Mediating Effect of Depression and Anxiety on the Relationship Between Grief Reaction and Post-Traumatic Stress Symptoms in Lebanese Volunteers
Article information
Abstract
Objective
The Lebanese people have endured through several disasters, such as the Beirut explosion, coronavirus pandemic, and cholera outbreak. However, volunteers who have tried to overcome such national disasters develop emotional stress after witnessing people’s death. This study was conducted to explore whether volunteers’ depression or anxiety mediates the relationship between grief response and post-traumatic stress disorder (PTSD) symptoms.
Methods
We conducted an anonymous online survey study and collected responses from 270 volunteers in Lebanon from March 20–26, 2023. Demographic information and responses to the questionnaires, which included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Post-Traumatic Stress Disorder Checklist for DSM-5 (PCL-5), Public Service Motivation scale (PSM scale), Connor-Davidson Resilience Scale-2, and Prolonged Grief Disorder (PG-13) were collected. Variables were compared between volunteers who did and did not witness people’s death. Furthermore, we explored the relationships among variables in volunteers who witnessed people’s death (n=72).
Results
Among 270 participants, 72 (26.67%) witnessed people’s death. The regression model demonstrated that scores for PG-13 (β= 0.31, p<0.001), PHQ-9 (β=0.21, p=0.011), and GAD-7 (β=0.44, p<0.001) were predictors of the PCL-5 score. Mediation analysis showed that grief reaction directly influenced PTSD symptoms (Z=6.19, p<0.001), whereas depression (Z=1.99, p=0.047) and anxiety (Z=2.79, p=0.005) individually mediated the relationship between grief reaction and PTSD symptoms.
Conclusion
Our study helps understand the mediating effects of volunteers’ depression or anxiety on the relationship between grief reactions and PTSD symptoms.
INTRODUCTION
Lebanon has faced numerous challenges throughout its history, including political instability, economic recessions, and environmental degradation. In recent years, Lebanon has been further challenged by an economic crisis exacerbated by the Lebanese revolution, COVID-19 pandemic, and massive Beirut explosion in 2020 [1] that resulted in over 190 deaths, 6,000 injuries, an estimated 10–15 billions USD worth of property damage, and the displacement of 300,000 people from their homes [2]. In turn, the explosion and the Lebanese revolution had also impacted the country’s response to the COVID-19 pandemic, considering that the health care system had already been struggling with limited resources [3]. This small country has also been impacted by regional political instabilities, like the Syrian revolution that triggered mass migration into Lebanon, placing an enormous strain on the country’s resource-contained economy and infrastructure. Furthermore, the Syrian refugee crisis has caused several healthcare issues, like the cholera outbreak brought to Lebanon by the Syrian immigrants, which had affected all Lebanese governorates and caused 5,105 suspected cholera cases with 23 associated deaths from 2021 to 2022.
Given these numerous crises, the Lebanese people have been forced to overcome considerable challenges, which could definitely be reflected in the extensive engagement in volunteer work. Lebanese volunteers have contributed extensively across various areas, such as providing humanitarian aid to Lebanese people and refugees needing them the most, addressing environmental issues, and supporting local businesses and communities. For instance, volunteers from all over Lebanon had played an important role in managing the massive destruction left behind by the Beirut blast by gathering together to offer their help in affected areas [4]. Additionally, volunteering in local and international health organizations, like the Lebanese Red Cross and Emergency and Relief Corps, had a significant impact during major incidents. Nonetheless, the role of volunteers was most prominent during the COVID-19 pandemic and the Beirut port explosion, wherein people suffered eminent health and financial losses. Moreover, volunteering in the firefighting and civil defense departments played a crucial role in saving Lebanese green spaces that suffer from huge fires each year, in addition to protecting the citizens’ lives in these situations [5]. Taken together, volunteering has become a vital means of fostering resilience and promoting positive change throughout the country following these unfortunate events.
The association between volunteers’ grief reactions and posttraumatic stress disorder (PTSD) has been well documented. In particular, volunteers who work under risky and physically demanding circumstances, are exposed to casualties and injuries, and observe the suffering or death of others experience major psychological stress. As such, volunteers are at particularly high risk of developing PTSD [6], a condition characterized by multiple distressing symptoms that include intrusive memories (e.g., vivid flashbacks and nightmares), persistent anxiety, and hypervigilance. Studies have found that several volunteers develop emotional numbness, avoid things that remind them of the trauma, have difficulty concentrating, and suffer from sleep disturbances [7]. In fact, many studies have highlighted the high prevalence of PTSD among volunteers working in various domains, such as firefighters [8], refugee aid workers, and emergency service workers [9].
Grief, a profound emotional response to loss, is commonly experienced by volunteers, especially among those who repeatedly witness death or provide physical and emotional support to individuals nearing the end of their life [10,11]. This response can be displayed as intense sadness, yearning, anger, or even guilt and may be accompanied by physical symptoms, such as fatigue, insomnia, and changes in appetite [12]. Unresolved grief can eventually contribute to the development of complicated grief or secondary traumatic stress, which further increases psychological distress.
Repeated exposure to traumatic events and loss places volunteers at risk for not only burnout but also overlapping symptoms of grief and PTSD, including emotional withdrawal, irritability, and difficulty finding meaning in their work [6,8-11]. Earlier studies have found a significant association between volunteers’ grief reactions and symptoms of depression and anxiety. Experiencing grief, particularly after repetitive exposure to loss or bereavement in volunteer roles, can cause emotional suffering that presents as persistent sadness, hopelessness, and a loss of interest in previously enjoyed activities, which are core symptoms of depression [13]. Grief can also trigger anxiety, which can manifest as excessive worry, restlessness, and difficulty concentrating [14].
Volunteers who are involved in bereavement support or work closely with individuals near death often report heightened emotional vulnerability, with their grief potentially progressing to more severe psychological conditions without adequate coping mechanisms or support, as mentioned earlier [15]. Given the cyclical nature of grief, these symptoms can persist or recur, further compromising volunteers’ mental and emotional well-being. Conversely, volunteering has been linked to higher levels of life satisfaction, happiness, and self-esteem [16]. Studies show that volunteers have higher levels of resilience, competence, and awareness of their basic needs and are driven by higher levels of motivation for public service. Furthermore, some studies highlight the importance of promoting volunteering as part of a healthy lifestyle and encouraging more people to engage in volunteer work in order to improve their overall health [17]. Currently available studies have reported some contradicting results. In particular, some studies have linked volunteering to higher levels of mental wellbeing [18], whereas more recent data show that volunteers are at increased risk for developing depression and anxiety [19]. As such, the current study aimed to provide additional reliable data about the pandemic grief response among volunteers, as well as its relationship with depression, anxiety, and PTSD symptoms, in order to clarify the advantages and disadvantages of volunteering and accurately determine its effects on mental health.
METHODS
Participants and procedure
A descriptive analytical cross-sectional study was conducted by requesting Lebanese volunteers to complete an online survey. Data collection was performed from March 20th 2023 to March 26th 2023. The inclusion criteria were as follows: 1) individuals living in Lebanon, 2) those over 18 years old, and 3) those affiliated with an association operating in Lebanon (Red cross, Islamic medical association, healthy authority, etc.). This study was conducted at multiple rural and urban areas throughout Lebanon to minimize selection bias as much as possible. Participants were contacted via phone call, recruited via social media platforms, such as Facebook and others, and asked for their consent to participate in the study. After clicking “yes” to the question asking their willingness to participate in this survey, participants anonymously completed the questionnaire through the Google Forms questionnaire software. This study was approved by the Institutional Review Board of the Sahel General Hospital (4/2023) which waived the need for obtaining written informed consent. The online survey form included questions on the volunteers’ sociodemographic characteristics, such as their sex, age, marital status, nationality, medical education, and death of someone close. Sample size calculation determined that 300 volunteers were required, which indicated that 30 samples needed to be allocated per cell (10 cells, sex × 5 age groups) according to the Central Limit Theorem [20].
Measures
The Patient Health Questionnaire-9
The Patient Health Questionnaire-9 (PHQ-9), developed by Kroenke and Spitzer [21], is a 9-item self-report measure for depressive symptoms. Each item is rated on a 4-point Likert scale, ranging from 0 (not at all) to 3 (nearly every day). The total score ranges from 0 to 27, with higher scores indicating more severe depression. Cutoff scores of 0–4, 5–9, 10–14, 15–19, and 20–27 were used for minimal, mild, moderate, moderately severe, and severe depressive symptoms. In the original study, the PHQ-9 was reported to be a reliable (Cronbach’s alpha=0.89) and valid rating scale. In the current study, the Cronbach’s alpha for our sample was 0.836.
The Generalized Anxiety Disorder-7
The Generalized Anxiety Disorder-7 (GAD-7), developed by Spitzer et al. [22], is a 7-item self-report questionnaire designed to identify individuals experiencing symptoms of generalized anxiety and related disorders. Each item is rated on a 4-point Likert scale, ranging from 0 (not at all) to 3 (nearly every day). The total score ranges from 0 to 21, with higher scores indicating greater anxiety severity. Cutoff scores of 0–4, 5–9, 10–14, and 15–21 were used for minimal, mild, moderate, and severe anxiety. In the original study, the GAD-7 was reported to be a reliable (Cronbach’s alpha=0.92) and valid rating scale. In the current study, the Cronbach’s alpha for our sample was 0.918.
The PTSD Checklist for DSM-5
The PTSD Checklist for DSM-5 (PCL-5), developed by Blevins et al. [23], is a 20-item self-report measure that assesses the 20 symptoms of PTSD based on the DSM-5. Each item is rated on a 5-point Likert scale, ranging from 0 (not at all) to 4 (extremely). The total score ranges from 0 to 80, with higher scores indicating more severe PTSD symptoms. In the original study, the PCL-5 was reported to be a reliable (Cronbach’s alpha=0.94) and valid rating scale. In the current study, the Cronbach’s alpha for our sample was 0.924.
The Public Service Motivation scale
The Public Service Motivation (PSM) scale consists of four dimensions: attraction to policy making, commitment to public interest, compassion, and self-sacrifice. Each dimension consists of multiple items, rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The scores for each dimension need to be examined in order to understand an individual’s motivation profile in the context of public service. Higher scores indicate a stronger presence of a particular dimension, reflecting an individual’s inclination toward that aspect of public service motivation [24]. In the original study, the PSM was reported to be a reliable (Cronbach’s alpha=0.90) and valid rating scale. In the current study, the Cronbach’s alpha for our sample was 0.858.
The Connor-Davidson Resilience Scale-2
The Connor-Davidson Resilience Scale-2 (CD-RISC2), developed by Vaishnavi et al. [25], is a 2-item self-rated measure of resilience, which evaluates an individual’s ability to cope with stress and adversity. Each item is rated on a 5-point Likert scale ranging from 0 (not true at all) to 4 (true nearly all the time). The total score ranges from 0 to 8, with higher scores indicating greater resilience. Interpretation involves comparing scores to normative data or using the scores to track changes in resilience over time. A previous study reported a Cronbach’s alpha of 0.726 among a national sample of Americans responding to the COVID-19 pandemic [26].. In the current study, the Cronbach’s alpha for our sample was 0.605.
The Prolonged Grief Disorder
The Prolonged Grief Disorder (PG-13) questionnaire, developed by Pohlkamp et al. [27], is a 13-item measure assessing grief symptoms and their duration after a loved one’s death. Each item is rated on a 5-point Likert scale ranging from 1 (never) to 5 (always). In the original study, the PSM was reported to be a reliable (Cronbach’s alpha=0.89) and valid rating scale. In the current study, the Cronbach’s alpha for this sample was 0.907.
Statistical analysis
Demographic information and rating scales scores were reported as mean and standard deviation. A two-tailed p-value of 0.05 indicated statistical significance. First, we categorized the participants into two groups based on whether they witnessed people’s death. Continuous and categorical variables were assessed using Student’s t-test and chi-square test, respectively. Second, Pearson’s correlation analysis was performed to explore correlations among variables, such as PCL-5, PG-13, PHQ-9, GAD-7, PSM, and CD-RISC2 in volunteers who witnessed people’s death. Third, to explore variables predicting PTSD symptoms (PCL-5), a linear regression analysis with enter methods was conducted. Finally, to examine whether depression and anxiety mediated the relationship between grief reaction and PTSD symptoms among volunteers who witnessed people’s death, the bootstrap method was implemented using 2,000 resamples. All statistical analyses were performed using SPSS version 21.0 for Windows (IBM Corp.) and JASP 0.16.4 (JASP team, University of Amsterdam,).
RESULTS
A total of 270 volunteers completed the survey, among whom 72 (26.67%) witnessed the death of someone close to them, 129 (47.78%) were male, and 149 (55.19%) were single. The vast majority of the participants were Lebanese (91.5%) and a quarter of them (25.1%) worked in the health care system (Table 1).
Demographic and clinical characteristics of Lebanese volunteers (N=270)
A comparison of rating scale scores between the group who did and did not witness people’s death found that the latter had significantly higher mean scores for PCL-5 (25.0 vs. 17.8) and GAD-7 (8.0 vs. 6.1). The mean score for PG-13 among those who witnessed the death of someone close to them was 28.7. No significant difference in the mean scores for the PHQ-9, PSM, and CD-RISC 2 was observed between the two groups (Table 2).
Rating scale results for Lebanese volunteers (N=270)
Correlation analysis showed that the PCL-5 score was significantly positively correlated with the PG-13 (r=0.55, p<0.001), PHQ-9 (r=0.64, p<0.001), and GAD-7 (r=0.70, p<0.001) scores. The PG-13 score was correlated with PHQ-9 (r=0.27, p<0.05) and GAD-7 scores (r=0.34, p<0.001), whereas the CD-RISC 2 score was negatively correlated with the PCL-5, PHQ-9, and GAD-7 scores (Table 3).
Correlation analysis among volunteers who witnessed people’ death (N=72)
The regression model demonstrated a significant effect on the dependent variable (PCL-5) as indicated by the F-statistic and p-value. The model suggested that 63% of the variance in PCL-5 score could be explained by the included variables. The results indicated that PG-13 (β=0.31, p<0.001), PHQ-9 (β=0.21, p=0.011), and GAD-7 (β=0.44, p<0.001) scores could serve as predictors of the PCL-5 score.
Table 4 and Figure 1 show that depression and anxiety had partial mediating effects on the relationship between grief and developing PTSD symptoms among those who witnessed people’s death. The total effect of grief on PTSD symptoms was significant, with an estimator of 0.49. The indirect effect of depression and anxiety on the relationship between grief and PTSD symptoms was also significant, with an estimator of 0.06 and 0.11, respectively.
Mediation analysis among volunteers who witnessed people’s death (N=72)
Mediation model showing the effect of grief reaction on post-traumatic stress disorder (PTSD) symptoms through depression and anxiety. *p<0.05; **p<0.01.
DISCUSSION
After reviewing available literature, we found numerous studies showing an association between volunteering and PTSD. The current study adds to existing data by investigating this particular association. Furthermore, the current study has been the first to examine the mediating effect of depression and anxiety on the relationship between grief reaction and PTSD symptoms. Our study examined various aspects, including the direct relationship between grief and PTSD symptoms among volunteers who witnessed people’s death, the indirect relationship between the two factors partially mediated by depression and anxiety, and the negative correlation between the CD-RISC2 score and PCL-5, PHQ-9, and GAD-7 scores.
Among the 270 volunteers included herein, a substantial proportion (26.67%) had witnessed people’s death. The analysis of their responses showed that volunteers who witnessed people’s death had higher PCL-5 scores among. Previous studies have shown a higher prevalence of PTSD among those who witnessed death of someone close [28]. Additionally, some studies have shown that persons witnessing someone’s death during their work time had an increased prevalence of PTSD [29]. Our results also showed that three out of four components, namely intrusion, negative alterations in cognitions and mood, and alterations in arousal and reactivity, were higher among those who witnessed someone’s death, whereas no significant difference in avoidance was observed between the two groups. Avoidance, one of the core symptoms of PTSD, is considered an adaptive response to loss [30] but sometimes acts as a factor that mediates the relationship between traumatic distress and yearning [31]. Studies have reported that firefighters use avoidance as a coping strategy to reduce their stress [32]. The lack of a significant difference in the level of avoidance between two groups included in the current study can be partially explained by the possibly high levels of engagement and commitment among the participants regarding volunteering, which was not explored in our study. However, our study could not directly assess whether being related to the deceased person aggravated the PTSD symptoms. One study reported that avoidance symptoms were elevated longitudinally [33]. Hence, follow-up assessments for the volunteers are needed to better address this issue.
Furthermore, volunteers who witnessed people’s death showed significantly increased GAD-7 scores, a finding consistent with previous studies describing anxiety as a stage of grief [34,35]. This finding has also been implicated in the prolongation of acute grief in some studies [36]. During disasters, volunteers also face physical or emotional threats, which may aggravate their anxiety response [37]. This anxiety response may become even more heighted among those witnessing people’s death during a disaster. Conversely, no significant difference in depression levels was noted between the two groups, which was contrary to our expectations [38,39]. This finding could be explained by the fact that volunteers who felt depressed had already stopped volunteering. Another possible explanation could be that depression appears later than anxiety responses, which occur immediately. In contrast, our results found no difference in positive service motivation between the two groups. Given that motivation itself prompted volunteers to continue their commitment with volunteering [40], the lack of a significant difference seems reasonable. Furthermore, correlation analysis revealed interesting patterns in the relationship between mental health variables among volunteers who witnessed people’s death. In particular, positive correlations were observed between PCL-5, PG-13, PHQ-9, and GAD-7 scores, highlighting the associations between post-traumatic stress, grief, depression, and anxiety. Previous studies have also found a relationship between these four variables [41]. However, our findings showed that the CD-RISC 2 score was negatively correlated with PCL-5, PHQ-9, and GAD-7 scores, emphasizing the buffering role of resilience against these mental health challenges, which is supported by previous studies [42]. These correlations provide a nuanced understanding on the interplay between various factors in the context of mental distress and psychologic conditions.
Additionally, the regression model further elucidated the impact of various factors on PTSD symptoms, with the model explaining 63% of the variance in PCL-5 scores. Notably, PG-13, PHQ-9, and GAD-7 scores emerged as significant predictors of PCL-5 scores. This significant predictive capacity highlights the complex nature of PTSD symptoms and the relevance of grief, depression, and anxiety in developing post-traumatic symptoms. In fact, some studies have shown the combined presence of some of these factors in highly susceptible populations [43], which may be partially explained by the existence of shared neurobiological features in their pathophysiology [44].
Our study went a step further by investigating the dynamics of developing PTSD. The significant total effect of grief on PTSD symptoms suggests its direct impact. Importantly, mediation analysis revealed substantial indirect effects, with depression and anxiety acting as mediators of the relationship between grief and PTSD symptoms. The estimators of 0.14 and 0.20 for depression and anxiety, respectively, underscore the intermediary roles of these mental health factors. This mediating effect was previously studied and confirmed in perinatal grief [45]. Considering its role, anxiety had been described as the forgotten stage of grief, with other studies showing its mediating effect between PTSD and grief [46]. These findings contribute to the theoretical understanding of the pathways through which grief may contribute to the development of PTSD symptoms, offering insights for targeted interventions.
This study has several limitations that warrant consideration. First, the sample size was relatively small, with only 72 people witnessing people’s death, which may limit the generalizability of our findings. Second, the study relied on self-reported data, which may be subject to recall bias or social desirability bias. Third, we cannot exclude the possible risk of biases due to repeated entries or inappropriate responses by online participants. However, during the disaster and COVID-19 pandemic, conducting face-to-face interviews was quite challenging. Fourth, the cross-sectional design of the study limited our ability to establish causality or determine the direction of observed associations. Finally, the study did not explore all potential factors that may influence volunteering behaviors. Hence, future research should aim to investigate additional variables that may contribute to volunteering.
In conclusion, volunteers are constantly exposed to various types of stressors, which places them at risk for developing psychological distress, specifically PTSD symptoms. This study contributes to our understanding of complex relationships between PTSD, grief, depression, and anxiety while also highlighting the role of resilience as a protective factor against these illnesses. Additionally, our results also showed that depression and anxiety had mediating effects in the development of PTSD symptoms. These findings should be considered when addressing a volunteer’s needs for psychological and mental support.
Notes
Availability of Data and Material
Data will be available from the authors when requested reasonably.
Conflicts of Interest
Seockhoon Chung, a contributing editor of the Psychiatry Investigation, was not involved in the editorial evaluation or decision to publish this article. All remaining authors have declared no conflicts of interest.
Author Contributions
Conceptualization: all authors. Data curation: Issa Kamal Eddine, Hussein Walid Mreydem, Lemir Majed El Ayoubi. Formal analysis: Issa Kamal Eddine, Hussein Walid Mreydem, Han-Sung Lee, Seockhoon Chung. Methodology: all authors. Writing—original draft: all authors. Writing—review & editing: all authors.
Funding Statement
None
Acknowledgments
None