offering longer term
support after the event to assist with residual effects (Wu, Chan, &
Ma, 2005 JTS). Notably, studies have found that, for some HCWs,
being on the front-line might have contributed to a greater adaptive
response after SARS. As Chua et al. (2004) suggested, support
from the media and community for their stalwart heroism and
sacrifice contributed to their positive experience (p. 389).
In conclusion, based on these preliminary findings, the psychological distress for SARS survivors appears to be substantial,
pervasive and long-lasting, and those working on the frontlines
seem to be notably at risk. Thus, there is a clear imperative to
address the psychological needs of survivors, both in the early
stages of a viral outbreak, as well as in the longer term. This is
particularly critical in the case of HCWs upon whom the public
relies during a health crisis.
Limitations and Considerations for Future Research

Although this review attempted to select studies based on their
language (English) and for their quality in terms of design and
methodology, there remained considerable heterogeneity in study
design, and inconsistencies in their use of assessment measures;
therefore, overall conclusions of findings remain imprecise. Additionally, because the largest proportion of SARS survivors were in
Asia, there remain a number of Chinese language studies, untranslated into English, that have not been included in this review, and
which may further contribute to this area. For example, there may
be cultural differences that could impact psychological outcomes
in different countries that would be worthwhile to examine. Also,
although the scope of this study did not allow for inclusion of the
psychological impact of the SARS epidemic for the nonpatient
health care community, this is an area that has been the subject of
extensive research (e.g., Lu, Shu, Chang, & Lung, 2006; Lung, Lu,
Chang, & Shu, 2009), and a review of the literature in this area
would be a valuable contribution. Furthermore, some studies have
found an association between certain aspects of physical health in
post-SARS patients and poorer quality of life and psychological
outcome (Ngai et al., 2010), although this was not consistently
examined across studies. Further research in this area may be
warranted to better understand the long-term psychological consequences of the illness, at the same time combining the associated
levels of physical impairment. This line of research would further
enhance understanding of the overall impact of contagious illnesses such as SARS.
Because future viral outbreaks are inevitable, increased levels of
preparedness in the research community is imperative to improve
11
the quality and comparability of study results in this important

area. In addition, multidisciplinary efforts that examine both the
physical and the psychological sequelae of infectious diseases, as
well as investigation of psychological intervention outcomes, both
in the early as well as later stages of recovery, are crucial in
helping to guide treatment and enhance outcomes.
Rsum
Le syndrome respiratoire aigu svre (SRAS) a t qualifi de
catastrophe de sant mentale. Cette pneumonie atypique infectieuse sest rpandue dans 29 pays en 2002-2003, infectant plus de
8000 personnes, parmi lesquelles 774 en sont mortes. Une recherche a t effectue au moyen des bases de donnes lectroniques
MEDLINE, PsycINFO, CINAHL et la Cochrane Library, en vue
dun rsum critique des articles en anglais sur les rpercussions
psychologiques du SRAS sur les survivants. Vingt tudes originales sur lexprience psychologique de patients ont rvl les
symptmes dominants suivants : dans les stades aigus et au dbut
du rtablissement, on note des symptmes psychotiques, la peur
pour la survie, la peur dinfecter autrui; a` tous les stades, on note
la stigmatisation, une qualit de vie amoindrie, la dtresse psychologue; a` tous les stades aprs le rtablissement, on note des
symptmes de stress post-traumatique. Les travailleurs de la sant
ayant eu le SRAS prsentaient des risques plus levs. Les limites
de nombre des tudes restreignent lutilit optimale des rsultats.
Les tudes utilises dans notre revue de littrature rapportaient
systmatiquement de hauts taux de troubles motifs parmi les
survivants, lesquels persistaient des annes aprs linfection. Des
recommandations sont formules en vue damliorer la comparabilit des tudes advenant de nouvelles pousses.
Mots-cls : SRAS, psychologie, syndrome de stress posttraumatique, travailleurs de la sant, maladies infectieuses.
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Received January 26, 2014

Revision received August 1, 2014
Accepted August 12, 2014

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Canadian Psychology/Psychologie

Canadian Psychology / Psychologie canadienne

2014 Canadian Psychological Association

Psychological Impact on SARS Survivors: Critical Review of the English

Sunnybrook Health Sciences Centre, St. Johns Rehab, Toronto,

St. Johns Rehab Hospital, Toronto, Ontario, Canada and

research into the impact of this viral epidemic reveals many

After its first emergence in Asia in November 2002, severe

Paula J. Gardner, Sunnybrook Health Sciences Centre, St. Johns Rehab,

GARDNER AND MOALLEF

Psychological factors across three time-frames post-SARS.

Chua et al. (2004)

Lau et al. (2005)

Acute phase, 1 month

Early acute phase

n 79 SARS patients Age

n 171 Mean age 37.4

n 195 Age range 18

n 180 Mean age 36.9

Sample and study

Medical record review

Medical record review

SARS database in Hong

10 to 18% reported PTSD,

Both SARS survivors and

35% reported severe or moderate

Some selection bias

Low response rate (42.4%)

New measure demonstrated

Cheng, Wong et al.

PSYCHOLOGICAL IMPACT ON SARS SURVIVORS

Cheng, Sheng et al.

Sheng et al. (2005)

Cheng et al. (2006)

Mean time since

n 100 SARS patients

n 102 Mean age 37.6

n 57 Mean age 38.1

n 41 Mean age 35.9

Sample and study

Medical record review

Medical record review

Medical record review

Medical record review,

High proportion of suspected

Physical functioning and lack

Causal relationships remain

Low response rate (33%)

Low response rate (37.2%)

Small sample size

Because perceived impact and

Factors surrounding both illness

Assists in understanding the nature

Mak, Law et al. (2009)

Moldofsky & Patcai

n 143 Mean age 38.4

n 22 Mean age 46.3

n 90 Mean age 41.1

Sample and study population

Social support and self-efficacy

Sleep features as well as mood

Support from family, friends

Highlights the need to enhance