|Ahead of print publication
COVID-warriors: Psychological impact of the severe acute respiratory syndrome coronavirus 2 pandemic on health-care professionals
Prashant Jambunathan1, Manisha Jindal2, Priyadarshee Patra2, T Madhusudan3
1 Department of Medicine, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
2 Department of Psychiatry, Command Hospital (EC), Kolkata, West Bengal, India
3 Department of Psychiatry, Command Hospital (CC), Lucknow, Uttar Pradesh, India
|Date of Submission||25-Apr-2020|
|Date of Decision||17-May-2020|
|Date of Acceptance||11-Jun-2020|
|Date of Web Publication||16-Sep-2020|
Department of Psychiatry, Command Hospital (EC), 17/1E, Alipore, Kolkata - 700 027, West Bengal
Source of Support: None, Conflict of Interest: None
Background: The COVID-19 pandemic, caused by the Severe Acute Respiratory Syndrome Corona Virus 2 (SARS CoV-2) has the potential to affect the mental health of health-care professionals in several adverse ways, owing to a multifactorial, unprecedented volley of evolving factors. It may contribute to the elevated levels of depression, anxiety, and worry among the personnel on the frontline, who are often affected by medical and psychosocial factors, including pre-existing illness, scarcity of resources, uncertainty of outcome, prolonged working hours, lack of consensus, prevalent societal misbeliefs, prevailing stigma, and a constant threat to safety. Aim: The aim of this study was to screen health-care professionals for symptoms of depression, anxiety, and worry during SARS CoV-2 pandemic. Methods: In this cross-sectional study, a questionnaire was designed based on Patient Health Questionnaire-9, generalized anxiety disorder-7. It was disseminated through web-based and mobile-based social networks, thereby keeping in line with the social distancing and lockdown protocols. Results: Two hundred and fifty-seven participants were included in the study. Anxiety and depression were present in 23% (n = 59) and 16.8% (n = 43) of participants, respectively, most cases being mild in intensity. Nearly 56.4% (n = 145) of the participants reported that they were worried about COVID 19 pandemic, major cause of worry being risk of family and friends to be infected by COVID 19. About 40.9% (n = 105) participants reported sleep disturbances. Nearly 33.5% (n = 86) of participants reported increase in their smoking/alcohol consumption during lockdown. Conclusions: A significant proportion of health-care professionals experienced worry, sleep disturbances, anxiety, and depressive symptoms. Having clear guidelines, policies and procedures, training on infection control measures, occasional drills and being able to maintain communication with family members while in quarantine can go a long way in reducing worry and psychological impact of pandemic on health-care professionals.
Keywords: Anxiety, coronavirus, COVID-19, depression, generalized anxiety disorder-7, Patient Health Questionnaire-9, worry
|How to cite this URL:|
Jambunathan P, Jindal M, Patra P, Madhusudan T. COVID-warriors: Psychological impact of the severe acute respiratory syndrome coronavirus 2 pandemic on health-care professionals. J Mar Med Soc [Epub ahead of print] [cited 2020 Sep 29]. Available from: http://www.marinemedicalsociety.in/preprintarticle.asp?id=295222
| Introduction|| |
The severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) first identified in Wuhan, China, is now a global pandemic and has caused more than 100,000 deaths worldwide. As per the data given by the Ministry of Health and Family Welfare, India, as on date has 18,668 cases with 775 deaths. With a population of 1,387,297,452 million people and dismal patient–doctor ratio of 1:1456, Indian health-care professionals are shouldering the burden of this pandemic.
Experience from the 2003 SARS outbreak and early reports related to COVID-19 show that health-care workers experience considerable anxiety, stress, and fear.,, A Chinese study involving 180 health-care workers involved in care of COVID cases found substantial levels of anxiety and stress that adversely influenced sleep quality and self-efficacy.
In India, as lockdown protocols continue to be in force, closure of schools, offices, malls, and other areas of social interaction have resulted in an atmosphere of social isolation and vulnerability. The stigmatization of patients and health-care workers owing to the misinformation and fear is another major factor affecting the mental status of the health-care workers. Delivering timely and appropriate health care to the population, often while being shunned and chastised, with reduced family and social support, has set the stage for an ongoing psychological catastrophe among health-care professionals.
Hence, this study aims to assess the levels of worry, depression, and anxiety in health-care professionals, which can serve as important evidence to direct the promotion of mental well-being among health-care workers by timely implementation of remedial measures. Our endeavor is that this study can contribute to the Indian literature on the subject and act as a nidus for further research in this field.
| Methods|| |
The study participants comprised the health-care workers who were dealing in various capacities, with the COVID 19 pandemic. Doctors (medical officers, specialists, and subspecialists) and nurses working in various tertiary care and secondary care hospitals across India in which care to suspected/confirmed COVID patients were being provided were included in the study.
Collection of data
This cross-sectional survey was conducted in the 1st and 2nd week of April 2020 during the nationwide lockdown. Because it was not feasible to do a community-based national sampling survey during this special period, we collected the data online. An online self-administered anonymous questionnaire was administered. The data were collected through Google Forms by sharing of the link, electronically.
The combined questionnaire included questions related to demographical details such as age, sex and profession, one question asking about their sources of information regarding COVID-19 pandemic, 9-item scale of Patient Health Questionnaire-9 (PHQ-9), and 7-item scale of generalized anxiety disorder-7 (GAD-7). It also included five binary questions (1) are you directly involved in caring for COVID patients? (2) Do you think that your hospital is ready for handling COVID-19 cases? (3) Do you feel that you have enough knowledge and skills to handle COVID-19 cases? (4) Are you worried about the ongoing pandemic and if yes, what is the cause of the worry. (5) Do you feel that there has been an increase in consumption of alcohol or smoking during the lockdown? [Table 1] shows the detailed questionnaire.
Depression was assessed by administering the nine-item PHQ-9, a self-report version of Primary Care Evaluation of Mental Disorders that assesses the presence of major depressive disorder using the Modified Diagnostic and Statistical Manual, Fourth edition criteria.,, It assesses the symptoms experienced by participants during the 2-week period before they take the survey. On the basis of participant response to the frequency of any particular symptom (0 = not at all, 1 = several days, 2 = more than ½ of the days, 3 = nearly every day), a total score ranging from 0 to 27 was obtained, with higher scores indicating patients' increased self-report of depression severity. It was found to have sensitivity and specificity of 0.88 and 0.85, respectively, in a 2019 meta-analysis of 58 studies. PHQ-9 scores can be further categorized into ratings of minimal (0–4), mild (5–9), moderate (10–14) to severe depression (≥15).
Anxiety was assessed by GAD-7 which is a 7-item, self-rated validated scale,,,, as a screening tool and severity indicator for anxiety in primary care setting. The frequency is reported like PHQ-9 on a Likert scale. Scoring is categorized into minimal (0–4), mild (5–9), moderate (10–14) to severe depression (≥15). The sensitivity and specificity of GAD-7 for screening for generalized anxiety disorder are 89% and 82%, respectively.,
The approval of the Institutional Ethics Committee was obtained for the study. All participants voluntarily gave their informed consent to participate in the study after being informed about the purpose of the study telephonically. Participants had to answer a yes-no question to confirm their willingness to participate voluntarily. Those participants who had significant scores on depression and anxiety scales were encouraged individually, to seek psychiatric consultation.
| Results|| |
A total of 261 responses were received. Out of which, 4 were excluded from the study due to prior history of psychiatric illness to prevent confounding. Rest 257 participants were included in the study. Out of 257 participants, 183 were doctors and 74 were nurses. The characteristics of the study participants are shown in [Table 2].
Concerns and worries about COVID-19 pandemic
Nearly 72.7% (n = 186) said that government recommended sites were their main source of information about the COVID-19 pandemic.
In response to a binary question, 56.4% (n = 145) of the participants reported that they were worried about COVID-19 pandemic. The distribution of major causes of worry is shown in [Figure 1].
Level of anxiety in study participants
Of the 257 health-care professionals, 77% (n = 198) participants had no symptoms of anxiety, whereas 23% (n = 59) of participants showed anxiety symptoms and distribution mild, moderate, and severe anxiety is shown in [Figure 2].
Level of depression in study participants
Of the 257 health-care professionals, 83.2% (n = 214) participants had no symptoms of depression, whereas 16.8% (n = 43) of participants showed the symptoms of depression and distribution of mild, moderate, and severe depression is shown in [Figure 3].
Nearly 40.9% (n = 105) participants reported that they had trouble falling asleep/staying asleep or they are sleeping too much. 1.1% (n = 3) reported thoughts of death or of hurting themselves.
Effect on substance use
Nearly 33.5% (n = 86) of participants reported increase in their smoking/alcohol consumption during lockdown.
| Discussion|| |
This cross-sectional survey enrolled 257 health-care professionals (including 184 doctors and 73 nurses) and revealed a high prevalence of psychological symptoms in health-care workers during COVID-19 pandemic. Twenty-three percent (n = 59) of participants showed anxiety symptoms with mild, moderate, and severe anxiety in 15.6% (n = 40), 6.7% (n = 17), and 0.7% (n = 2), respectively. The results were comparable to a study based in Fujian, China, done by Wen Lua et al. with 2299 study participants which showed that 22.6% of medical staff showed mild-to-moderate anxiety and 2.9% severe anxiety.
In this study, depression was present in 16.8% (n = 43) of participants with mild, moderate, and severe depression in 11.7% (n = 30), 4% (n = 10), and 1.1% (n = 3), respectively. This is also comparable to that found by Wen Lua et al. which showed that 11.8% of the medical staff presented with mild-to-moderate depression, and 0.3% with severe depression out of 2299 study participants.
About 40.9% (n = 105) participants reported sleep disturbances in terms of initiation/maintenance of sleep or too much sleep. This was similar to study done by Jianbo Lai and Wang which reported insomnia in 34% of total 1257 health-care professionals.
Stress reactions, anxiety, depression, posttraumatic stress disorder, sleep disorders, and other psychological symptoms are observed commonly after the disaster. Resilience promotes physical, social, and emotional well-being and acts as an important protective factor. Altruistic acceptance of work reduces the negative impact. Symptoms of depression and anxiety are, to a large extent, a normal reaction to natural disaster. Most affected individuals recover with time, support, and reassurance without any psychotropic medication. Need for definitive treatment depends on the duration and severity of symptoms.
These psychological effects of pandemic, which is a natural disaster, can be related to many factors, including uncertainty about the duration of the crisis, lack of proven therapies or a vaccine, and potential shortages of health-care resources, including personal protective equipment. Varying levels of preparedness for the pandemic also contribute to the distress. In our study, 60.7% (n = 156) participants felt that their hospital is not ready for handling COVID-19 cases and another 71.3% (n = 183) participants felt that they have insufficient knowledge and skills to handle COVID-19 cases. Health-care workers are also distressed with the possibility of personal and family illness as reflected in this study where 56.4% (n = 145) of the participants reported they were worried about COVID-19 pandemic, major cause of worry being risk of family and friends to be infected by COVID-19. Many of them are staying away from families to reduce the risk of spread to families adding onto the distress. All these concerns are often amplified by the rapid dissemination of misinformation on the Internet and social media and by their own personal logistic and childcare issues. The resulting strain may be internalized and create anxiety and depression.
Nearly 33.5% (n = 86) of participants reported increase in their smoking/alcohol consumption during lockdown. Whether this is a maladaptive coping mechanism or contributing factor in psychological distress needs to be further investigated. However, this indicates the need for mental health professionals to be on high alert for increase in number of cases of substance abuse in coming times. A study done by Wu et al. showed that even 3 years after the SARS outbreak, the experience of being quarantined or having worked in high-risk locations such as SARS wards during the outbreak resulted in higher alcohol use symptom counts among health-care workers.
The strength of the study is the widespread sample size despite being in a critical state of COVID-19 outbreak. The results of the study need to be examined further among health-care professionals for broader generalization. Follow-up studies could help assess for progression or even a potential rebound effect of psychological manifestations once the imminent threat of COVID-19 subsides.
| Conclusions|| |
Based on the findings of the study, we recommend promotion of mental health among all health-care professionals. Lessons learnt from previous pandemics show that having clear guidelines, policies and procedures, training on infection control measures, occasional drills and having knowledge of how they fit into the whole operation reduces worry and anxiety-provoking uncertainty among health-care workers. Buddy systems pairing more experienced and less experienced health-care workers can help not only to transfer skills, but also to reduce social isolation and promote a sense of support.
Psychosocial programs that are mindful of providing services for the families of health-care workers and lending cellular phones, laptops, or tablets to health-care workers and their families to ensure they can maintain ongoing communication, can go a long way in protecting their morale. Furthermore, health-care workers should be regularly reminded and trained in infection control measures when they return home; for example, reminding staff of handwashing and to change clothes before entering their homes to protect family members. They should keep themselves updated about the latest COVID-19 guidelines provided by the World Health Organization and Center for Disease Control and Prevention as well as national policies to reduce worry arising out of lack of knowledge in handling such cases.
Health-care professionals should look after their mental health by avoiding substance abuse and excessive caffeine, practicing relaxation techniques, working in evenly spaced shifts with opportunity to rest in between whenever feasible keeping in mind scarcity of trained workforce and limiting exposure to misinformation by social media.,
Deaths and errors should be analyzed objectively instead of blaming or shaming members of the team to reduce risk of self-harm/mental stress in health-care professionals.
Challenges shall abound on the multiple levels, but there is no substitute for battle readiness.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Torales J, O'Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J Soc Psychiatry 2020. pii: 20764020915212.
Chen R, Chou KR, Huang YJ, Wang TS, Liu SY, Ho LY. Effects of a SARS prevention programme in Taiwan on nursing staff's anxiety, depression and sleep quality: A longitudinal survey. Int J Nurs Stud 2006;43:215-25.
Moldofsky H, Patcai J. Chronic widespread musculoskeletal pain, fatigue, depression and disordered sleep in chronic post-SARS syndrome; a case-controlled study. BMC Neurol 2011;11:37.
Wu KK, Chan SK, Ma TM. Posttraumatic stress, anxiety, and depression in survivors of severe acute respiratory syndrome (SARS). J Trauma Stress 2005;18:39-42.
Xiao H, Zhang Y, Kong D, Li S, Yang N. The effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (COVID-19) in January and February 2020 in China. Med Sci Monit 2020;26:e923549.
Daray FM, Hunter F, Anastasia A, Fornaro M. Psychometric properties of the Patient Health Questionnaire nine-item version (PHQ-9) for use among hospitalized non-psychiatric medical patients. Gen Hosp Psychiatry 2019;61:69-75.
Sakman F. Calculated decisions: Patient health questionnaire-9 (PHQ-9). Emerg Med Pract 2019;21:CD1-2.
Saldivia S, Aslan J, Cova F, Vicente B, Inostroza C, Rincon P. Psychometric characteristics of the Patient Health Questionnaire (PHQ-9). Rev Med Chil 2019;147:53-60.
Pierson ME, Prenoveau JM, Craske MG, Netsi E, Stein A. Psychometric properties of the Generalized Anxiety Disorder Questionnaire-IV (GAD-Q-IV) in postpartum mothers. Psychol Assess 2017;29:1391-9.
Toussaint A, Husing P, Gumz A, Wingenfeld K, Harter M, Schramm E, et al
. Sensitivity to change and minimal clinically important difference of the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7). J Affect Disord 2020;265:395-401.
Ruiz MA, Zamorano E, Garcia-Campayo J, Pardo A, Freire O, Rejas J. Validity of the GAD-7 scale as an outcome measure of disability in patients with generalized anxiety disorders in primary care. J Affect Disord 2011;128:277-86.
Sousa TV, Viveiros V, Chai MV, Vicente FL, Jesus G, Carnot MJ, et al.
Reliability and validity of the Portuguese version of the generalized anxiety disorder (GAD-7) scale. Health Qual Life Outcomes 2015;13:50.
Tiirikainen K, Haravuori H, Ranta K, Kaltiala-Heino R, Marttunen M. Psychometric properties of the 7-item Generalized Anxiety Disorder Scale (GAD-7) in a large representative sample of Finnish adolescents. Psychiatry Res 2019;272:30-5.
Sawaya H, Atoui M, Hamadeh A, Zeinoun P, Nahas Z. Adaptation and initial validation of the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 Questionnaire (GAD-7) in an Arabic speaking Lebanese psychiatric outpatient sample. Psychiatry Res 2016;239:245-52.
Wen Lua HW, Linc Y, Lia L. Psychological status of medical workforce during the COVID-19 pandemic: A cross-sectional study. Psychiatry Res 2020;288:3.
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al
. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA network open 2020;3:e203976.
Huremović D. Mental health of quarantine and isolation. In: Huremović D, editor. Psychiatry of Pandemics: A Mental Health Response to Infection Outbreak. 1st
ed.., Vol 1. Switzerland: Springer International Publishing; 2019. p. 100-5.
Wu P, Fang Y, Guan Z, Fan B, Kong J, Yao Z, et al
. The psychological impact of the SARS epidemic on hospital employees in China: Exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry 2009;54:302-11.
Wu P, Liu X, Fang Y, Fan B, Fuller CJ, Guan Z, et al
. Alcohol abuse/dependence symptoms among hospital employees exposed to a SARS outbreak. Alcohol Alcoholism 2008;43:706-12.
Wong EL, Wong SY, Lee N, Cheung A, Griffiths S. Healthcare workers' duty concerns of working in the isolation ward during the novel H1N1 pandemic. J Clin Nurs 2012;21:1466-75.
Greenberg N, Docherty M, Gnanapragasam S, Wessely S. Managing mental health challenges faced by healthcare workers during covid-19 pandemic. BMJ 2020;368:m1211.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]