title: Psychological Distress among Ebola Survivors Discharged from an Ebola Treatment Unit in Monrovia, Liberia - A Qualitative Study.
abstract: BACKGROUND
  A consequence of the West Africa Ebola outbreak 2014-2015 was the unprecedented number of Ebola survivors discharged from the Ebola Treatment Units (ETUs). Liberia alone counted over 5,000 survivors. We undertook a qualitative study in Monrovia to better understand the mental distress experienced by survivors during hospitalization and reintegration into their community.
  
  
  METHODS
  Purposively selected Ebola survivors from ELWA3, the largest ETU in Liberia, were invited to join focus group discussions. Verbal-informed consent was sought. Three focus groups with a total of 17 participants were conducted between February and April 2015. Thematic analysis approach was applied to analyze the data.
  
  
  RESULTS
  The main stressors inside the ETU were the daily exposure to corpses, which often remained several hours among the living; the patients' isolation from their families and worries about their well-being; and sometimes, the perception of disrespect by ETU staff. However, most survivors reported how staff motivated patients to drink, eat, bathe, and walk. Additionally, employing survivors as staff fostered hope, calling patients by their name increased confidence and familiarity, and organizing prayer and singing activities brought comfort. When Ebola virus disease survivors returned home, the experience of being alive was both a gift and a burden. Flashbacks were common among survivors. Perceived as contagious, many were excluded from their family, professional, and social life. Some survivors faced divorce, were driven out of their houses, or lost their jobs. The subsequent isolation prevented survivors from picking up daily life, and the multiple losses affected their coping mechanisms. However, when available, the support of family, friends, and prayer enabled survivors to cope with their mental distress. For those excluded from society, psychosocial counseling and the survivor's network were ways to give a meaning to life post-Ebola.
  
  
  CONCLUSIONS
  Exposure to death in the ETU and stigma in the communities induced posttraumatic stress reactions and symptoms of depression among Ebola survivors. Distress in the ETU can be reduced through timely management of corpses. Coping mechanisms can be strengthened through trust relationships, religion, peer/community support, and community-based psychosocial care. Mental health disorders need to be addressed with appropriate specialized care and follow-up.
authors.affiliation: Monrovia Project, Médecins Sans Frontières - Operational Centre Brussels , Monrovia , Liberia.
authors.forename: Ionara
authors.initials: I
authors.lastname: Rabelo
authors.affiliation: Monrovia Project, Médecins Sans Frontières - Operational Centre Paris , Monrovia , Liberia.
authors.forename: Virginia
authors.initials: V
authors.lastname: Lee
authors.affiliation: The Liberian-U.S. Joint Clinical Research Partnership/National Institute of Health Bethesda, Maryland, Liberia; Ministry of Health and Social Welfare, Monrovia, Liberia.
authors.forename: Mosoka P
authors.initials: MP
authors.lastname: Fallah
authors.affiliation: Ministry of Health and Social Welfare, Monrovia, Liberia; Clinton Health Access Initiative, Monrovia, Liberia.
authors.forename: Moses
authors.initials: M
authors.lastname: Massaquoi
authors.affiliation: Monrovia Project, Médecins Sans Frontières - Operational Centre Brussels , Monrovia , Liberia.
authors.forename: Iro
authors.initials: I
authors.lastname: Evlampidou
authors.affiliation: Operational Department, Médecins Sans Frontières, Operational Centre Brussels , Brussels , Belgium.
authors.forename: Rosa
authors.initials: R
authors.lastname: Crestani
authors.affiliation: Medical Department, Médecins Sans Frontières, Operational Centre Brussels , Brussels , Belgium.
authors.forename: Tom
authors.initials: T
authors.lastname: Decroo
authors.affiliation: Medical Department, Médecins Sans Frontières, Operational Centre Brussels , Brussels , Belgium.
authors.forename: Rafael
authors.initials: R
authors.lastname: Van den Bergh
authors.affiliation: Medical Department, Médecins Sans Frontières, Operational Centre Brussels , Brussels , Belgium.
authors.forename: Nathalie
authors.initials: N
authors.lastname: Severy
keywords: Ebola virus disease; Liberia; emergency response; psychological distress; qualitative research