After escaping from "the gates of hell", as some patients and doctors graphically described their encounter, a number of those who have recovered from the disease are still finding it difficult to resume their normal lives.

Many of the recovered patients are encountering problems of differing degrees, said Gao Wenbin, a psychologist with the Institute of Psychology under the Chinese Academy of Sciences, and who heads a research project on the psychological state of such patients.

Gao and his colleagues have had consultations with 20 discharged patients and offered counseling to 15.

Two showed signs of clinical depression.

They are not the only psychologists offering their expertise to those who may have recovered their physical health, but still carry invisible hurts.

Wei Jing, an associate professor of psychology with Peking Union Medical College Hospital, and her colleagues have also set up a special psychological intervention program.

Society needs such a service, she said.

The victims

Wei said she and her colleagues found that some of the recovered SARS patients were experiencing emotional problems, psychological barriers, difficulty in adapting, and more disturbingly anxiety, depression and post-traumatic stress disorder.

The problems vary from one person to another, from one family to another.

For example, a young nurse who contracted SARS at work, and now fully recovered refuses to go home, irrationally fearing she may infect her family.

Her abnormal fears have left her family totally perplexed as they just only want to care for her.

The worst psychological traumas have, not surprisingly, been found in those recovered patients whose family members died of the disease.

One man who recovered from SARS, but whose beloved wife died after contracting it while caring for him, has profound problems.

After his recovery, the guilt ridden father did not know how to explain to his nine-year-old son what had happened.

"It was undoubtedly the worst situation. The man may be prone to serious psychological troubles," said Gao.

Another man told Gao and his colleagues how he could not shake off the mental burden of having been a SARS patient. He described how each time he went out he became convinced passers-by were looking at him oddly.

"The discrimination simply came from himself and it was he who had labeled himself," said Gao.

For some people, returning to work can lead to problems, both real and imaginary. Those who had worked for privately owned firms or owned their own business, suddenly found it hard to pick up where they had left off in their business relationships. People experiencing these sorts of problems were among the first calls for counseling Gao and his colleagues received.

While those in more secure jobs, such as in state-owned enterprises or working for the government, tended to be at less of a risk of developing psychiatric problems. This, said Gao, highlighted the need for society to help those who have since lost their jobs, especially migrant workers, among the poorest and most vulnerable groups in society.

Gao said there is a gap between patients' expectations of society and the reality when they are discharged. He believes this is a major contributing factor to the manifest psychological problems.

Some patients lower their expectations about their lives outside hospital and over-exaggerate the problems they will encounter. This phenomenon was especially significant among college students.

For them, although the disease itself was a thing of the past, they found themselves worrying about school work, if they would fail to graduate, or whether the stigma of SARS would jeopardize their career prospects.

"They gave too much thought to such things," said Gao. In particular the question mark over SARS affecting their getting a job. "This worry is totally unnecessary, for their history of contracting SARS would not be recorded (on their personal files), " he explained.

Other patients went to the other extreme, expecting a special level of care and attention from others. When they found themselves being treated no differently they felt depressed and rejected.

"It is just like jumping from a 2-metre-high platform. If you are fully prepared, then nothing will happen to you. However, if you are not, you might have a nasty accident," said Gao.

To try and address some of the difficulties each discharged patient is being given a psychological prescription.

The families

Many family members who did not contract SARS may also experience some kind of psychological crisis.

Paying a last visit to see the dead is an age-old tradition which serves to relieve the fear and pressure of relatives. But as mystery still surrounds the SARS virus, those who die from the disease are immediately cremated and the usual rituals foregone. This derogation has added to the grief of many, explained Gao.

Another problem has worried relatives whose family members continue to experience a residue of the symptoms of SARS, such as temperature fluctuations, coughing and breathing difficulties.

"They are just at a loss what to do," he said.

For most of the recovered, few have been shunned by their families.

On the contrary, "The family mainly showed excessive care for the patients when they returned home," said Gao.

The medical workers

Despite their training and generally better level of understanding, medical workers have not escaped the psychological problems. They were among the worst affected groups, suffering many infections and fatalities.

When treating and caring for the SARS patients, many medical workers were sometimes left at a loss what to do when their patients condition worsened abruptly.

They felt a sense of helplessness and questioned their very roles, Gao said.

According to the institute's survey of 250 medical workers in Xiaotangshan Hospital, about 10 percent of them developed what Gao and his colleagues term psychological troubles.

In those hospitals hit by the SARS outbreak, some medical workers spoke of their terror, how they could not help trembling the first day they returned to work after recovering from SARS.

The sheer fatigue experienced by many, the suspension of normal life and relationships, in a way exemplified by the impersonal layers of protective garb they had to wear, all combined to harm their mental well-being.

The public also needs to shed its fear of SARS.

The unprecedented level of publicity, images of masks and quarantine, reports concerning the infectious nature of the disease, are all ingrained on the minds of the public.

Intervention

The battle against the virus is all but won this season, but long-term damage lingers.

"The end of the SARS epidemic does not necessarily mean that the psychological impact it has created will disappear accordingly," said Professor Wei.

"It requires a long process of psychological rebuilding, not only for the recovered and their families."

Now a year-long project at her hospital, which began last Tuesday, is attempting to help the recovered rebuild their psychological health, and ensure no shadow is left over their minds.

In face-to-face talks with former SARS patients, Wei and her colleagues give them a chance to reflect on all their feelings - from their sometimes life-and-death struggles in hospital, to the period of isolation after returning home, and then a return to normal life.

"The psychological intervention is mainly based on talks, but sometimes can be supplemented with drugs depending on the individual patients," said Wei.

In addition to Peking Union Medical College Hospital, other specialist mental hospitals in the capital, including the Huilongguan Hospital, the Sixth Hospital affiliated to Peking University and Anding Hospital, have also opened consultative outpatient departments for ex-SARS patients.

Despite the availability of these services few people have come for counseling.

"We have only received two patients since the opening day of the special department," said Ma Zheng, a senior doctor at Anding Hospital.

Numbers at the Peking Union Medical College Hospital were higher, because it is one of the best general hospitals.

In collaboration with Xiaotangshan Hospital and the Sino-Japanese Friendship Hospital, the CAS' Institute of Psychology also initiated in early June a project named "Psychological intervention of SARS patients and medical workers," to provide long-time psychological support for discharged SARS patients.

In the coming weeks, doctor Gao and his colleagues will continue to provide help on their hot-line.

(China Daily July 2, 2003)