The Cost Nobody Invoices: Psychological Burden, Clinical Evidence, and What It Asks of a Technician

1. Introduction: the uncounted cost

The economic analysis published elsewhere in this journal noted that the health burden of infestation is a cost no model has seriously attempted to price, and that including tenant costs would strengthen the case for early and thorough intervention. This paper takes that thread seriously and asks what the clinical literature actually establishes.

The subject sits awkwardly for a pest control company. It concerns matters outside our competence, it is easy to sensationalise, and doing so would serve our commercial interest. We have tried to resist that, and the central finding of this paper is in fact a corrective to the way the evidence is usually presented.

2. What the scoping review found

The most systematic treatment is a scoping review published in the International Journal of Public Health.¹

The review employed a five stage methodology to systematically map the literature, resulting in 51 articles detailing psychological distress associated with bed bugs.¹

2.1 The proportions

The review found that infestations can lead to insomnia, anxiety, PTSD and depression, affecting 54.9 per cent of the identified articles.¹ Diagnosable psychiatric disorders were described in 15 articles, or 29.4 per cent, and 7 articles, 13.7 per cent, described serious psychiatric manifestations.²

2.2 How to read those numbers

An important caveat, and one the figures themselves invite. These are proportions of articles, not proportions of affected people. An article reporting a diagnosable disorder in one patient counts the same as one reporting a population survey.

What the distribution establishes is that the clinical literature on this subject exists, is reasonably substantial, and spans from general distress through to serious presentations. It does not establish prevalence in the infested population.

2.3 The context of the resurgence

The review situates the problem within the global resurgence since the mid-1990s, noting that between 2000 and 2006 Australia experienced a reported increase in infestations of 4,500 per cent.¹ A change of that magnitude means a great many households encountered the problem with no cultural memory of it, which is relevant to §5.

3. The PTSD study, read carefully

The single most cited primary source in this area is Goddard and de Shazo, published in the American Journal of Medicine.³ It is also, in our view, the most frequently misquoted.

3.1 The method

The authors used a previously published PTSD checklist to analyse online blogs and other internet sites where bed bug postings occur, assessing postings for evidence of emotional trauma. One hundred and thirty five postings were read and analysed.³

3.2 The results in full

110 of the 135 postings, or 81 per cent, reported psychological effects from bed bug infestations. Scoring with the PTSD checklist revealed a range of 0 to 52, with a mean of 13.25 and a standard deviation of 9.38. One met the criteria, a score of 50 or above, considered positive for PTSD.³

The authors' own conclusion is appropriately hedged: based on their survey of online postings, an as yet to be determined proportion of individuals who experience bed bug bites develop moderate to severe negative emotional symptoms after infestations.³

3.3 What the study actually supports

It supports the claim that psychological effects are very commonly reported by people discussing infestation online. It does not support the claim that infestation commonly causes diagnosable PTSD, and the authors do not make that claim.

The mean score of 13.25 against a positive threshold of 50 is the number that gets omitted when this paper is cited, and it is the number that gives the result its shape.

4. Why the distinction matters

We want to be explicit about why we are labouring this point, because it may look like a company minimising a problem it profits from.

Overstatement is falsifiable. A trade claim that infestations cause PTSD invites a clinician to check, find the mean score of 13.25, and discount everything else the industry says about health impacts. Accuracy is the stronger position.

The real finding is strong enough. Eighty one per cent of people posting about infestation reported psychological effects.³ That is a substantial burden on its own terms and needs no inflation.

Conflation obscures the people who are seriously affected. If ordinary distress is described in the same terms as psychiatric emergency, the minority experiencing the latter become harder to identify rather than easier.

Methodological limits deserve stating. Postings on bed bug forums are not a random sample of infested households. People in acute distress are more likely to be posting.³

5. The symptom picture

The clinical descriptions are consistent across sources and worth setting out plainly, because they explain behaviour that technicians encounter and frequently misread.

Psychological sequelae reported include nightmares, flashbacks, hypervigilance to keep the bugs away, insomnia, anxiety, avoidance behaviours and personal dysfunction.³⁴

A broader list from the emergency medicine literature adds sleep disturbances, mood changes, panic, agitation, phobias, delusions and social withdrawal.⁵

5.1 Why hypervigilance makes sense

Hypervigilance is the symptom most worth understanding, because it is the one most likely to be mistaken for unreasonableness.

A person who is bitten at night while asleep has experienced a threat that occurs specifically when they are unconscious and defenceless, in the place they are supposed to be safest. Remaining alert at that time is not irrational. It is an appropriate response to the actual situation, which happens also to be the response that prevents sleep.

5.2 The functional consequences

Infestations and the associated fear can lead to substantial decreases in work-related productivity and quality of life.⁴ Psychiatric manifestations may include new-onset depression, anxiety and insomnia as well as exacerbation of underlying psychiatric illness.⁴

That last clause matters for §6. The effect is not uniform. It depends substantially on where a person was before the infestation started.

6. Populations at elevated risk

The distribution of harm here follows the same pattern identified in the economics analysis published elsewhere in this journal.

Vulnerable populations, including people experiencing homelessness and those with pre-existing mental health conditions, are at greater risk of suffering significant mental health impacts from infestations.¹

Psychiatric manifestations can depend on a patient's level of functioning prior to infestation.⁴ And persons who live in poverty and in urban areas can have higher rates of pre-existing mental health conditions and distress from increased anxiety and stress.⁵

6.1 The compounding

Assemble those findings and the picture is uncomfortable. The households most likely to experience infestation, because they are in older multi-unit rental housing, are also those with the highest baseline rates of the conditions infestation exacerbates, and the least capacity to fund a private solution.

Bed bugs can exacerbate a person's stress, adversely affect quality of life, and may cause or worsen an existing mental health condition.⁵

7. Serious outcomes

The literature does report severe presentations, and we report them here because a paper on this subject that omitted them would be dishonest.

Impairment may be of sufficient severity to cause suicidality and warrant inpatient hospitalisation.⁴ Reports in the emergency medicine literature include suicide among the associated outcomes.⁵

These are the minority presentations captured in the 13.7 per cent of articles describing serious psychiatric manifestations.²

7.1 The appropriate response

Nothing in this paper equips a pest control technician to assess psychiatric risk, and we are not suggesting otherwise. The relevant professional conclusion is narrower: the conclusion of this literature is that the psychiatric implications are important to consider and treat when attempting to control and contain infestations,⁴ which means the clinical side belongs with clinicians and the coordination belongs with whoever is managing the building.

Where a resident appears to be in serious difficulty, the correct action for an operator is to ensure the property manager or the appropriate health service is aware, not to attempt an assessment. That is a low bar and it is one the industry does not currently teach.

8. Where the literature disagrees

The evidence is not unanimous and it would be misleading to present it as such.

Few research or epidemiological investigations have evaluated the psychological effects of bed bugs, and most of what has been published is anecdotal.⁵ While some published reports suggest association with insomnia, anxiety, depression and PTSD-like symptoms, other reports show no association between insomnia and depression related to bed bug infestations.⁵

8.1 How to hold both

Disagreement of this kind usually reflects differences in population, measure and design rather than contradiction. A cross-sectional survey of an urban infested population and an emergency department sample are measuring different things in different people.

The stronger studies use validated instruments. Two of the five articles focused exclusively on mental health effects applied DSM-IV criteria, one for PTSD symptoms and one for depression and anxiety symptoms.² That is the methodological standard the field should be judged against, and much of the literature does not meet it.

8.2 The current direction

The field is still active. A 2025 cross-sectional survey in Lyon examined predictors of bed bug-related stress in people who had experienced a recent infestation, framing the problem in terms of lower quality of life, insomnia and symptoms that may resemble those of post-traumatic stress disorders.⁶

The phrase may resemble is doing careful work there, and it is the right formulation.

9. The reflexive case

One finding inverts the usual direction of causation and has direct operational relevance.

In certain individuals, a perceived but unconfirmed infestation may indicate the onset of psychosis.⁴ The literature distinguishes actual from feared and perceived infestations for precisely this reason.²

9.1 The harm of treating anyway

It is commercially easy to treat a unit where nothing has been found. The client is distressed and wants action, and a treatment is what we sell.

Doing so applies pesticide for no entomological reason, confirms a belief that the inspection contradicted, and delays a person from reaching help they may need. The correct action is to report the finding accurately, offer monitoring so the question stays open and testable, and decline to treat.

10. The feedback loop with control

There is a practical reason the psychological dimension cannot be filed separately from the technical one.

Preparation is a substantial determinant of outcome, as set out in the residential material elsewhere on this site. Preparation requires sustained organised effort, frequently over days, in the place where the person is not sleeping.

A resident experiencing insomnia, anxiety and functional impairment⁴ is being asked to perform exactly the kind of task their condition most impairs. When preparation is incomplete, treatment reaches less of the population, the infestation persists, and the persistence confirms the belief that nothing will work.

10.1 The implication

Where a resident is struggling, the intervention with the highest return may be help with preparation rather than a further treatment. That is an unusual thing for a pest control company to conclude, and it follows directly from the evidence.

11. What this asks of a technician

Nothing clinical. Several things that are simply competent.

Treat reported distress as information rather than as noise. It is the most commonly reported consequence in the literature.³

Understand hypervigilance before judging it. A client checking the bed repeatedly is responding rationally to a threat that occurs while they sleep.

Give honest timelines. False reassurance produces a second disappointment, and the persistence of the problem is what drives the distress.

Be specific about what was found. Ambiguity feeds hypervigilance. A clear statement of what was inspected and what was present is more useful than a vague reassurance.

Say when there is nothing. Per §9, an honest negative is the finding, and treating anyway is the wrong answer.

Escalate rather than assess. Where someone appears to be in serious difficulty, make sure the property manager or an appropriate service knows.

Do not moralise about clutter. Clutter is a preparation problem to be solved, and in some cases it is a symptom rather than a cause.

12. What it asks of landlords and institutions

The larger share of the response sits with whoever controls the building.

Speed is a health intervention. If distress scales with duration, then the interval between report and resolution is a health variable and not only a cost one.

Preparation support is cheap relative to repeat treatment. Given §10, assistance with preparation may improve outcomes more than another visit, and it costs less.

Communication reduces harm at no cost. Residents told what is happening and when are not managing uncertainty on top of infestation.

The distributional point. Because risk concentrates in the same populations that carry higher baseline vulnerability,¹⁵ social and supportive housing providers are handling the highest-consequence version of this problem, usually with the least resource.

13. Limitations and open questions

The primary evidence base is thin. The emergency medicine literature states plainly that few research or epidemiological investigations have evaluated these effects and that most published material is anecdotal.⁵ We have tried to reflect that rather than write around it.

The most-cited study analysed online postings. That is a self-selected sample skewed toward acute distress, and the authors present their conclusion as an undetermined proportion.³

Article proportions are not people proportions. The scoping review figures describe the literature, not the infested population.¹²

No prevalence estimate exists that we could find. Nobody appears to have measured what fraction of infested households experience clinically significant distress, which is the number that would actually be needed to price this cost.

We are not clinicians. This is a review of published literature by a pest control company. Nothing here is clinical guidance, and the practice recommendations in §11 are deliberately confined to communication and escalation.

Our commercial interest runs one way. Emphasising harm supports demand for our services. We have tried to counterweight that by making the central argument a correction against overstatement.

14. Conclusion

A scoping review of 51 articles found that 54.9 per cent reported insomnia, anxiety, PTSD or depression, 29.4 per cent described diagnosable psychiatric disorders and 13.7 per cent described serious manifestations.¹² In the most cited primary study, 110 of 135 postings reported psychological effects, while the mean PTSD checklist score was 13.25 against a positive threshold of 50 and exactly one posting met full criteria.³

The accurate summary is that distress is common and formal diagnosis is rare. Both halves matter. The first is why this is a real burden that belongs in any honest accounting of what an infestation costs. The second is why the industry should stop reaching for the word trauma, which invites a clinician to check the number and discount everything else we say.

The burden falls hardest on people with pre-existing conditions and those experiencing homelessness,¹ which is the same population that carries the highest infestation risk and the least capacity to pay for a private solution. And it feeds back into control, because the impairment infestation produces is precisely the impairment that makes preparation hard.

None of this makes a pest control technician a clinician, and the practical asks are modest: give honest timelines, be specific about findings, say plainly when an inspection found nothing rather than treating anyway, and make sure someone knows when a person appears to be in serious difficulty. That is not a clinical role. It is the ordinary competence the evidence suggests the situation requires, and it is more than the trade currently teaches.

References

1. Ashcroft, R., Seko, Y., Chan, L.F., Dere, J., Kim, J. & McKenzie, K. (2015). The mental health impact of bed bug infestations: a scoping review. International Journal of Public Health, 60(7), 827–837. doi:10.1007/s00038-015-0713-8. Source for the five stage methodology identifying 51 articles, the finding that infestations can lead to insomnia, anxiety, PTSD and depression across 54.9 per cent of identified articles, the elevated risk to people experiencing homelessness and those with pre-existing mental health conditions, and the reported 4,500 per cent increase in Australian infestations between 2000 and 2006. https://www.academia.edu/15543925/The_mental_health_impact_of_bed_bug_infestations_a_scoping_review
2. Psychiatric Consequences of Actual Versus Feared and Perceived Bed Bug Infestations: A Case Series Examining a Current Epidemic. Source for diagnosable psychiatric disorders described in 15 articles (29.4 per cent) and serious psychiatric manifestations in 7 articles (13.7 per cent), the identification of five articles focused exclusively on mental health effects, and the use of DSM-IV validated criteria for PTSD symptoms by Goddard and de Shazo and for depression and anxiety symptoms by Susser and colleagues. https://www.researchgate.net/publication/221726137_Psychiatric_Consequences_of_Actual_Versus_Feared_and_Perceived_Bed_Bug_Infestations_A_Case_Series_Examining_a_Current_Epidemic
3. Goddard, J. & de Shazo, R. (2012). Psychological Effects of Bed Bug Attacks (Cimex lectularius L.). The American Journal of Medicine, 125(1), 101–103. doi:10.1016/j.amjmed.2011.08.010. Source for the analysis of 135 online postings using a published PTSD checklist, the finding that 110 postings (81 per cent) reported psychological effects, the score range of 0 to 52 with mean 13.25 and standard deviation 9.38, the single posting meeting the positive threshold of 50, the symptom list including nightmares, flashbacks, hypervigilance, insomnia, anxiety, avoidance behaviours and personal dysfunction, and the authors' hedged conclusion. https://www.amjmed.com/article/S0002-9343(11)00749-2/fulltext
4. Human Health Considerations: Mental Health Effects. Bed bug research reference collection, The Ohio State University. Source for psychiatric manifestations depending on level of functioning prior to infestation, new-onset depression, anxiety and insomnia alongside exacerbation of underlying psychiatric illness, substantial decreases in work-related productivity and quality of life, impairment of sufficient severity to cause suicidality and warrant inpatient hospitalisation, the observation that a perceived but unconfirmed infestation may indicate onset of psychosis, and the conclusion that psychiatric implications are important to consider and treat when attempting to control infestations. https://u.osu.edu/bedbugs/research-refs/health/mental-health-effects/
5. Associations Between Bed Bugs and Mental Illness Among Emergency Department Patients. Source for the observation that few research or epidemiological investigations have evaluated these effects and most published material is anecdotal, the broader symptom list including sleep disturbances, mood changes, panic, agitation, phobias, delusions, social withdrawal, suicide and PTSD-like symptoms, the finding that other reports show no association between insomnia and depression related to infestations, and the elevated baseline rates of mental health conditions among people living in poverty and in urban areas. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8198719/
6. Barbalat and colleagues (2025). Predictors of bed bug-related stress in people who have experienced a recent infestation: results from a cross-sectional survey in the city of Lyon, France. Pest Management Science. doi:10.1002/ps.8731. Source for the current framing of infestation consequences as lower quality of life, insomnia and symptoms that may resemble those of post-traumatic stress disorder. See also Susser, S.R., Perron, S., Fournier, M., Jacques, L., Denis, G., Tessier, F. & Roberge, P. (2012), Mental health effects from urban bed bug infestation, BMJ Open, 2, e000838. https://scijournals.onlinelibrary.wiley.com/doi/10.1002/ps.8731