The role of psychological inflexibility on post-traumatic stress symptoms among COVID-19 survivors

The role of psychological inflexibility on post-traumatic stress symptoms among COVID-19 survivors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The role of psychological inflexibility on post-traumatic stress symptoms among COVID-19 survivors Kadir Karakuş, Tacettin Kuru, Seher Kömürcü, Veysel Doğan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8969637/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The COVID-19 outbreak spread rapidly around the world, causing a pandemic and negatively affecting the mental health of society. During this process, one of the most mentally affected groups has been patients who contracted COVID-19.Post-traumatic stress disorder (PTSD) is reported to be an important public health problem after pandemics. In this study, we aimed to investigate the relationship between psychological inflexibility, which is thought to underlie mental problems, and PTSD symptoms in Covid-19 survivors. Methods A total of 194 patients between ages 18–65 who were admitted to the Chest Diseases Outpatient Clinic with a previous Covid-19 infection and who agreed to participate were included in the study. Socio-demographic information form as well as questionnaire forms for Hospital Anxiety and Depression Scale (HADS), Acceptance and Action Questionnaire II (AAQ-II), Impact of Events Scale-Revised (IES-R) and Insomnia Severity Index (ISI) were conducted on the patients. Results Female gender, participants with lower education level, and those with additional chronic diseases had significantly higher IES-R values (p = 0.014, p = 0.029 and p = 0.011, respectively). IES-R scores showed a significant positive correlation with HADS-Anxiety (A) (p < 0.001), HADS-Depression (D) (p < 0.001), AAQ-II (p < 0.001) and ISI (p < 0.001) scores. AAQ-II scores significantly predicted HADS-A scores (p = 0.0053), and similarly, the effect of HADS-A scores on IES-R scores was also significant (p = 0.0009). The mediating role of HADS-A scores in the effect of AAQ-II scores on IES-R scores was significant (β = 0.0757, 95% CI = 0.0024 to 0.1785). AAQ-II scores had a significant predictor effect on ISI scores (β = 0.1263, p = 0.0033). Similarly, ISI scores had a significant effect on IES-R scores (β = 1.3882, p < 0.001). In this model, ISI scores significantly mediated the relationship between AAQ-II scores and IES-R scores (β = 0.1753, 95% CI = 0.0640 to 0.3060). Conclusion In our study, we found that female gender, low education level and additional chronic diseases were the risk factors for PTSD in Covid-19 survivors. We also found that psychological inflexibility may be a common factor associated with PTSD, depression and anxiety symptoms and insomnia severity. Psychotherapeutic interventions to reduce psychological inflexibility, especially in patients who suffered an infection like COVID-19 during the pandemics, may prevent these patients from experiencing anxiety, depression, PTSD symptoms and sleep problems. Covid-19 survivors Post-traumatic stress disorder Psychological inflexibility Figures Figure 1 Introduction The COVID-19 outbreak spread widely around the world in a short period of a few months, causing a pandemic. In many countries, countermeasures have had to be taken, including closure of workplaces and schools, curfews, social distancing rules and quarantine [ 1 ]. Primarily affecting the respiratory system, COVID-19 has caused respiratory distress in patients and even death in severe cases [ 2 ]. According to the World Health Organization (WHO) data, as of November 19, 2023, more than 772 million confirmed cases and more than six million deaths have been reported worldwide [ 3 ]. The COVID-19 pandemic has also negatively affected people's mental health. During this process, one of the most mentally affected groups has been patients who contracted COVID-19. In a systematic review and meta-analysis of early pandemic studies, it was reported that the prevalence of anxiety, depression and sleep disorders in COVID-19 patients was higher than in the general population [ 4 ]. Post-traumatic stress disorder (PTSD) is also a major public health concern after pandemics caused by infectious diseases, including COVID-19 [ 5 ]. In a meta-analysis of 13 studies in patients who suffered COVID-19, the pooled prevalence of PTSD was estimated to be 16% [ 6 ]. Conditions such as baseline depression and anxiety symptoms, social isolation or long hospitalization period, female gender, dyspnea, life threat perception and lack of social support in patients who contracted Covid-19 during the pandemic were found to be factors associated with PTSD [ 7 – 9 ]. Psychological inflexibility (PI) is a transdiagnostic concept defined as a pattern in which behavior is excessively controlled by the individual's thoughts, feelings and other internal experiences, or avoided at the expense of more effective and meaningful actions [ 10 ]. PI is thought to underlie psychological disorders [ 11 ]. A growing number of studies support this theory. Studies on this matter have associated PI with anxiety, depression, general anxiety, somatization, stress and sleep disorders [ 12 – 14 ]. PI is not an immutable and inflexible process, but rather changeable in different contexts with psychotherapeutic interventions [ 15 ]. In general, psychiatric studies on COVID-19 have been conducted on healthcare professionals and the general population, yet fewer studies have been conducted on COVID-19 survivors [ 16 ]. In the literature, there are studies conducted in other groups during the COVID-19 pandemic period, which associate PI with PTSD symptoms [ 17 – 20 ], mood symptoms [ 21 ] and anxiety symptoms [ 22 ]. However, these studies were carried out on different samples of the general population. To the best of our knowledge, there is no study in literature regarding the relationship between PI and PTSD in COVID-19 survivors. Considering the presence of relatively high rates of PTSD and other mental problems among COVID-19 survivors even one year later [ 23 ], early recognition of these problems and identification of factors associated with these problems are important for potential interventions. In our study, we mainly aimed to investigate the relationship between PI and PTSD in individuals who contracted Covid-19. It was also aimed to examine the role of depression, anxiety and sleep in such probable relationship. Methods Study design and sample A total of 210 patients between ages 18–65 who were admitted to the Chest Diseases Outpatient Clinic, Faculty of Medicine, ………………… University Hospital between August 1, 2021 and February 1, 2022 for Covid 19 infection, whose positivity was confirmed by PCR tests and who agreed to participate were included in this study. A total of 16 patients who were on active psychiatric treatment and filled out the scales incompletely were excluded. Hence, a total of 194 patients were included in the study. Self-report scales were used in this study. Written informed consent was obtained from the participants after explaining the purpose and method of the study and how to complete the scales. The research protocol was approved by the local ethics committee (Date: 09.06.2021, Decision Num: 10 − 01). Those with clinically significant cognitive impairment and active mental disorders, and those who completed the scales incompletely were excluded. The study was conducted in accordance with the Helsinki Declaration Principles. After obtaining informed consent from the patients who agreed to participate in the study, in addition to the sociodemographic information form, the questionnaires for Hospital Anxiety and Depression Scale (HADS) [ 24 ], Acceptance and Action Questionnaire II (AAQ-II) [ 10 ], Impact of Events Scale-Revised (IES-R) [ 25 ] and Insomnia Severity Index (ISI) [ 26 ], the validity and reliability studies of which were conducted to test the hypothesis, were completed. Measurements Sociodemographic and clinical characteristics form It is an interview questionnaire designed by researchers, which includes information on age, gender, education, occupational and marital status, comorbid physical diseases (obesity, asthma, etc.) and clinical characteristics related to trauma. Hospital Anxiety and Depression Scale (HADS) It is a self-administered scale that screens patients for symptoms of anxiety and depression and is frequently used in hospital settings [ 24 ]. The cut-off score of the HADS depression and anxiety subscales is ≥ 8. The Turkish translation of the scale was validated by Aydemir et al. [ 27 ]. Acceptance and Action Questionnaire II (AAQ-II) It is a seven-item Likert-type scale that measures psychological resilience [ 10 ]. The scale has been adapted into Turkish. The increase in the scores obtained from the scale indicates an increase in PI and experiential avoidance [ 28 ]. Impact of Events Scale-Revised (IES-R) It is a scale consisting of 22 items and 3 subscales that assesses traumatic stress symptoms and severity [ 25 ]. Turkish validity and reliability study was conducted, and the internal consistency coefficient was calculated as 0.94 for the total score [ 29 ]. The maximum score that can be obtained from the scale is 88, and it was determined that people who scored 24 or higher experienced mild or more severe PTSD [ 30 ]. Insomnia Severity Index (ISI) It was developed to assess the severity of insomnia [ 26 ]. Turkish validity and reliability study of the scale was conducted in 2010 [ 31 ]. The scale consists of seven questions and the items are scored between 0–4. Scores that can be obtained from the scale vary between 0 and 28. High scores on the scale indicate deterioration in sleep quality. Statistical analysis Descriptive statistics of the data were calculated as mean and standard deviation for continuous data. The examination of whether the data obtained through the scales were normally distributed was performed by examining the kurtosis skewness results, Q-Q plot and histogram graphs. Values in the range ± 1 for kurtosis and skewness were interpreted as normal distribution (Hair et al., 2014). Whether the variances were homogeneously distributed was interpreted by Levene's test. VIF values were reviewed for multicollinearity. Pearson correlation coefficients were calculated for correlation between the data. Three separate mediation models were tested in which IES-R was the outcome variable (Y), AAQ-II was the predictor (X) and HADS-Anxiety (A), HADS-Depression (D) and ISI were the mediating variables separately. For each mediating variable, other variables (HADS-A, HADS-D and ISI) as well as age, gender, education level and presence of comorbidity were controlled. Mediation analysis was performed using SPSS PROCESS V.2.16.1. Mediation models were tested using bootstrap analysis. In these analyses, the mediation effect was considered significant if the 95% bias-corrected and accelerated confidence intervals (CIs) (lower and upper bounds) for the indirect effect (IE) based on 5000 boots trapped samples were not equal to zero (Hayes AF, 2017). P < 0.05 was considered significant. SPSS version 22 was used for all examinations and calculations. Results The study included 194 patients diagnosed with Covid-19 who volunteered to participate in the study after informed consent. 117 (60.3%) of the participants were female. The mean age was 45.83 (± 13.27). 84 (43.3%) of the patients had comorbidities and 29 (14.9%) were smokers. 43 (22.2%) were hospitalized due to COVID-19. 11 (5.7%) were followed up in intensive care conditions. 135 (69.6%) of the participants were vaccinated for COVID-19. The sociodemographic characteristics of the participants is shown in Table 1 . Table 1 Comparison of IES-R results in terms of sociodemographic characteristics N Mean Std. D t p 95% CI of the Difference Lower Upper Gender Female 117 29.84 18.752 Male 77 23.56 16.196 2.480 0.014 1.282 11.276 Marital Status Married 154 26.30 17.851 Single/divorce/widowed 40 31.38 18.246 -1.595 0.112 -11.353 1.200 Education Primary School 99 30.10 19.271 High school and beyond 95 24.47 16.186 2.198 0.029 0.577 10.677 Comorbidity Yes 84 31.07 19.188 No 110 24.50 16.574 2.555 0.011 1.498 11.645 Previous psychiatric illness Yes 18 32.33 22.123 No 176 26.84 17.524 1.236 0.218 -3.277 14.273 Smoking Yes 29 23.34 14.418 No 165 28.05 18.510 -1.300 0.195 -11.841 2.434 Hospitalization Yes 43 31.47 19.771 No 151 26.17 17.359 1.709 0.089 -0.815 11.401 Bereavement Yes 30 31.10 17.682 No 164 26.66 18.030 1.244 0.215 -2.600 11.483 Vaccination Yes 135 27.12 18.202 No 59 27.86 17.683 -0.265 0.791 -6.301 4.809 CI: Confidence Interval, Independent sample t-Test Women had statistically significantly higher mean IES-R values than men ( t (192) = 2.480, p = 0.014). Participants with lower education level and those with additional chronic diseases had significantly higher IES-R values ( t (192) = 2.198, p = 0.029 and t (192) = 2.555, p = 0.011, respectively). IES-R values did not show a significant difference in terms of marital status ( p = 0.112), past psychiatric illness ( p = 0.218), smoking ( p = 0.195), need for hospitalization ( p = 0.089), need for intensive care follow-up ( p = 0.360), bereavement ( p = 0.215) and vaccination ( p = 0.791) investigated in the study (Table 1 ). The mean and standard deviation values of the scales used in the study are shown in Table 2 . All measurements showed kurtosis and skewness values supporting normal distribution (In addition, histogram and Q-Q plot graphs were analyzed to evaluate normal distribution). IES-R scores were significantly positively correlated with HADS-A (r = 0.61, p < 0.001), HADS-D (r = 0.054, p < 0.001), AAQ-II (r = 0.49, p < 0.001) and ISI (r = 0.66, p < 0.001) scores. There was no multicollinearity among the predictor variables to be tested (VIF values between 1.396 and 2.089). All scales had very good internal consistency results as determined by Cronbach's alpha (Table 2 ). Table 2 Descriptive statistics and correlation values of the scales used in the study N = 194 Mean ± SD (Min-Max) HADS-D HADS-A AAQ-II ISI IES-R Skew Kurt α Age 45.83 ± 13.27(18–78) 0.17 * -0.01 0.05 0.03 0.09 - - - HADS-D 7.41 ± 4.87 (0–21) 1 0.67 ** 0.45 ** 0.41 ** 0.54 ** 0.451 -0.436 0.819 HADS-A 8.20 ± 4.57 (0–19) 1 0.49 ** 0.48 ** 0.61 ** 0.315 -0.660 0.854 AAQ-II 19.25 ± 9.45 (7–46) - 1 0.43 ** 0.49 ** 0.736 -0.129 0.916 ISI 9.19 ± 5.51 (0–24) - - 1 0.66 ** 0.480 -0.317 0.871 IES-R 27.35 ± 18 (0–80) - - - - 0.667 -0.188 0.939 ** : P < 0.001, * : p < 0.05, α = Cronbach’s alpha HADS-D: Hospital Anxiety and Depression Scale-Depression, HADS-A: Hospital Anxiety and Depression Scale-Anxiety, AAQ-II: Acceptance and Action Questionnaire II, IES- R: Impact of Events Scale-Revised, ISI: Insomnia Severity Index In the first model (Fig. 1 A), in which AAQ-II scores were the predictor, IES-R scores were the dependent variable and HADS-A was the mediator, AAQ-II significantly predicted HADS-A ( β = 0.0773, p = 0.0053), and similarly the effect of HADS-A on IES-R was also significant ( β = 0.9786, p = 0.0009). The mediating role of HADS-A in the effect of AAQ-II on IES-R was significant [ β = 0.0757, 95% CI = 0.0024 to 0.1785) (Table 3 ). Approximately 58% of the variance in IES-R was explained by the variables constituting the first model (Adj. R2 = 0.5759). Table 3 Mediation analysis for IES-R outcome variable β SE P 95% CI LLCI ULCI Total Effect AAQ-II→HADS-A →IES-R 0 .2958 0.1110 0.0084 0.0769 0.5147 AAQ-II →ISI→IES-R 0.3954 0.1225 0.0015 0.1538 0.6370 Indirect Effects AAQ-II →HADS-A →IES-R 0.0757 0.0450 - 0.0024 0.1785 AAQ-II →ISI→IES-R 0.1753 0.0624 - 0.0640 0.3060 Direct Effect (AAQ-II →IES-R) 0.2201 0.1102 0.0474 0.0026 0.4376 CI: Confidence interval, LLCI: The lower limit confidence interval, ULCI: The upper limit confidence interval HADS-A: Hospital Anxiety and Depression Scale-Anxiety, AAQ-II: Acceptance and Action Questionnaire II, IES- R: Impact of Events Scale-Revised, ISI: Insomnia Severity Index In the second model in which HADS-D was tested as a mediator, AAQ-II scores significantly predicted HADS-D ( β = 0.068, p = 0.0298). However, HADS-D did not significantly predict IES-R scores ( β = 0.489, p = 0.0577). Therefore, the second model mediation effect was not tested. In the third model in which the mediating role of ISI scores was examined (Fig. 1 B), AAQ-II scores had a significant predictor effect on ISI ( β = 0.1263, p = 0.0033). Similarly, ISI scores had a significant effect on IES-R ( β = 1.3882, p < 0.001). In this model, ISI significantly mediated the relationship between AAQ-II and IES-R [ β = 0.1753, 95% CI = 0.0640 to 0.3060) (Table 3 ). Approximately 45% of the variance in IES-R was explained by the variables comprising this model (Adj. R2 = 0.4489). Discussion As the most important result in our study, we found that PI predicts PTSD in COVID-19 survivors. Our results also revealed the mediating role of anxiety and sleep problems in this effect of PI on PTSD. In the literature review, we did not find any study investigating the effect of PI on PTSD symptoms in Covid-19 survivors. However, our finding is consistent with previous studies linking PI with PTSD symptoms in the general population [ 17 – 20 , 34 ]. The Covid-19 pandemic has caused intense stress on patients, and high levels of PI, also during stressful life events, can prevent a person from adapting to adverse situations and worsen mental health [ 35 ]. It has also been shown during the COVID-19 pandemic that psychological flexibility, which is also considered as the opposite of PI, is protective against psychological distress [ 36 ]. In our study, we also found that PI had a predictive effect for anxiety and depression symptoms and sleep problems in patients who contracted Covid-19. In other words, we identified high levels of PI as a risk factor for anxiety and depression symptoms and sleep problems in Covid-19 patients. The effect of PI on depression and anxiety during the pandemic was emphasized in the findings obtained from studies conducted in people suspected of COVID-19 [ 22 ], in the general population[ 37 – 39 ] and in teachers[ 40 ] although not in patients who contracted Covid-19 during the pandemic and results consistent with our findings were obtained. PI emphasizes how a person relates to their distress rather than the distress itself. As an indicator of PI, patients' careful devotion to their distressing feelings and thoughts related to the pandemic or resistance to their experience throughout the respective period may have increased their anxiety and decreased their resistance to mental problems [ 12 , 41 ]. Another finding in our study was that anxiety symptoms had a predictive effect on PTSD symptoms in patients who contracted Covid-19. Previous studies on these subject obtained results consistent with this finding of ours. Studies conducted during the pandemic showed that anxiety symptoms in patients who suffered Covid-19 [ 8 ], fears and worries in university students under quarantine [ 42 ], and health anxiety in the general population [ 43 ] have been shown to be associated with PTSD symptoms. Infected patients with high anxiety symptoms may have been more affected by the negative factors associated with Covid-19 during the pandemic and may have been more concerned about their health, economic situation, relatives and conditions such as quarantine. This may have increased the PTSD symptoms of the patients. In our study, we also found that PI had a predictive role on sleep problems, and sleep problems had a predictive role on PTSD symptoms in patients who contracted Covid-19. Thus, we observed that PI indirectly affects PTSD symptoms through sleep problems. In other words, those with higher PI had more sleep problems and those with more sleep problems had higher PTSD symptoms. PI has been shown to be associated with poor sleep quality [ 44 ]. There are studies looking at the effect of psychological flexibility (the opposite of PI) on sleep in different groups, although not in patients who suffered from a Covid-19 infection during the pandemic. In these studies, similar to our findings, psychological flexibility was found to be positively associated with sleep quality in nurses (Wang et al., 2023), and negatively associated with insomnia symptoms in the general population [ 46 ]. In addition, the relationship between insomnia severity and PTSD symptoms, which is another finding of ours, is consistent with the findings that poor sleep quality increases the severity of post-traumatic stress symptoms in patients who suffered Covid-19 [ 47 ] and that subjective poor sleep quality is a predictor of PTSD symptoms in the general population during the pandemic [ 48 ]. In our study, we found that female gender and lower education level were associated with higher PTSD scores. The mean values of IES-R, which investigates PTSD symptoms, were higher in female Covid-19 survivors compared to males. Our finding is consistent with studies conducted in patients who suffered from infections during the Covid-19 pandemic and the previous SARS pandemic [ 7 , 49 – 52 ] and the prevalence of PTSD in the general population [ 53 ]. Underlying psychological, genetic and hormonal factors in women may have contributed to higher susceptibility to PTSD following a stressor [ 54 , 55 ]. One of our findings was that patients with lower education level had higher IES-R scores. A study conducted on this subject during the pandemic also supported our finding, namely it was found that among COVID-19 survivors, patients with low education level were more likely to develop PTSD [ 51 ]. It is stated that patients with a higher level of education may apply better coping methods because they have better social support and economic resources [ 56 , 57 ]. Accordingly, patients with higher education level who suffered Covid-19 may have been less affected by the disease process, and PTSD symptoms may have appeared less. In our study, we determined that among Covid-19 survivors, patients with comorbid chronic diseases had higher PTSD symptoms. In support of our findings, a study conducted in patients who contracted the disease during the previous SARS outbreak found that the presence of chronic medical illness before SARS was a factor associated with chronic PTSD [ 52 ]. In a study conducted in Covid-19 survivors, obesity was also reported to be a risk factor for PTSD [ 58 ]. A study conducted in the USA found the prevalence of PTSD to be higher in black adults with two or more of the conditions associated with Covid-19 mortality, i.e. obesity, hypertension, diabetes, heart disease or asthma [ 59 ]. The fact that diseases such as diabetes, hypertension and chronic lung diseases were expressed as risky conditions for Covid-19 mortality especially in the early stages of the COVID-19 pandemic, may have caused these patients to feel more threatened than others, causing them to be more traumatized during the pandemic. Strengths and limitations The cross-sectional nature of our study requires a cautious approach to the results that contain causal relationships. We used self-report measures to assess PTSD, depression, anxiety, sleep problems and PI. We were unable to obtain additional information on psychiatric diagnoses because we were unable to conduct a structured psychiatric interview. Therefore, our data may be prone to bias due to common method variance. We conducted our study on a population of Covid-19 survivors; thus, we cannot generalize our study to other populations. Studies conducted during the pandemic have usually been carried out online in the general population and healthcare workers. There are very few studies in patients who contracted Covid-19. Our study is the first to evaluate the effect of PI on PTSD symptoms in Covid-19 survivors, and the direct application of the scales to patients in an outpatient setting renders this study significant. Conclusions In this study, we found that female gender, low education level and additional chronic diseases constitute risk groups for PTSD after Covid-19 infection. We also found that PI may be a common factor associated with anxiety, depression, PTSD symptoms and insomnia severity. Psychotherapy interventions to reduce PI, especially in patients who suffered Covid-19 during the pandemic, may prevent these patients from experiencing PTSD, anxiety and depression symptoms, and sleep problems. Our current findings support the development and assessment of psychotherapeutic interventions that encourage the alleviation of PI during the pandemics like COVID-19. Abbreviations PTSD Post-traumatic stress disorder PI Psychological inflexibility HADS Hospital Anxiety and Depression Scale AAQ-II Acceptance and Action Questionnaire II IES-R Impact of Events Scale-Revised SPSS Statistical Package for the Social Sciences ISI Insomnia Severity Index CIs Confidence intervals IE Indirect effect Declarations I confirm all relevant ethical guidelines have been followed, and ethics approval has been obtained. Ethics approval The survey protocol received ethical approval from the the local ethics committee, and written informed consent was obtained from all participants. Conflict of interest The authors declare that there are no conflicts of interest. AI use declarations The author confirms that no AI or AI -assisted technologies were used in the writing process Funding No funding was received for this study. Author Contribution KK contributed to the study conception, data collection, and writing; and approved the final version. TK contributed to the study conception, data collection and interpretation, and review; and approved the final version. SK contributed to the study conception, data interpretation, and review; and approved the final version. VD contributed to the study conception, data interpretation, and review; and approved the final version. References Guessoum SB, Lachal J, Radjack R, Carretier E, Minassian S, Benoit L, et al. Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown. Psychiatry Res. 2020;291:113264. https://doi.org/10.1016/j.psychres.2020.113264 . Fu L, Wang B, Yuan T, Chen X, Ao Y, Fitzpatrick T, et al. 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Yeni Symposium. 2006;44:14–22. Creamer M, Bell R, Failla S. Psychometric properties of the Impact of Event Scale—Revised. Behav Res Ther. 2003;41:1489–96. https://doi.org/10.1016/j.brat.2003.07.010 . Boysan M, Güleç M, Besiroglu L, Kalafat T. Uykusuzluk Siddeti Indeksi’nin Türk örneklemindeki psikometrik özellikleri. Anadolu Psikiyatri Derg. 2010;11:248–52. Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Multivariate Data Analysis Pearson Education Limited. 2014. Hayes AF. Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: Guilford Press; 2017. Cheng ZH, Lozier CC, Lewis MM, O’Neil ME, Luoma JB, Morasco BJ. Investigating the role of psychological inflexibility, mindfulness, and self-compassion in PTSD. J Contextual Behav Sci. 2021;22:102–7. https://doi.org/10.1016/j.jcbs.2021.10.004 . Masuda A, Anderson PL, Wendell JW, Chou Y-Y, Price M, Feinstein AB. Psychological flexibility mediates the relations between self-concealment and negative psychological outcomes. Pers Individ Dif. 2011;50:243–7. https://doi.org/10.1016/j.paid.2010.09.037 . Kroska EB, Roche AI, Adamowicz JL, Stegall MS. Psychological flexibility in the context of COVID-19 adversity: Associations with distress. J Contextual Behav Sci. 2020;18:28–33. https://doi.org/10.1016/j.jcbs.2020.07.011 . Pakenham KI, Landi G, Boccolini G, Furlani A, Grandi S, Tossani E. The moderating roles of psychological flexibility and inflexibility on the mental health impacts of COVID-19 pandemic and lockdown in Italy. J Contextual Behav Sci. 2020;17:109–18. https://doi.org/10.1016/j.jcbs.2020.07.003 . Arslan G, Yıldırım M, Tanhan A, Buluş M, Allen K-A. Coronavirus Stress, Optimism-Pessimism, Psychological Inflexibility, and Psychological Health: Psychometric Properties of the Coronavirus Stress Measure. Int J Ment Health Addict. 2021;19:2423–39. https://doi.org/10.1007/s11469-020-00337-6 . Smith BM, Twohy AJ, Smith GS. Psychological inflexibility and intolerance of uncertainty moderate the relationship between social isolation and mental health outcomes during COVID-19. J Contextual Behav Sci. 2020;18:162–74. https://doi.org/10.1016/j.jcbs.2020.09.005 . Ilhan C, Ahmet T, Metin B. Psychological inflexibility predicts depression and anxiety during covid-19 pandemic. i-manager’s. J Educational Psychol. 2021;15:11. https://doi.org/10.26634/jpsy.15.1.18198 . Presti G, Mchugh L, Gloster A, Karekla M, Hayes SC. The dynamics of fear at the time of covid-19: a contextual behavioral science perspective. Clin Neuropsychiatry. 2020;17:65–71. Tang W, Hu T, Hu B, Jin C, Wang G, Xie C, et al. Prevalence and correlates of PTSD and depressive symptoms one month after the outbreak of the COVID-19 epidemic in a sample of home-quarantined Chinese university students. J Affect Disord. 2020;274:1–7. https://doi.org/10.1016/j.jad.2020.05.009 . Coloma-Carmona A, Carballo JL. Predicting PTSS in general population during COVID-19 pandemic: The mediating role of health anxiety. J Affect Disord. 2021;294:329–36. https://doi.org/10.1016/j.jad.2021.07.032 . Ye B, Wang Q, Zhang Y, Yang Q. Adverse childhood experiences and depressive symptoms among adolescents during the COVID-19 pandemic: mediating roles of poor sleep quality and psychological inflexibility. Psychol Health Med. 2023;28:2095–107. https://doi.org/10.1080/13548506.2023.2190986 . Wang D, Lin B, Liang H, Deng Y, Zhang L. Mediating role of psychological flexibility in the effect of obsessive-compulsive symptoms on sleep quality among nurses during the COVID-19 pandemic. Curr Psychol. 2023. https://doi.org/10.1007/s12144-023-04546-9 . McCracken LM, Badinlou F, Buhrman M, Brocki KC. The role of psychological flexibility in the context of COVID-19: Associations with depression, anxiety, and insomnia. J Contextual Behav Sci. 2021;19:28–35. https://doi.org/10.1016/j.jcbs.2020.11.003 . Nowakowski S, Kokonda M, Sultana R, Duong BB, Nagy SE, Zaidan MF, et al. Association between Sleep Quality and Mental Health among Patients at a Post-COVID-19 Recovery Clinic. Brain Sci. 2022;12:586. https://doi.org/10.3390/brainsci12050586 . Sun L, Sun Z, Wu L, Zhu Z, Zhang F, Shang Z, et al. Prevalence and risk factors for acute posttraumatic stress disorder during the COVID-19 outbreak. J Affect Disord. 2021;283:123–9. https://doi.org/10.1016/j.jad.2021.01.050 . De Lorenzo R, Conte C, Lanzani C, Benedetti F, Roveri L, Mazza MG, et al. Residual clinical damage after COVID-19: A retrospective and prospective observational cohort study. PLoS ONE. 2020;15:e0239570. https://doi.org/10.1371/journal.pone.0239570 . Hong X, Currier GW, Zhao X, Jiang Y, Zhou W, Wei J. Posttraumatic stress disorder in convalescent severe acute respiratory syndrome patients: a 4-year follow-up study. Gen Hosp Psychiatry. 2009;31:546–54. https://doi.org/10.1016/j.genhosppsych.2009.06.008 . Ju Y, Liu J, Ng RMK, Liu B, Wang M, Chen W, et al. Prevalence and predictors of post-traumatic stress disorder in patients with cured coronavirus disease 2019 (COVID-19) one month post-discharge. Eur J Psychotraumatol. 2021;12:1915576. https://doi.org/10.1080/20008198.2021.1915576 . Mak IWC, Chu CM, Pan PC, Yiu MGC, Ho SC, Chan VL. Risk factors for chronic post-traumatic stress disorder (PTSD) in SARS survivors. Gen Hosp Psychiatry. 2010;32:590–8. https://doi.org/10.1016/j.genhosppsych.2010.07.007 . Christiansen DM, Hansen M. Accounting for sex differences in PTSD: A multi-variable mediation model. Eur J Psychotraumatol. 2015;6:26068. https://doi.org/10.3402/ejpt.v6.26068 . Olff M. Sex and gender differences in post-traumatic stress disorder: an update. Eur J Psychotraumatol. 2017;8. https://doi.org/10.1080/20008198.2017.1351204 . Verma R, Balhara YS, Gupta C. Gender differences in stress response: Role of developmental and biological determinants. Ind Psychiatry J. 2011;20:4. https://doi.org/10.4103/0972-6748.98407 . Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Rep. 2014;129 1suppl2:19–31. https://doi.org/10.1177/00333549141291S206 . Tang B, Deng Q, Glik D, Dong J, Zhang L. A Meta-Analysis of Risk Factors for Post-Traumatic Stress Disorder (PTSD) in Adults and Children after Earthquakes. Int J Environ Res Public Health. 2017;14:1537. https://doi.org/10.3390/ijerph14121537 . Tarsitani L, Vassalini P, Koukopoulos A, Borrazzo C, Alessi F, Di Nicolantonio C, et al. Post-traumatic Stress Disorder Among COVID-19 Survivors at 3-Month Follow-up After Hospital Discharge. J Gen Intern Med. 2021;36:1702–7. https://doi.org/10.1007/s11606-021-06731-7 . Archibald P, Thorpe R. Chronic Medical Conditions as Predictors of the Likelihood of PTSD among Black Adults: Preparing for the Aftermath of COVID-19. Health Soc Work. 2021;46:268–76. https://doi.org/10.1093/hsw/hlab025 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8969637","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":597043968,"identity":"373d8202-daf8-4e6a-b201-a8d699ea51f9","order_by":0,"name":"Kadir Karakuş","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIiWNgGAWjYBACCSBmbGBgMGBgSGxgSPxnA+I3HiBeywe2NDCfWC0JDIwz2A6DRfFqkWw/+/DjzLY6Y/725LbPPDzn7da2HwbaUmMTjUuLNE+6seTGtsNmEmceNs/mkbidvO1MIlDLsbTcBhxa5BjSGCQfth2wYbiR2MzMY3A72ewAUAtjw2HcWvifMf982FZnIw/WknAu2ez8Q/xapCXS2IAOYzYzAGphnHHggJ3ZDQK2SM54xmY549xhY0OgXxg+NiQnmN0A2pKAxy8S59OYb/aU1RnOO57+GBg1dvZm59MfPvhQY4NTCwZIBKtMIFY5CNiTongUjIJRMApGBgAAVglme0fSBFcAAAAASUVORK5CYII=","orcid":"","institution":"Alanya Alaaddin Keykubat University","correspondingAuthor":true,"prefix":"","firstName":"Kadir","middleName":"","lastName":"Karakuş","suffix":""},{"id":597043969,"identity":"4c24307c-59bf-49bd-9c7b-b9c4c67b5466","order_by":1,"name":"Tacettin Kuru","email":"","orcid":"","institution":"Alanya Alaaddin Keykubat University","correspondingAuthor":false,"prefix":"","firstName":"Tacettin","middleName":"","lastName":"Kuru","suffix":""},{"id":597043970,"identity":"b9d2c94d-ec40-4960-acb0-5235ef157922","order_by":2,"name":"Seher Kömürcü","email":"","orcid":"","institution":"Alanya Alaaddin Keykubat University","correspondingAuthor":false,"prefix":"","firstName":"Seher","middleName":"","lastName":"Kömürcü","suffix":""},{"id":597043971,"identity":"5879c266-b8a2-4cbd-8b58-57997d0f6ed4","order_by":3,"name":"Veysel Doğan","email":"","orcid":"","institution":"Alanya Alaaddin Keykubat University","correspondingAuthor":false,"prefix":"","firstName":"Veysel","middleName":"","lastName":"Doğan","suffix":""}],"badges":[],"createdAt":"2026-02-25 16:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8969637/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8969637/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103602163,"identity":"195b5c0a-08c4-4ac7-b7c9-690b6d4be5a5","added_by":"auto","created_at":"2026-02-27 14:12:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":112045,"visible":true,"origin":"","legend":"\u003cp\u003eMediation models\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8969637/v1/d5b933f29bbca2efbbd917db.png"},{"id":104399432,"identity":"73de8845-acb6-43dd-ba02-9c2ccdf92048","added_by":"auto","created_at":"2026-03-11 12:06:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":917298,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8969637/v1/e324d0cf-9aca-47ce-9eff-2c26a509e2b1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The role of psychological inflexibility on post-traumatic stress symptoms among COVID-19 survivors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe COVID-19 outbreak spread widely around the world in a short period of a few months, causing a pandemic. In many countries, countermeasures have had to be taken, including closure of workplaces and schools, curfews, social distancing rules and quarantine [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Primarily affecting the respiratory system, COVID-19 has caused respiratory distress in patients and even death in severe cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. According to the World Health Organization (WHO) data, as of November 19, 2023, more than 772\u0026nbsp;million confirmed cases and more than six million deaths have been reported worldwide [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic has also negatively affected people's mental health. During this process, one of the most mentally affected groups has been patients who contracted COVID-19. In a systematic review and meta-analysis of early pandemic studies, it was reported that the prevalence of anxiety, depression and sleep disorders in COVID-19 patients was higher than in the general population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Post-traumatic stress disorder (PTSD) is also a major public health concern after pandemics caused by infectious diseases, including COVID-19 [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In a meta-analysis of 13 studies in patients who suffered COVID-19, the pooled prevalence of PTSD was estimated to be 16% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Conditions such as baseline depression and anxiety symptoms, social isolation or long hospitalization period, female gender, dyspnea, life threat perception and lack of social support in patients who contracted Covid-19 during the pandemic were found to be factors associated with PTSD [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychological inflexibility (PI) is a transdiagnostic concept defined as a pattern in which behavior is excessively controlled by the individual's thoughts, feelings and other internal experiences, or avoided at the expense of more effective and meaningful actions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. PI is thought to underlie psychological disorders [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A growing number of studies support this theory. Studies on this matter have associated PI with anxiety, depression, general anxiety, somatization, stress and sleep disorders [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. PI is not an immutable and inflexible process, but rather changeable in different contexts with psychotherapeutic interventions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn general, psychiatric studies on COVID-19 have been conducted on healthcare professionals and the general population, yet fewer studies have been conducted on COVID-19 survivors [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the literature, there are studies conducted in other groups during the COVID-19 pandemic period, which associate PI with PTSD symptoms [\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], mood symptoms [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] and anxiety symptoms [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. However, these studies were carried out on different samples of the general population. To the best of our knowledge, there is no study in literature regarding the relationship between PI and PTSD in COVID-19 survivors.\u003c/p\u003e \u003cp\u003eConsidering the presence of relatively high rates of PTSD and other mental problems among COVID-19 survivors even one year later [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], early recognition of these problems and identification of factors associated with these problems are important for potential interventions.\u003c/p\u003e \u003cp\u003eIn our study, we mainly aimed to investigate the relationship between PI and PTSD in individuals who contracted Covid-19. It was also aimed to examine the role of depression, anxiety and sleep in such probable relationship.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and sample\u003c/h2\u003e \u003cp\u003e A total of 210 patients between ages 18\u0026ndash;65 who were admitted to the Chest Diseases Outpatient Clinic, Faculty of Medicine, \u0026hellip;\u0026hellip;\u0026hellip;\u0026hellip;\u0026hellip;\u0026hellip;\u0026hellip; University Hospital between August 1, 2021 and February 1, 2022 for Covid 19 infection, whose positivity was confirmed by PCR tests and who agreed to participate were included in this study. A total of 16 patients who were on active psychiatric treatment and filled out the scales incompletely were excluded. Hence, a total of 194 patients were included in the study. Self-report scales were used in this study. Written informed consent was obtained from the participants after explaining the purpose and method of the study and how to complete the scales. The research protocol was approved by the local ethics committee (Date: 09.06.2021, Decision Num: 10\u0026thinsp;\u0026minus;\u0026thinsp;01). Those with clinically significant cognitive impairment and active mental disorders, and those who completed the scales incompletely were excluded. The study was conducted in accordance with the Helsinki Declaration Principles.\u003c/p\u003e \u003cp\u003eAfter obtaining informed consent from the patients who agreed to participate in the study, in addition to the sociodemographic information form, the questionnaires for Hospital Anxiety and Depression Scale (HADS) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], Acceptance and Action Questionnaire II (AAQ-II) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], Impact of Events Scale-Revised (IES-R) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and Insomnia Severity Index (ISI) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], the validity and reliability studies of which were conducted to test the hypothesis, were completed.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasurements\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eSociodemographic and clinical characteristics form\u003c/strong\u003e \u003cp\u003eIt is an interview questionnaire designed by researchers, which includes information on age, gender, education, occupational and marital status, comorbid physical diseases (obesity, asthma, etc.) and clinical characteristics related to trauma.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eHospital Anxiety and Depression Scale (HADS)\u003c/strong\u003e \u003cp\u003eIt is a self-administered scale that screens patients for symptoms of anxiety and depression and is frequently used in hospital settings [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The cut-off score of the HADS depression and anxiety subscales is \u0026ge;\u0026thinsp;8. The Turkish translation of the scale was validated by Aydemir et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eAcceptance and Action Questionnaire II (AAQ-II)\u003c/strong\u003e \u003cp\u003eIt is a seven-item Likert-type scale that measures psychological resilience [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The scale has been adapted into Turkish. The increase in the scores obtained from the scale indicates an increase in PI and experiential avoidance [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eImpact of Events Scale-Revised (IES-R)\u003c/strong\u003e \u003cp\u003eIt is a scale consisting of 22 items and 3 subscales that assesses traumatic stress symptoms and severity [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Turkish validity and reliability study was conducted, and the internal consistency coefficient was calculated as 0.94 for the total score [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The maximum score that can be obtained from the scale is 88, and it was determined that people who scored 24 or higher experienced mild or more severe PTSD [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInsomnia Severity Index (ISI)\u003c/strong\u003e \u003cp\u003eIt was developed to assess the severity of insomnia [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Turkish validity and reliability study of the scale was conducted in 2010 [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The scale consists of seven questions and the items are scored between 0\u0026ndash;4. Scores that can be obtained from the scale vary between 0 and 28. High scores on the scale indicate deterioration in sleep quality.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics of the data were calculated as mean and standard deviation for continuous data. The examination of whether the data obtained through the scales were normally distributed was performed by examining the kurtosis skewness results, Q-Q plot and histogram graphs. Values in the range\u0026thinsp;\u0026plusmn;\u0026thinsp;1 for kurtosis and skewness were interpreted as normal distribution (Hair et al., 2014). Whether the variances were homogeneously distributed was interpreted by Levene's test. VIF values were reviewed for multicollinearity. Pearson correlation coefficients were calculated for correlation between the data. Three separate mediation models were tested in which IES-R was the outcome variable (Y), AAQ-II was the predictor (X) and HADS-Anxiety (A), HADS-Depression (D) and ISI were the mediating variables separately. For each mediating variable, other variables (HADS-A, HADS-D and ISI) as well as age, gender, education level and presence of comorbidity were controlled. Mediation analysis was performed using SPSS PROCESS V.2.16.1. Mediation models were tested using bootstrap analysis. In these analyses, the mediation effect was considered significant if the 95% bias-corrected and accelerated confidence intervals (CIs) (lower and upper bounds) for the indirect effect (IE) based on 5000 boots trapped samples were not equal to zero (Hayes AF, 2017). P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant. SPSS version 22 was used for all examinations and calculations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 194 patients diagnosed with Covid-19 who volunteered to participate in the study after informed consent. 117 (60.3%) of the participants were female. The mean age was 45.83 (\u0026plusmn;\u0026thinsp;13.27). 84 (43.3%) of the patients had comorbidities and 29 (14.9%) were smokers. 43 (22.2%) were hospitalized due to COVID-19. 11 (5.7%) were followed up in intensive care conditions. 135 (69.6%) of the participants were vaccinated for COVID-19. The sociodemographic characteristics of the participants is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of IES-R results in terms of sociodemographic characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStd. D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e95% CI of the Difference\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLower\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eUpper\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.752\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.282\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11.276\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.851\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle/divorce/widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-1.595\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-11.353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1.200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school and beyond\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.186\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.577\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e10.677\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eComorbidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.574\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.555\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.498\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11.645\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePrevious psychiatric illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.524\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-3.277\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e14.273\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14.418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.510\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-1.300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-11.841\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.434\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHospitalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.771\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.709\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-0.815\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11.401\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBereavement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.682\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-2.600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e11.483\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVaccination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18.202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.683\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e-0.265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.791\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-6.301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e4.809\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eCI: Confidence Interval, Independent sample t-Test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWomen had statistically significantly higher mean IES-R values than men (\u003cem\u003et\u003c/em\u003e \u003csub\u003e(192)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;2.480, p\u0026thinsp;=\u0026thinsp;0.014). Participants with lower education level and those with additional chronic diseases had significantly higher IES-R values (\u003cem\u003et\u003c/em\u003e \u003csub\u003e(192)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;2.198, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.029 and \u003cem\u003et\u003c/em\u003e \u003csub\u003e(192)\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;2.555, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011, respectively). IES-R values did not show a significant difference in terms of marital status (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.112), past psychiatric illness (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.218), smoking (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.195), need for hospitalization (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.089), need for intensive care follow-up (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.360), bereavement (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.215) and vaccination (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.791) investigated in the study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe mean and standard deviation values of the scales used in the study are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All measurements showed kurtosis and skewness values supporting normal distribution (In addition, histogram and Q-Q plot graphs were analyzed to evaluate normal distribution). IES-R scores were significantly positively correlated with HADS-A (r\u0026thinsp;=\u0026thinsp;0.61, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), HADS-D (r\u0026thinsp;=\u0026thinsp;0.054, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), AAQ-II (r\u0026thinsp;=\u0026thinsp;0.49, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and ISI (r\u0026thinsp;=\u0026thinsp;0.66, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) scores. There was no multicollinearity among the predictor variables to be tested (VIF values between 1.396 and 2.089). All scales had very good internal consistency results as determined by Cronbach's alpha (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics and correlation values of the scales used in the study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;194\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (Min-Max)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHADS-D\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHADS-A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAAQ-II\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eISI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIES-R\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSkew\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eKurt\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eα\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.83\u0026thinsp;\u0026plusmn;\u0026thinsp;13.27(18\u0026ndash;78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.17\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHADS-D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.41\u0026thinsp;\u0026plusmn;\u0026thinsp;4.87 (0\u0026ndash;21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.67\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.45\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.41\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.54\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.451\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.436\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.819\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHADS-A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.20\u0026thinsp;\u0026plusmn;\u0026thinsp;4.57 (0\u0026ndash;19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.49\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.48\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.61\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.660\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.854\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAAQ-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.25\u0026thinsp;\u0026plusmn;\u0026thinsp;9.45 (7\u0026ndash;46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.43\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.49\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.736\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.916\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eISI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.19\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51 (0\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.66\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIES-R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.35\u0026thinsp;\u0026plusmn;\u0026thinsp;18 (0\u0026ndash;80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.188\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003e**\u003c/sup\u003e : P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003csup\u003e*\u003c/sup\u003e: p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, α\u0026thinsp;=\u0026thinsp;Cronbach\u0026rsquo;s alpha\u003c/p\u003e \u003cp\u003eHADS-D: Hospital Anxiety and Depression Scale-Depression, HADS-A: Hospital Anxiety and Depression Scale-Anxiety, AAQ-II: Acceptance and Action Questionnaire II, IES- R: Impact of Events Scale-Revised, ISI: Insomnia Severity Index\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the first model (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA), in which AAQ-II scores were the predictor, IES-R scores were the dependent variable and HADS-A was the mediator, AAQ-II significantly predicted HADS-A (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0773, p\u0026thinsp;=\u0026thinsp;0.0053), and similarly the effect of HADS-A on IES-R was also significant (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.9786, p\u0026thinsp;=\u0026thinsp;0.0009). The mediating role of HADS-A in the effect of AAQ-II on IES-R was significant [\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.0757, 95% CI\u0026thinsp;=\u0026thinsp;0.0024 to 0.1785) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Approximately 58% of the variance in IES-R was explained by the variables constituting the first model (Adj. R2\u0026thinsp;=\u0026thinsp;0.5759).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMediation analysis for IES-R outcome variable\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eβ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLLCI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eULCI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTotal Effect\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAAQ-II\u0026rarr;HADS-A \u0026rarr;IES-R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 .2958\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0084\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0769\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.5147\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAAQ-II \u0026rarr;ISI\u0026rarr;IES-R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.3954\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1538\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.6370\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eIndirect Effects\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAAQ-II \u0026rarr;HADS-A \u0026rarr;IES-R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.0757\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.0024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.1785\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAAQ-II \u0026rarr;ISI\u0026rarr;IES-R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.1753\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.0624\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.0640\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.3060\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDirect Effect\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(AAQ-II \u0026rarr;IES-R)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.2201\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.1102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.0474\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.4376\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eCI: Confidence interval, LLCI: The lower limit confidence interval, ULCI: The upper limit confidence interval\u003c/p\u003e \u003cp\u003eHADS-A: Hospital Anxiety and Depression Scale-Anxiety, AAQ-II: Acceptance and Action Questionnaire II, IES- R: Impact of Events Scale-Revised, ISI: Insomnia Severity Index\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the second model in which HADS-D was tested as a mediator, AAQ-II scores significantly predicted HADS-D (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.068, p\u0026thinsp;=\u0026thinsp;0.0298). However, HADS-D did not significantly predict IES-R scores (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.489, p\u0026thinsp;=\u0026thinsp;0.0577). Therefore, the second model mediation effect was not tested. In the third model in which the mediating role of ISI scores was examined (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB), AAQ-II scores had a significant predictor effect on ISI (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.1263, p\u0026thinsp;=\u0026thinsp;0.0033). Similarly, ISI scores had a significant effect on IES-R (\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.3882, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In this model, ISI significantly mediated the relationship between AAQ-II and IES-R [\u003cem\u003eβ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.1753, 95% CI\u0026thinsp;=\u0026thinsp;0.0640 to 0.3060) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Approximately 45% of the variance in IES-R was explained by the variables comprising this model (Adj. R2\u0026thinsp;=\u0026thinsp;0.4489).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs the most important result in our study, we found that PI predicts PTSD in COVID-19 survivors. Our results also revealed the mediating role of anxiety and sleep problems in this effect of PI on PTSD. In the literature review, we did not find any study investigating the effect of PI on PTSD symptoms in Covid-19 survivors. However, our finding is consistent with previous studies linking PI with PTSD symptoms in the general population [\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The Covid-19 pandemic has caused intense stress on patients, and high levels of PI, also during stressful life events, can prevent a person from adapting to adverse situations and worsen mental health [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. It has also been shown during the COVID-19 pandemic that psychological flexibility, which is also considered as the opposite of PI, is protective against psychological distress [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, we also found that PI had a predictive effect for anxiety and depression symptoms and sleep problems in patients who contracted Covid-19. In other words, we identified high levels of PI as a risk factor for anxiety and depression symptoms and sleep problems in Covid-19 patients. The effect of PI on depression and anxiety during the pandemic was emphasized in the findings obtained from studies conducted in people suspected of COVID-19 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], in the general population[\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] and in teachers[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] although not in patients who contracted Covid-19 during the pandemic and results consistent with our findings were obtained. PI emphasizes how a person relates to their distress rather than the distress itself. As an indicator of PI, patients' careful devotion to their distressing feelings and thoughts related to the pandemic or resistance to their experience throughout the respective period may have increased their anxiety and decreased their resistance to mental problems [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother finding in our study was that anxiety symptoms had a predictive effect on PTSD symptoms in patients who contracted Covid-19. Previous studies on these subject obtained results consistent with this finding of ours. Studies conducted during the pandemic showed that anxiety symptoms in patients who suffered Covid-19 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], fears and worries in university students under quarantine [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], and health anxiety in the general population [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] have been shown to be associated with PTSD symptoms. Infected patients with high anxiety symptoms may have been more affected by the negative factors associated with Covid-19 during the pandemic and may have been more concerned about their health, economic situation, relatives and conditions such as quarantine. This may have increased the PTSD symptoms of the patients.\u003c/p\u003e \u003cp\u003eIn our study, we also found that PI had a predictive role on sleep problems, and sleep problems had a predictive role on PTSD symptoms in patients who contracted Covid-19. Thus, we observed that PI indirectly affects PTSD symptoms through sleep problems. In other words, those with higher PI had more sleep problems and those with more sleep problems had higher PTSD symptoms. PI has been shown to be associated with poor sleep quality [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. There are studies looking at the effect of psychological flexibility (the opposite of PI) on sleep in different groups, although not in patients who suffered from a Covid-19 infection during the pandemic. In these studies, similar to our findings, psychological flexibility was found to be positively associated with sleep quality in nurses (Wang et al., 2023), and negatively associated with insomnia symptoms in the general population [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In addition, the relationship between insomnia severity and PTSD symptoms, which is another finding of ours, is consistent with the findings that poor sleep quality increases the severity of post-traumatic stress symptoms in patients who suffered Covid-19 [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] and that subjective poor sleep quality is a predictor of PTSD symptoms in the general population during the pandemic [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, we found that female gender and lower education level were associated with higher PTSD scores. The mean values of IES-R, which investigates PTSD symptoms, were higher in female Covid-19 survivors compared to males. Our finding is consistent with studies conducted in patients who suffered from infections during the Covid-19 pandemic and the previous SARS pandemic [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR50 CR51\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e] and the prevalence of PTSD in the general population [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Underlying psychological, genetic and hormonal factors in women may have contributed to higher susceptibility to PTSD following a stressor [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. One of our findings was that patients with lower education level had higher IES-R scores. A study conducted on this subject during the pandemic also supported our finding, namely it was found that among COVID-19 survivors, patients with low education level were more likely to develop PTSD [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. It is stated that patients with a higher level of education may apply better coping methods because they have better social support and economic resources [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]. Accordingly, patients with higher education level who suffered Covid-19 may have been less affected by the disease process, and PTSD symptoms may have appeared less.\u003c/p\u003e \u003cp\u003eIn our study, we determined that among Covid-19 survivors, patients with comorbid chronic diseases had higher PTSD symptoms. In support of our findings, a study conducted in patients who contracted the disease during the previous SARS outbreak found that the presence of chronic medical illness before SARS was a factor associated with chronic PTSD [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. In a study conducted in Covid-19 survivors, obesity was also reported to be a risk factor for PTSD [\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. A study conducted in the USA found the prevalence of PTSD to be higher in black adults with two or more of the conditions associated with Covid-19 mortality, i.e. obesity, hypertension, diabetes, heart disease or asthma [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. The fact that diseases such as diabetes, hypertension and chronic lung diseases were expressed as risky conditions for Covid-19 mortality especially in the early stages of the COVID-19 pandemic, may have caused these patients to feel more threatened than others, causing them to be more traumatized during the pandemic.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe cross-sectional nature of our study requires a cautious approach to the results that contain causal relationships. We used self-report measures to assess PTSD, depression, anxiety, sleep problems and PI. We were unable to obtain additional information on psychiatric diagnoses because we were unable to conduct a structured psychiatric interview. Therefore, our data may be prone to bias due to common method variance. We conducted our study on a population of Covid-19 survivors; thus, we cannot generalize our study to other populations. Studies conducted during the pandemic have usually been carried out online in the general population and healthcare workers. There are very few studies in patients who contracted Covid-19. Our study is the first to evaluate the effect of PI on PTSD symptoms in Covid-19 survivors, and the direct application of the scales to patients in an outpatient setting renders this study significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this study, we found that female gender, low education level and additional chronic diseases constitute risk groups for PTSD after Covid-19 infection. We also found that PI may be a common factor associated with anxiety, depression, PTSD symptoms and insomnia severity. Psychotherapy interventions to reduce PI, especially in patients who suffered Covid-19 during the pandemic, may prevent these patients from experiencing PTSD, anxiety and depression symptoms, and sleep problems. Our current findings support the development and assessment of psychotherapeutic interventions that encourage the alleviation of PI during the pandemics like COVID-19.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePTSD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Post-traumatic stress disorder\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Psychological inflexibility\u003c/p\u003e\n\u003cp\u003eHADS \u0026nbsp; \u0026nbsp; \u0026nbsp; Hospital Anxiety and Depression Scale\u003c/p\u003e\n\u003cp\u003eAAQ-II \u0026nbsp; \u0026nbsp; Acceptance and Action Questionnaire II\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIES-R \u0026nbsp; \u0026nbsp; \u0026nbsp; Impact of Events Scale-Revised\u003c/p\u003e\n\u003cp\u003eSPSS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Statistical Package for the Social Sciences\u003c/p\u003e\n\u003cp\u003eISI \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Insomnia Severity Index\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCIs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Confidence intervals\u003c/p\u003e\n\u003cp\u003eIE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Indirect effect\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e I confirm all relevant ethical guidelines have been followed, and ethics approval has been obtained.\u003c/p\u003e \u003ch2\u003eEthics approval\u003c/h2\u003e \u003cp\u003e The survey protocol received ethical approval from the the local ethics committee, and written informed consent was obtained from all participants.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConflict of interest\u003c/strong\u003e \u003cp\u003eThe authors declare that there are no conflicts of interest.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAI use declarations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe author confirms that no AI or AI -assisted technologies were used in the writing process\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKK contributed to the study conception, data collection, and writing; and approved the final version. TK contributed to the study conception, data collection and interpretation, and review; and approved the final version. SK contributed to the study conception, data interpretation, and review; and approved the final version. VD contributed to the study conception, data interpretation, and review; and approved the final version.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGuessoum SB, Lachal J, Radjack R, Carretier E, Minassian S, Benoit L, et al. Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown. 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Health Soc Work. 2021;46:268\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/hsw/hlab025\u003c/span\u003e\u003cspan address=\"10.1093/hsw/hlab025\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Covid-19 survivors, Post-traumatic stress disorder, Psychological inflexibility","lastPublishedDoi":"10.21203/rs.3.rs-8969637/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8969637/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe COVID-19 outbreak spread rapidly around the world, causing a pandemic and negatively affecting the mental health of society. During this process, one of the most mentally affected groups has been patients who contracted COVID-19.Post-traumatic stress disorder (PTSD) is reported to be an important public health problem after pandemics. In this study, we aimed to investigate the relationship between psychological inflexibility, which is thought to underlie mental problems, and PTSD symptoms in Covid-19 survivors.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 194 patients between ages 18\u0026ndash;65 who were admitted to the Chest Diseases Outpatient Clinic with a previous Covid-19 infection and who agreed to participate were included in the study. Socio-demographic information form as well as questionnaire forms for Hospital Anxiety and Depression Scale (HADS), Acceptance and Action Questionnaire II (AAQ-II), Impact of Events Scale-Revised (IES-R) and Insomnia Severity Index (ISI) were conducted on the patients.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFemale gender, participants with lower education level, and those with additional chronic diseases had significantly higher IES-R values (p\u0026thinsp;=\u0026thinsp;0.014, p\u0026thinsp;=\u0026thinsp;0.029 and p\u0026thinsp;=\u0026thinsp;0.011, respectively). IES-R scores showed a significant positive correlation with HADS-Anxiety (A) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), HADS-Depression (D) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), AAQ-II (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and ISI (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) scores. AAQ-II scores significantly predicted HADS-A scores (p\u0026thinsp;=\u0026thinsp;0.0053), and similarly, the effect of HADS-A scores on IES-R scores was also significant (p\u0026thinsp;=\u0026thinsp;0.0009). The mediating role of HADS-A scores in the effect of AAQ-II scores on IES-R scores was significant (β\u0026thinsp;=\u0026thinsp;0.0757, 95% CI\u0026thinsp;=\u0026thinsp;0.0024 to 0.1785). AAQ-II scores had a significant predictor effect on ISI scores (β\u0026thinsp;=\u0026thinsp;0.1263, p\u0026thinsp;=\u0026thinsp;0.0033). Similarly, ISI scores had a significant effect on IES-R scores (β\u0026thinsp;=\u0026thinsp;1.3882, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In this model, ISI scores significantly mediated the relationship between AAQ-II scores and IES-R scores (β\u0026thinsp;=\u0026thinsp;0.1753, 95% CI\u0026thinsp;=\u0026thinsp;0.0640 to 0.3060).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn our study, we found that female gender, low education level and additional chronic diseases were the risk factors for PTSD in Covid-19 survivors. We also found that psychological inflexibility may be a common factor associated with PTSD, depression and anxiety symptoms and insomnia severity. Psychotherapeutic interventions to reduce psychological inflexibility, especially in patients who suffered an infection like COVID-19 during the pandemics, may prevent these patients from experiencing anxiety, depression, PTSD symptoms and sleep problems.\u003c/p\u003e","manuscriptTitle":"The role of psychological inflexibility on post-traumatic stress symptoms among COVID-19 survivors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-27 14:11:41","doi":"10.21203/rs.3.rs-8969637/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a3abaaa4-c6fc-45f0-a8c3-9cae67a0d7ae","owner":[],"postedDate":"February 27th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-27T18:54:16+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-27 14:11:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8969637","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8969637","identity":"rs-8969637","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}