Introduction
The coronavirus 2019 (COVID-19) emerged in Wuhan, China in early December 2019 and quickly spread throughout China and several other countries [1]. Because of its high contagion power, this virus quickly spread worldwide and infected all countries in less than 4 months [2]. The COVID-19 infection, which is caused by an RNA virus, mostly affects the respiratory system of the affected people and may be associated with irreversible complications, including death [3]. Currently, the number of people with this disease and its associated death rate is high in the world. This pandemic has brought the risk of death because of its infection and targets individuals’ mental health by creating unbearable psychological pressure. One of the most important factors that affected the weakening of mental health, especially during the initial peaks of the disease, was the unfavorable condition of patients isolated in intensive care units with acute respiratory problems along with the absence of effective drug treatment, death, fear of contracting an incurable disease, being under strict quarantine measures for a long time, economic problems and unemployment caused by this situation, and spreading the feeling of uncontrollability of the situation, confusion, and uncertainty at the level of society and between people [4, 5].
Endangered people at different levels of society include patients, healthcare workers, and their families [6]. Therefore, it is necessary to maintain the mental health of people at risk in the conditions of COVID-19 because the presence of stress and poor mental health can weaken the immune system and expose people to more diseases and exacerbation makes consequences more severe [7, 8].
Post-traumatic stress disorder (PTSD) is a mental health condition caused by an unfortunate event. Symptoms may include nightmares, severe anxiety, and uncontrollable thoughts about the event [9]. The symptoms of PTSD can be classified into the three following categories: 1) re-imagining the accident through phenomena, such as dreams, memories of the past, and disturbing thoughts; 2) avoiding situations that remind the person of the accident; and 3) excessive stimulation which is characterized by various symptoms, such as sleep and concentration problems [10]. The mentioned symptoms may affect interpersonal relationships and physical health and may interfere with a person’s overall performance. The prevalence of PTSD is affected by the severity, duration, and time interval of the experienced accident [11, 12]. Experiencing life-threatening diseases, such as COVID-19, can cause the symptoms of PSTD, and if this psychological disorder is not controlled, patients can suffer permanent injuries, such as flashbacks, distractions, avoidance behaviors, irritability, and numbing of emotions [13, 14]. The relationship between COVID-19 and PTSD in patients with COVID-19 and their families [9] and healthcare workers [11, 14] has been investigated in several studies. Identifying people prone to psychological disorders at different levels of society is essential to maintain the mental health of these people with suitable psychological solutions and techniques. Individuals who refer to welfare organizations for counseling services are one of the weakest sections of society and may be more exposed to psychological damage, such as PTSD, and subsequent reduction in sleep quality compared to other people. The present study aims to investigate the prevalence of PTSD symptoms and the quality of sleep among individuals who were referred to the Mazandaran Welfare Organization Counseling Center after the outbreak of COVID-19.

Materials and Methods
This descriptive-analytical study was conducted during the first 6 months of the COVID-19 pandemic. The sampling was in the form of a census and all people who referred to the counseling center of Mazandaran Welfare Organization in Mazandaran Province, Iran (by phone or in person) during the mentioned period and agreed to participate in the study were evaluated. A total of 255 people were included in the study and responded to The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) post-traumatic stress disorder checklist (PCL-5), and the Pittsburg sleep quality questionnaire (PSQI).
The inclusion criteria were having over 18 years of age, covered by welfare (including the disabled, the elderly, prisoners and families with poor guardians and orphans, and marginalized people), and having one of their family members or themselves were infected with COVID-19. The exclusion criteria included people suffering from mental retardation and dementia, along with an unwillingness to participate in the study. It took approximately 30 min to complete the questionnaires. The participants whose response time was less than 2 min or more than 30 min were excluded from the study to ensure the quality of the questionnaires.
Study instruments
Demographic questionnaire
A demographic information questionnaire was used to collect data on gender, age, educational background, current place of living, and history of being infected with COVID-19 or recent exposure (history of direct exposure or travel or contact with a person who has returned from travel).
Post-traumatic stress disorder checklist
To evaluate symptoms related to PTSD, the 20-item PTSD questionnaire was used. This tool is fully compatible with the diagnostic criteria of PTSD based on DSM-5. The PCL-5 instrument is a 5-point Likert-type scale (0=none, 4=severe) and its scores range from 0 to 80 [15]. The cut-off point for the diagnosis of PTSD has been reported at 33 in most studies. The cut-off point has been reported from 28 to 35 in some studies and 44 to 47 for early versions of the PCL. In the present study, we used a cut-off point of 33. The PTSD questionnaire consists of the 4 following subscales: disturbance (B), avoidance (C), negative mood changes (D), and arousal of emotional numbness (E). The Cronbach α coefficient of this tool was obtained at 0.95 and the convergent validity of its English version was 0.89 [15]. In a study on the Iranian population in 2018 by Vermaghani et al., the Cronbach α coefficient of the whole scale was obtained at 0.92 [16]. The results of the exploratory factor analysis showed that this questionnaire has a 5-factor structure in Iranian culture. The significant correlation (0.46) between the scores of this scale and the resilience scores indicated its favorable divergent validity [17].
In the present study, the Cronbach α reliability coefficient for the entire PTSD questionnaire was equal to 0.946. The reliability index for subscales of annoyance (B), avoidance (C), negative mood changes (D), and arousal of emotional numbness was obtained at 0.84, 0.63, 0.79, and 0.90, respectively, which was similar to other studies [16, 19].
Pittsburgh sleep quality index
The Pittsburgh sleep quality index examines patients’ attitudes regarding the quality of sleep during the last 4 weeks [18]. The Pittsburg sleep quality questionnaire has 7 scores for the scales, including the general description of the person’s sleep quality, delay in falling asleep, length of useful sleep, useful sleep, sleep disorders, the number of consumed sleeping pills, daily functioning disorders, and a total score. The score of each scale of the questionnaire ranges from 0 to 3. Scores of 0, 1, 2, and 3 on each scale indicate a normal condition, mild, moderate, and severe problems, respectively. The time to answer this questionnaire ranges from 5 to 10 min. The Pittsburg sleep quality questionnaire was used in the Iranian population by Shahri Fero et al. in 1988 and had a validity of 86% and a reliability of 89%.
Data analysis 
Based on the Kolmogorov-Smirnov test, the distribution of scores of the PTSD questionnaire (P<0.001) and the Pittsburg sleep quality questionnaire (P<0.001) were not normal. Therefore, the nonparametric Mann-Whitney test was used to compare the two groups, and the Kruskal-Wallis test was used to compare more than two groups. Descriptive statistics, including mean and frequency along with inferential statistics, including the Spearman correlation coefficient and the Chi-square test at 0.05 significance level were used to analyze the data via the SPSS software, version 20.

Results
A total of 255 people participated in this research, of which 95(37.3%) were women and 160(62.7%) were men. The mean age of the participants was 36.12±10.22 years. Among the participants, 155 were married (60.8%) and 94 people had a university education (36.8%). Also, 75.3% lived in urban areas while 24.7% were rural citizens. In total, 39(15.3%) people had a history of hypertension, 67(26.3%) people had a history of diabetes, 36(14.1%) people reported other underlying diseases, 32(12.5%) people had a history of taking psychotropic drugs, 75(29.4%) people had a history of taking sleeping pills, 24(9.4%) people had a history of psychosis, and 48(18.8%) people had a history of sleep disorders. The characteristics of the participants regarding the presence of PTSD are presented in Table 1.



In terms of population classification, the majority of the participants were from the general public (62.48%), followed by 12(4.7%) people from the healthcare staff. Among all the participants, 24(9.4%) people had a history of COVID-19, and 84(32.9%) people had a history of COVID-19 in at least one of their family members. Among all the participants, 23(9%) people had lost their family members due to COVID-19.
In the present study, the average score of the PCL-5 questionnaire in the welfare clients was 32.87, which is almost equal to the determined cut-off point of 33 [18]. Based on the cut-point of 33 in PCL-5, the prevalence of PTSD in the high-risk population of welfare clients was estimated at 40.4%. The prevalence of PTSD was 44.4% in women and 33.7% in men, which was not significantly different based on the Chi-square test (P>0.05). The results showed that the scores of the questionnaire and its subscales were not related to gender, except for negative changes (D) with P=0.047 (P>0.05).

The prevalence of PTSD had no relationship with the place of residence (P=0.07), marital status (P=0.90), and occupation (P=0.06); however, the level of education had a relationship with the subscales of annoyance (B) (P<0.001), arousal (E) (P=0.04), and the total scores (P=0.03). The highest prevalence was in undergraduates at 54.2% and the lowest was in illiterates at 23.1%. No significant correlation was observed between age and PCL-5 scores (P>0.05). Blood pressure diseases (P=0.93), diabetes (P=0.31), other diseases (P=0.84), use of psychiatric drugs (P=0.97), history of sleep disorder (P=0.63), and use of sleeping pills (P=0.89) had no relationship with the prevalence of PTSD. History of psychotic diseases had a significant relationship with negative mood changes (D) (P=0.003), arousal (E) (P=0.028), and the total score (P=0.017). A person’s history of being infected with COVID-19 had a significant relationship only with the subscale of negative mood changes (D) (P=0.017). Infection with COVID-19 (P=0.60) and death caused by this disease in the family (P=0.56) had no relationship with the prevalence of PTSD and its sub-components.
There was a positive and significant correlation of 30.2% between sleep quality scores and PCL-5 questionnaire scores (P<0.001). The correlation of different dimensions of the questionnaire with sleep quality is shown in Table 2. There was no significant difference between the PCL-5 scores in the two groups with and without sleep disorder (P>0.05).




Discussion
Considering that COVID-19 has caused fear and concern worldwide, this study was conducted to investigate the prevalence of PTSD symptoms and the sleep quality among patients referred to the counseling center of Mazandaran Welfare Organization in Mazandaran Province, Iran, after the outbreak of COVID-19. The results showed that considering a cut-point of 33 in the PCL-5 questionnaire, the prevalence of PTSD symptoms in welfare clients was 44.4%. This rate may be higher compared to the prevalence rate reported in many previous studies. The main reason for the difference can be because of the study population in our study and other research. In a study, Lu et al. [14] examined the prevalence of PTSD symptoms, sleep problems, and psychological distress among healthcare workers dealing with COVID-19 in Taiwan, which, unlike the present study, reported a prevalence of 23%. In a systematic review and meta-analysis by Li et al. [11], the prevalence of PTSD among healthcare workers during the COVID-19 pandemic in 21 countries was reported to be 22%. In a meta-analysis study on 63 studies in different countries of the world with 124 952 individuals, Yunitri et al. reported the overall prevalence of PTSD to be 17.52% (with a 95% confidence interval between 13.89% and 21.86%) [20]. The basis of this study is that the prevalence of PTSD in some Asian and Middle Eastern countries was reported to be over 40%; however, the overall prevalence rate was higher in our study, which could be due to the difference in the study population. The present study population was the clients of the counseling center of the welfare organization, who are often from the low strata of society, have less health information, and are considered a high-risk population. Another reason may be related to the variety of tools and different cut points used in these studies.
A study by Ju et al. [9] to evaluate the prevalence and predictors of PTSD in people treated for COVID-19 showed that 36% had the cut-off score for diagnosing PTSD according to the impact of event scale-6, which is more consistent with the results of the present study. Simultaneously, the correlation of the negative changes subscale of the questionnaire with the person’s infection with COVID-19 in our study can confirm that the experience of COVID-19 causes fear, negative changes, and symptoms of PTSD, which is a similar result of both studies. In Ju et al.’s study [9], female gender, lower education level, higher anxiety levels, and lower perception of emotional support during hospitalization predicted a higher risk for temporary PTSD, which is consistent with the relationship between gender and education level in the present study. With the prevalence of PTSD, it is significant that welfare clients also feel they may receive less emotional support when suffering from an illness.
Another result of this study showed a significant correlation of 30% between stress disorder scores and adverse sleep quality based on the score of the Pittsburg questionnaire. In different studies, the relationship between insomnia, lack of sleep, or sleep quality with post-traumatic stress was confirmed [13], which was similar to the present study. In the study by Lu et al. in Wuhan, China, the prevalence of PTSD in women was higher compared to men and it was related to poor sleep quality, which was similar to our findings, according to their use of the Petersbaugh sleep quality questionnaire [21].

Conclusion
Because this pandemic has caused fear and concern worldwide, the time of disease outbreak in different countries was different, and controlling methods and policies of the governments were different, the prevalence of mental disorders and anxiety of people in different times have been altering. Both the prevalence of PTSD and the prevalence of COVID-19 are time-dependent
Study limitations 
One of the limitations of our study is due to conducting the study at a point in time when COVID-19 was at one of its main peaks in Mazandaran Province, Iran. Therefore, the process of decreasing or increasing PTSD over time was not evaluated. Another limitation of our study was concerning the communication with some patients by phone, which was due to the severity of the disease at that time. In any case, our study seems to be the only study that has been conducted on this particular group of people who refer to welfare counseling centers, considering the high prevalence of PTSD in these people. On the other hand, considering the availability of most of these individuals, the harm to this group can be reduced with health plans in the welfare organization.

Ethical Considerations

Compliance with ethical guidelines
An informed consent letter was obtained from all participants and the approval of the Ethics Committee for this study was received from the Ethics Committee of Mazandaran University of Medical Sciences (Ethical code: IR.MAZUMS.REC.1399.101). After explaining the purpose of the survey, the participants were assured that all responses and information would remain confidential.

Funding
This project was fully supported and funded by MazandaranUniversity of Medical Sciences.
 
Authors' contributions
Design: Farkhondeh Neyestani, Zahra Kashi and Forouzan Elyasi; Collecting Data: Farzad Gohardehi and Ramzanali Golchobi Firozjah; Data analysis: Reza Ali Mohammadpour; First draft: Farkhondeh Neyestani, Zahra Kashi, Zahra Hosseini-Khah, Zohreh Rezaeian; Final approval: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
We would like to thank all the visitors to Mazandaran Welfare Organization who participated in this research.

 

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