Mental health impact of the Middle East respiratory syndrome, SARS, and COVID-19: A comparative systematic review and meta-analysis

Table 1 21 studies that are included in meta-analysis for Middle East respiratory syndrome

Study ID	Ref.	Study type	Sample size	Country	Exposure	Outcome	P value	Quality assessment (NOS)
1	Shin et al[36]	Quantitative	63	Korea	MERS patients	PTSD, Sleep problem, anxiety, depression, suicidality, phobic anxiety, addiction, aggression	Not specified	7
2	Um et al[37]	Quantitative	64	Korea	MERS patients and HCWs	PTSD, depression	Not specified	7
3	Abolfotouh et al[38]	Quantitative	1031	Saudi Arabia	HCWs	Level of Concern	Not specified	7
4	Jung et al[39]	Quantitative	147	Korea	HCWs	PTSD	Not specified	6
5	Ahn et al[40]	Quantitative	63	Korea	MERS Patients	Suicide, fatigue	Not specified	6
6	Lee et al[41]	Quantitative	52	Korea	MERS Patients	Depression, PTSD, fatigue	Not specified	6
7	Kim et al[42]	Quantitative	112	Korea	HCWs	PTSD, burnout	Not specified	7
8	Oh et al[43]	Quantitative	313	Korea	HCWs	Stress	Stress: 0.066	7
9	Seo et al[44]	Quantitative	171	Korea	HCWs	Burnout	Not specified	5
10	Son et al[45]	Quantitative	280	Korea	HCWs and general public	PTSD	Not specified	6
11	Park et al[46]	Quantitative	187	Korea	HCWs	Stress	Not specified	6
12	Jeong et al[24]	Qualitative	1692	Korea	MERS patients and general public	Anxiety	Not specified	7
13	Al-Rabiaah et al[47]	Quantitative	174	Saudi Arabia	General public	Anxiety	Not specified	7
14	Park et al[48]	Quantitative	63	Korea	MERS Patients	PTSD, depression	Not specified	7
15	Cho et al[49]	Quantitative	111	Korea	General public	PTSD	PTSD: 0.3	7
16	Kim et al[50]	Quantitative	27	Korea	General public	Depression	Not specified	5
17	Lee et al[51]	Quantitative	359	Korea	HCWs	PTSD	Not specified	6
18	Kim and Choi[52]	Quantitative	215	Korea	HCWs	Burnout, stress	Not specified	6
19	Bukhari et al[53]	Quantitative	386	Saudi Arabia	HCWs	Worry	Not specified	6
20	Mollers et al[54]	Quantitative	72	Netherlands	General public	PTSD	Not specified	5
21	Kim and Choi[52]	Quantitative	215	Korea	HCWs	PTSD: 0.017	PTSD: 0.017	6

PTSD: Post-traumatic stress disorder; MERS: Middle East respiratory syndrome; HCW: Healthcare worker.

Table 2 39 studies that are included in meta-analysis for severe acute respiratory syndrome

Study ID	Ref.	Study type	Sample size	Country/region	Exposure	P value	Quality assessment (NOS)
1	Kwek et al[20]	Cross-sectional	360	Singapore	SARS patients	PTSD: 0.79; Depression: 0.7; Anxiety: 0.51	7
2	Fang et al[55]	Cross-sectional	1278	China	SARS patients	Anxiety: 0.291; Depression: 0.705; PTSD: 0.2	8
3	Liang[56]	Prospective cohort	769	China, Taiwan	SARS patients	PTSD: > 0.05; Anxiety: > 0.05	7
4	Dang et al[57]	Cross-sectional	549	China	General public	Anxiety: < 0.00001; Depression: 0.000361	7
5	Yip[58]	Prospective cohort	218	China, Hong Kong	SARS patients	Not specified	6
6	Cheng et al[59]	Cross-sectional	10	China, Hong Kong	SARS patients	Anxiety: > 0.05; Depression: > 0.05	5
7	Wu et al[60]	Cross-sectional	286	China, Hong Kong	SARS patients	PTSD: < 0.001; Depression: < 0.05; Anxiety: < 0.01	6
8	MaK et al[61]	Retrospective cohort	126	China, Hong Kong	SARS patients	Not specified	5
9	Lee et al[62]	Cross-sectional	10511	China, Hong Kong	Were not HCWs	Not specified	7
10	Hong et al[63]	Cross-sectional	1050	China	SARS patients	PTSD: 0.0323	7
11	Wang[64]	Prospective cohort	22	China	SARS patients	Not specified	4
12	Hu et al[65]	Cross-sectional	763	China	Attended hospital for other reasons	Not specified	5
13	Chen et al[66]	Prospective cohort	325	China, Taiwan	Non-infected HCWs in the largest obligatory SARS hospital, with high SARS contact	Anxiety: 0.55 Depression: 0.93	6
14	Ko et al[67]	Cross-sectional	72	China, Taiwan	General public of outbreak area	Depression: 0.02	5
15	Lee et al[21]	Cross-sectional	114	China, Hong Kong	General public of outbreak area	Not specified	6
16	Hawryluck et al[68]	Cross-sectional	652	Canada, Toronto	General public of outbreak area	Depression: 0.85; PTSD: 0.82	7
17	Liu et al[69]	Cross-sectional	96	China, Beijing	Non-infected HCWs of SARS hospital	Depression: < 0.05	7
18	Su et al[70]	Prospective cohort	57	China, Taiwan	Non-infected HCWs in SARS outbreak region with high exposure risk vs low exposure risk	PTSD: > 0.05; Depression: < 0.05	7
19	Lam et al[71]	Retrospective cohort	116	China, Hong Kong	SARS patients	Not specified	6
20	Shi et al[72]	Prospective cohort	87	China, Beijing	SARS outbreak region	Not specified	5
21	Huang et al[73]	Cross-sectional	4481	China, Beijing	Were not HCWs	Not specified	6
22	Yu et al[74]	Prospective cohort	180	China, Hong Kong	General public of outbreak area	Not specified	5
23	Chang and Sivam[75]	Cross-sectional	146	Singapore	General public of outbreak area	Not specified	5
24	Moldofsky and Patcai[76]	Retrospective cohort	107	Canada, Toronto	SARS patients, who were HCWs	Not specified	6
25	Sun et al[77]	Prospective cohort	1557	China, Xianxi	SARS patients	PTSD: 0.67	7
26	Lau et al[78]	Cross-sectional	333	China, Hong Kong	General public of outbreak area	Not specified	5
27	Reynolds et al[79]	Cross-sectional	89	Canada	General public of outbreak area, quarantined; non-infected HCWs in SARS outbreak region, quarantined	Not specified	5
28	Lancee et al[80]	Cross-sectional	613	Canada, Toronto	Non-infected HCWs in SARS outbreak region	Not specified	6
29	Lin et al[81]	Cross-sectional	6280	China, Taiwan, Taichung	Non-infected HCWs in in region without major SARS outbreak	Not specified	6
30	Gao et al[82]	Prospective cohort	127	China, Tianjin	SARS patients	Not specified	5
31	Xu et al[83]	Cross-sectional	129	China, Xianxi	Non-infected HCWs in SARS hospital	PTSD: > 0.05	6
32	Wong et al[84]	Cross-sectional	0 (?)	China, Hong Kong	Non-infected HCWs from SARS hospitals	Not specified	4
33	Sim et al[85]	Cross-sectional	90	Singapore	Non-infected HCWs in SARS outbreak region	Not specified	5
34	Wu et al[19]	Cross-sectional	133	China, Beijing	Non-infected HCWs in SARS hospital	Not specified	6
35	Chen et al[86]	Cross-sectional	103	China, Taiwan, Kaohsiung	Non-infected HCWs in SARS hospital, with high SARS contact; non-infected HCWs in SARS hospital; with low SARS contact	Not specified	6
36	Tham et al[87]	Cross-sectional	90	Singapore	Non-infected HCWs in SARS hospital with extra risk of exposure	Not specified	5
37	Maunder et al[88]	Cross-sectional	90	Canada, Toronto	Non-infected HCWs of outbreak area, unspecified (mix of SARS affected and non SARS affected hospitals	PTSD: < 0.01	7
38	Mak et al[89]	Retrospective cohort	126	China, Hong Kong	SARS patient	Not specified	6
39	McAlonan et al[90]	Cross-sectional	0 (?)	China, Hong Kong	Non-infected HCWs in SARS outbreak region with high exposure risk vs low exposure risk	Not specified	3

PTSD: Post-traumatic stress disorder; MERS: Middle East respiratory syndrome; HCW: Healthcare worker; CI: Confidence interval; SARS-CoV-2: Severe acute respiratory syndrome coronavirus-2.

Table 3 Pooled prevalence and confidence interval of anxiety across Middle East respiratory syndrome coronavirus, severe acute respiratory syndrome coronavirus and severe acute respiratory syndrome coronavirus-2

Anxiety	Prevalence (%)	95%CI	Heterogeneity I2 (%)
MERS	17.35	8.36-36.02	95.62
SARS-CoV-2	21.48	18.68-24.71	99.76
SARS-CoV	25.20	18.41-34.5	93.47

CI: Confidence interval; MERS: Middle East respiratory syndrome; SARS-CoV-2: Severe acute respiratory syndrome coronavirus-2.

Table 4 Pooled prevalence and confidence interval of depression across three diseases

Depression	Prevalence (%)	95%CI	Heterogeneity I2 (%)
MERS	33.65	22.02-51.42	69.86
SARS-CoV-2	27.64	24.59-31.06	99.69
SARS-CoV	23.10	18.14-29.4	95.03

CI: Confidence interval; MERS: Middle East respiratory syndrome; SARS-CoV-2: Severe acute respiratory syndrome coronavirus-2.

Table 5 Pooled prevalence and confidence interval of post-traumatic stress disorder across three diseases

PTSD	Prevalence (%)	95%CI	Heterogeneity I2 (%)
MERS	35.97	29.6-43.72	75.2
SARS-CoV-2	25.03	18.15-34.51	99.58
SARS-CoV	18.20	14.94-22.18	91.37

PTSD: Post-traumatic stress disorder; CI: Confidence interval; MERS: Middle East respiratory syndrome; SARS-CoV-2: Severe acute respiratory syndrome coronavirus-2.

Table 6 Subgroup analysis on Middle East respiratory syndrome data based on different age groups

Subgroup-age	MERS
		Prevalence (%)	95%CI	Heterogeneity I2 (%)
Anxiety	10-19	-	-	-
	20-29	-	-	-
	30-39	-	-	-
	40-49	18.51	8.11-42.23	96.43
	50-59	-	-	-
Depression	20-29	-	-	-
	30-39	-	-	-
	40-49	38.45	25.81-57.26	60.55
	50-59	-	-	-
PTSD	20-29	49.70	38.2-64.67	0
	30-39	19.32	14.82-25.18	0
	40-49	26.69	13.21-53.91	80.63
	50-59	-	-	-
	60-69	17.87	12.4-25.74	0

MERS: Middle East respiratory syndrome; PTSD: Post-traumatic stress disorder; CI: Confidence interval.

Table 7 Subgroup analysis on severe acute respiratory syndrome coronavirus-2 data based on different age groups

Subgroup-age	SARS-CoV-2
		Prevalence (%)	95%CI	Heterogeneity I2 (%)
Anxiety	10-19	34.40	33.17-35.68	0
	20-29	25.70	19.38-34.08	99.25
	30-39	22.86	17.86-29.26	99.64
	40-49	15.59	9.65-25.17	99.66
	50-59	20.13	10.43-38.84	99.42
	60-69	7.75	0.79-76.29	99.47
Depression	10-19	43.91	42.12-45.77	0
	20-29	31.03	24.04-40.04	99.12
	30-39	30.4	25.15-36.74	99.48
	40-49	20.0	13.26-30.18	99.4
	50-59	19.98	15.84-25.19	92.68
	60-69	4.93	3.45-7.05	90.00
PTSD	20-29	32.40	6.54-160.49	98.29
	30-39	21.96	12.77-37.78	99.33
	40-49	27.72	19.88-38.66	97.59
	50-59	5.38	3.76-7.69	0
	60-69	-	-	-

SARS-CoV-2: Severe acute respiratory syndrome coronavirus-2; PTSD: Post-traumatic stress disorder; CI: Confidence interval.

Table 8 Subgroup analysis on severe acute respiratory syndrome coronavirus data based on different age groups

Subgroup-age	SARS-CoV
		Prevalence (%)	95%CI	Heterogeneity I2 (%)
Anxiety	10-19	-	-	-
	20-29	-	-	-
	30-39	24.60	13.29-45.55	85.81
	40-49	15.63	10.97-22.26	60.57
	50-59	51.62	38.53-69.16	0
Depression	20-29	-	-	-
	30-39	27.47	16.09-46.9	89.58
	40-49	20.30	13.36-30.85	81.57
	50-59	22.49	14.8-34.17	0
	60-69	25.85	17.69-37.75	0
PTSD	20-29	24.43	15.53-38.44	72.18
	30-39	32.13	23.1-44.68	89.33
	40-49	11.68	8.45-16.15	86.20
	50-59	67.80	43.57-100	0
	60-69	7.54	2.64-21.54	53.28

SARS-CoV: Severe acute respiratory syndrome coronavirus; PTSD: Post-traumatic stress disorder; CI: Confidence interval.

Table 9 Subgroup analysis on Middle East respiratory syndrome data based on different type of people

Subgroup-occupation	MERS
		Prevalence (%)	95%CI	Heterogeneity I2 (%)
Anxiety	General Public	6.04	2.86-12.79	93.9
	HCW	-	-	-
	Patient	33.95	20.65-55.82	68.57
Depression	General Public	40.70	18.89-87.71	0
	HCW	20.52	11.81-35.67	41.71
	Patient	41.69	23.73-73.22	71.77
PTSD	General Public	19.02	14.01-25.81	0
	HCW	49.87	45.09-55.16	0
	Patient	37.70	27.47-51.74	0

MERS: Middle East respiratory syndrome; HCW: Healthcare worker; PTSD: Post-traumatic stress disorder; CI: Confidence interval.

Table 10 Subgroup analysis on severe acute respiratory syndrome coronavirus-2 data based on different type of people

Subgroup-occupation	SARS-CoV-2
		Prevalence (%)	95%CI	Heterogeneity I2 (%)
Anxiety	General Public	21.18	17.88-25.09	99.82
	HCW	22.35	17.42-28.66	99.36
	Patient	-	-	-
Depression	General Public	27.6	23.36-32.24	99.8
	HCW	27.71	23.22-33.08	98.79
	Patient	-	-	-
PTSD	General Public	24.83	14.97-41.18	99.67
	HCW	25.16	16.62-38.08	99.33
	Patient	-	-	-

SARS-CoV-2: Severe acute respiratory syndrome coronavirus-2; HCW: Healthcare worker; PTSD: Post-traumatic stress disorder; CI: Confidence interval.

Table 11 Subgroup analysis on studies under severe acute respiratory syndrome coronavirus data based on different type of people

Subgroup-occupation	SARS-CoV
		Prevalence (%)	95%CI	Heterogeneity I2 (%)
Anxiety	General Public	26.19	11.93-57.48	98.22
	HCW	98.44	22.67-427.49	0
	Patient	24.21	17.34-33.79	85.16
Depression	General Public	23.31	14.64-37.11	97.97
	HCW	25.42	13.74-47.03	90.29
	Patient	21.96	16.86-28.6	78.1
PTSD	General Public	18.36	13.59-24.81	81.69
	HCW	16.97	12.28-23.45	91.8
	Patient	19.80	14.28-27.46	90.44

SARS-CoV: Severe acute respiratory syndrome coronavirus; HCW: Healthcare worker; PTSD: Post-traumatic stress disorder; CI: Confidence interval.

Table 12 Sensitivity analysis for anxiety and depression studies under severe acute respiratory syndrome coronavirus-2

	Exposure	Outcome	Prevalence with 95%CI (before)	Prevalence with 95%CI (after)	P value
(g)	SARS-CoV-2	Anxiety	21.48 (18.66-24.71)	25.82 (23.98-27.8)	< 0.05
(h)	SARS-CoV-2	Depression	27.64 (24.59-31.06)	29.3 (26.98-31.81)	> 0.05

SARS-CoV-2: Severe acute respiratory syndrome coronavirus-2; CI: Confidence interval.