|Year : 2021 | Volume
| Issue : 1 | Page : 31-36
Mental health problems among health-care workers during the COVID-19 pandemic
Anil Bindu Sukumaran1, L Manju1, Regi Jose1, Meghana Narendran1, C Padmini2, P NazeemaBeevi1, Divija Vijith1, R Beena Kumari3, Shilpa Prakash1, Jithu S. J. Nath1, PV Benny1
1 Department of Community Medicine, Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala, India
2 Department of Psychiatry, Government Medical College, Kannur, Kerala, India
3 Department of Physiology, Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala, India
|Date of Submission||18-Aug-2020|
|Date of Decision||16-Sep-2020|
|Date of Acceptance||03-Apr-2021|
|Date of Web Publication||29-Jun-2021|
Dr. Anil Bindu Sukumaran
Sree Gokulam Medical College and Research Foundation, Thiruvananthapuram, Kerala
Source of Support: None, Conflict of Interest: None
Introduction: As the pandemic of COVID-19 stretches, its wings across the different parts of the world over the past few months, it is very likely that mental health problems increase, particularly among the health-care workers who have higher risk of exposure to the disease and also to sufferings of the people affected with the disease.
Objective: To assess the prevalence and factors associated with depression, anxiety, and stress among health-care workers from Kerala during the COVID-19 pandemic.
Materials and Methods: A cross-sectional study among 544 health-care workers from Kerala was conducted by a self-administered online questionnaire in Google Forms by chain referral sampling with Depression, Anxiety, and Stress Scale-21 scale during initial phase of the COVID-19 pandemic. The tests of significance used were Mann–Whitney U-tests and Kruskal–Wallis tests. Odds ratios and 95% confidence interval are estimated.
Results: During the early pandemic period, 9.7% of health-care workers had mild depression and 13.3% had moderate-to-severe depression. While 4% had mild anxiety and 3.5% had moderate-to-severe anxiety, about 6.8% had mild stress and 6.4% had moderate-to-severe stress. The anxiety symptoms were significantly higher among nurses compared to doctors. Emotional and social support from higher health authorities is a significant protective factor against stress and depression. Frontline workers have 84% higher risk to have depression.
Conclusions: Frontline health-care workers who are directly involved in the screening, diagnosis, treatment, and care for patients with COVID-19 are at higher risk of experiencing poor mental health outcomes. Emotional and social support from higher health authorities is a significant protective factor against depression and stress among health-care workers.
Keywords: Anxiety, COVID-19, depression, health care workers, Kerala, stress
|How to cite this article:|
Sukumaran AB, Manju L, Jose R, Narendran M, Padmini C, NazeemaBeevi P, Vijith D, Kumari R B, Prakash S, Nath JS, Benny P V. Mental health problems among health-care workers during the COVID-19 pandemic. Indian J Community Fam Med 2021;7:31-6
|How to cite this URL:|
Sukumaran AB, Manju L, Jose R, Narendran M, Padmini C, NazeemaBeevi P, Vijith D, Kumari R B, Prakash S, Nath JS, Benny P V. Mental health problems among health-care workers during the COVID-19 pandemic. Indian J Community Fam Med [serial online] 2021 [cited 2021 Dec 6];7:31-6. Available from: https://www.ijcfm.org/text.asp?2021/7/1/31/319967
| Introduction|| |
Millions of people across the world are facing challenges due to COVID-19 since the past few months. The novel coronavirus disease emerged in December 2019 in Wuhan, China. Since then, the virus has been threatening the health and lives of millions of people. High communicability of disease with the possibility of causing severe respiratory disease and lack of specific treatment has quickly affected health systems in many countries. Director-General of the World Health Organization declared that the outbreak of novel coronavirus as Public Health Emergency of International Concern On January 30, 2020. The COVID-19 disease has achieved pandemic status. On May 19, 2020, there were 4,731,458 cases of COVID-19 and 316,169 deaths in the world. Many countries including India adopted extraordinary measures such as lockdown and social distancing to prevent the spread and limit the outbreak. The lives of millions of people had a drastic change globally during the past few months during the COVID-19 pandemic.
As the pandemic of COVID-19 continue to spreads in the different parts of the world over the past few months, it is likely that mental health problems increase among people, and this may be particularly high among the health-care professionals who have higher risk of exposure to the disease and also to sufferings of the people affected with the disease. The health-care workers are involved in triaging, diagnosing, treating, and caring patients who may have the infection, which they are not sure till the person gets tested and diagnosed for COVID-19. There may be many asymptomatic and mildly symptomatic cases, who are not diagnosed. Health-care workers face them frequently and hence may have an increased risk of contracting COVID-19 infection, while most of the population is sitting inside. On a positive note, health-care workers are likely to feel much positive experiences such as pride and satisfaction in taking part in the big war against COVID-19 and they consider this as service to humanity in the face of the pandemic. Even without considering their risk of being infected, they show great altruism and dedication in the work setting. However, the psychological feelings of fear of being infected and risk of infecting family and friends along with many other stressors such as stigmatization toward the health-care providers working with COVID-19 patients, physical strain of personal protective equipment, and higher demands in work setting may lead to increasing levels of stress, anxiety, and depression.
Across the world, many health care workers get affected by the disease, leading to the loss of their lives. Among the health-care workers, in different studies showed that 14%–15% had clinically relevant (that is, moderate or severe) depression, and was 12%–24% had anxiety.,
Kerala, a small state in the southern end of India, which has a population of nearly 37 million, is known for its high literacy and relatively good health indicators. The first case in India was reported on January 30 in Kerala in a student who returned from Wuhan, China.
Three months after the first case, Kerala is managing well and keeping test positive caseload at a considerably low number of 642, of which 497 are declared cured, with 3 deaths and 142 remaining active cases in hospitals as of May 20, 2020.
The objectives of this study are to assess the depression, anxiety, and stress among health-care workers from Kerala during the COVID-19 pandemic and the factors associated with it. This study will offer governments and policymakers' relevant data for an evidence-based strategy to improve mental health intervention among health-care workers.
| Materials and Methods|| |
A cross-sectional survey was conducted among health-care providers from Kerala. All health care workers which include modern medicine doctors, nurses, and other paramedical workers were included in the study. Those who do not give a consent and who are not working now were excluded from the study. Data were collected from 544 health-care workers including doctors, nurse, and other paramedical worker from various districts of Kerala. Study period was May–June 2020. Sample size was calculated with the prevalence of depression as 15% and alpha as 5% and relative precision as 20% of prevalence. The participants were invited from all districts in Kerala to participate in the online survey by chain referral sampling through the contact network of the investigators and students of the institution. The link of the questionnaire was sent through e-mails, WhatsApp, and other social media to the contacts of all the investigators from all 14 districts of Kerala who could refer more health-care providers and they were requested to roll out the questionnaire to more participants through social media groups of health-care personnel. The participants were encouraged to roll out the survey to as many health-care workers in their area as possible. Thus, the link was forwarded to health-care workers apart from the first point of contact and so on. After receiving and clicking the link, the participants were auto directed to the information about the study and informed consent. Once they agreed to participate in the survey, they filled up self-reported questionnaire. As this was a self-administered questionnaire, a consent form was introduced first to ensure autonomy and they were invited to fill the questionnaire in Google Forms after giving their consent. The validated Depression, Anxiety, and Stress Scale-21 (DASS-21) was used to assess anxiety, depression, and stress among health-care workers from Kerala. The self-reported questionnaire also included information on socio-personal characteristics such as age, sex, marital status, profession, seniority in experience, presence of chronic medical illness, type of profession, type of hospital, presence of elderly, or children <12 years at residence. Participants were also asked whether they were directly engaged in clinical activities of triaging, diagnosing, treating, or providing nursing care to patients with elevated temperature or patients with suspected/confirmed COVID-19. The health-care workers who answered yes were defined as frontline workers, and those who answered no were defined as second-line workers. The DASS-21 is the shortened version of the DASS developed by Lovibond which contains 21 questions to assess symptoms of depression, anxiety, and stress among adults. It consists of 21 items in a four-point scale. After collecting data, scores on three subscales namely Depression, Anxiety, and Stress were calculated and categorized depending on the score obtained into normal, mild, moderate, severe, and extremely severe.
Approval of the Institutional Ethics Committee (IEC) of SGMC and RF was obtained before starting the study (SGMC IEC No. 37/515/04/2020). Confidentiality of data was maintained. Personal details are omitted to maintain confidentiality.
Data in excel were imported to SPSS (version 16.0) SPSS Inc, Chicago, Illinois, US for analysis. Descriptive and inferential statistical analysis was done. Mean and standard deviation (SD) were calculated for normally distributed continuous variables. Median and interquartile range (IQR) were calculated for quantitative variables which are not normally distributed. The nonparametric Mann–Whitney U-tests and Kruskal–Wallis tests were used to compare the severity symptoms between 2 or more groups when variables were nonnormally distributed. P < 0.05 was considered as significant. To identify risk factors for symptoms of depression, anxiety, and stress in participants, univariate binary logistic regression followed by multivariate logistic regression was done, and the measure of effect for significant variables is presented in terms of odds ratios (ORs) and 95% confidence interval (CI).
| Results|| |
Among the 544 participants, 358 (65.8%) were females. The participants were of age ranging from 22 to 78 years. The mean age of the participants was 31.1 ± 10.8 years. [Table 1] shows the socio-personal details of the study participants. Among the participants, 236 (43.4%) were currently married. Out of the total, 255 (46.9%) were reported to be workers who are in the front line, involved in triage, diagnosis, treatment, or care of patients with suspected/probable/confirmed cases of COVID-19. Out of the total 544 health-care professionals, 391 (71.9%) were doctors, 63 (11.6%) were nurses, and the rest 90 were other paramedical workers from all districts of Kerala, working in primary, secondary, or tertiary care hospitals. History of previous mental illness was reported by 6 (1.1%). [Table 2] show the prevalence of depression, stress, and anxiety among health-care workers. Majority of the participants (67%) got emotional and social support from family, colleagues and also higher health authorities.
|Table 2: Prevalence of levels of depression, anxiety, and stress among health-care workers (n=544)|
Click here to view
The symptoms of anxiety, depression, and stress were significantly higher among the frontline workers. The frontline workers had a significantly higher median score of DASS depression, stress, and anxiety scales compared to non-frontline workers. The median score of anxiety among frontline workers was higher (2 with IQR of 4), compared to a median of 1 among non-frontline workers with IQR of 3 (P < 0.001). The median score of stress among frontline workers was also high (6 with IQR of 10) compared to a median score of stress of 4 among non-frontline workers with IQR of 10 (P = 0.001). The median score of depression among frontline workers was 2 with IQR of 10 compared to a median of 2, among non-frontline workers with IQR of 6 (P = 0.02).
Furthermore, the DASS depression (P = 0.026), anxiety (P = 0.029), and stress (P = 0.041) scores were significantly higher among those who had children <12 at home. The median score of depression, anxiety, and stress among health-care workers with children <12 at home were 4, 2, and 6 with IQR of 10, 4, and 12, respectively, compared to a median of 2, 1, and 4 among those who do not have children at home with IQR of 6, 3, and 10, respectively.
The symptoms of depression were higher among health-care providers below the age of 40 years. The median DASS depression score among health-care providers below the age of 40 years (2 with IQR of 8) was significantly higher (P = 0.012) than the median score among those above the age of 40 years (0 with IQR of 6). However, anxiety and stress had no association with the presence of elderly at home (P > 0.05).
The symptoms of anxiety are found to be more among those who are <40 years of age compared to those above 40 years. The median DASS anxiety score among health-care providers below the age of 40 years (1 with IQR of 3) was significantly higher (P < 0.001) than the median score among those above the age of 40 years (0 with IQR of 2). However, there was no statistically significant difference (P = 0.089) in the median DASS stress score between health-care providers below the age of 40 years (4 with IQR of 10) and those above the age of 40 years (2 with IQR of 8).
There was a significant difference in anxiety scores between different professional categories, but there was no significant difference in stress and depression scores between different professional categories. In order to find out which of the two groups showed significant difference, post hoc pair-wise comparison was done. Post hoc test showed that the anxiety scores were significantly higher (P = 0.006) among nurses (median = 2, IQR = 4) compared to doctors (median = 1, IQR = 3) [Table 3].
Those who have a previous history of mental illness had higher median anxiety and stress scores compared to those who do not have mental illness in the past, which was found to be statistically significant (P = 0.011, P = 0.046). There was no statistically significant difference in depression scores among those who had a previous history of mental illness (P = 0.137). There was no statistically significant difference in median DASS scores between different genders, marital status, types of hospital, seniority level, and the presence of elderly at home.
For variables that were found to be statistically significant, the anxiety, stress, and depression levels were categorized into two groups (normal and mild as Group 1 and the rest as Group 2) to estimate the measure of effect OR and 95% CI.
Frontline health-care workers have higher risk of having stress (OR = 2.04 [95% CI: 1.03–4.03, P = 0.04]), anxiety (OR = 3.3,1 [95% CI: 17–9.29], P = 0.024), and depression (OR = 2.386 [95% CI: 1.42–4.006], P = 0.001) compared to those are not a frontline worker. Those who have children <12 years at home had 98.8% more risk to have stress (OR = 1.988 [95% CI: 1.006–3.928], [P = 0.048]).
Emotional or social support from family and colleagues is associated with stress (χ2 = 13.37, P = 0.001) and depression (χ2 = 6.977, P = 0.031) but not associated with anxiety (χ2 = 5.921, P = 0.052). Emotional or social support from health authorities is associated with stress (χ2 = 13.054, P = 0.001) and depression (χ2 = 14.77, P = 0.001) but not associated with anxiety (χ2 = 2.700, P = 0.259).
Univariate analysis by binary logistic regression revealed that emotional or social support from family and colleagues is a protective factor for stress and depression.
We have clubbed the different categories of independent variable emotional and social support into two groups, “Not at all/A little” category as Group 1 and “much/very much/extremely” category as the Group 2. By keeping Group 1 as the reference category, it is found that those who have got enough emotional or social support from family and colleagues have 75% less stress (OR = 0.249; 95% CI: 0.109–0.570) compared to the Group 1. By considering depression as the dependent variable, it is found that Group 2 has 57% less depression (OR = 0.427; 95% CI: 0.204–0.894) compared to Group 1.
Next, we did the binary logistic regression by taking stress as the dependent variable and emotional and social support from health authorities as independent variable. Here also, we clubbed the categories into Group 1 and Group 2 as before and did the binary logistic regression. Those who have got emotional and social support from higher health authorities have 71% less stress compared to Group 1 (OR = 0.291; 95% CI: 0.146–0.578). There is 64% less depression in Group 2 compared to Group 1 (OR = 0.364; 95% CI: 0.212–0.625).
Finally, multiple logistic regression was done using stress as dependent variable, and independent variables are those which are found to be significant in univariate analysis. The results revealed that stress is associated with emotional and social support from higher health authorities with P = 0.022 (OR = 0.404; 95% CI: 0.186–0.878). Multiple logistic regression analysis by keeping depression as the dependent variable yielded two variables frontline workers (P = 0.027; OR = 1.844; 95% CI: 1.073–3.167) and emotional and social support from health authorities (P = 0.006; OR = 0.432; 95% CI: 0.238–0.782) as a significant.
| Discussion|| |
In this study conducted among 544 participants, 21.5% had depression, 7.5% had anxiety and 13.8% had stress.
In a review study done by Chou et al., it is reported that the proportion of health-care workers who had moderate or severe depression was 14%–15%, while 12%–24% had moderate-to-severe anxiety.,,, The lower prevalence in anxiety could be due to the lower case load of COVID-19 in Kerala during the study period, and the health authorities could limit the COVID-19 transmission to a level which can be managed by the health system. The prevalence was even higher in a study conducted in china, where 50.4% of participants reported symptoms of depression and 44.6% reported having anxiety. Medical health workers had prevalence rates of 13% of anxiety, and 12.2% depression compared to 8.5% and 9.5% among nonmedical health workers in another study.
In our study, the frontline health-care workers in COVID-19 control had higher odds of having depression. In a study, Lai et al. also report that frontline health-care workers engaged in COVID-19 control were associated with a higher risk of symptoms of depression (OR: 1.52; 95% CI: 1.11–2.09; P = 0.01), anxiety (OR: 1.57; 95% CI: 1.22–2.02; P < 0.001). In the above study, nurses reported more severe degrees of mental health symptoms than other health-care workers (e.g., median [IQR] Patient Health Questionnaire scores among physicians vs. nurses: 4.0 [1.0–7.0] vs. 5.0 [2.0–8.0]; P =.007). In our study also, nurses had a higher anxiety scores (P = 0.006) than doctors (among nurses with median 2 [IQR: 4] vs. doctors median 1[IQR: 3]). In a study by Tan et al., it was found that the prevalence of anxiety was higher among nonmedical health-care workers than medical personnel (20.7% vs. 10.8%, P = 0.011).
In our study, there was no difference in mental health outcome between male and female (P > 0.05), but women had higher anxiety median score in a study by Lai et al. with Generalized Anxiety Disorder scale scores among men versus women: 2.0 (0–6.0) versus 4.0 (1.0–7.0); P < 0.001. However, some studies reported men to have more depression.
Mohindra et al. also suggests some positive emotional support that health-care workers need to be given such as validation and appreciation by colleagues, supportive and proud family and colleagues, positive role models in senior colleagues and peers, and appreciation and gratitude of patients.
Emotional and social support from family and colleagues is found to be a protective factor for stress and depression, when univariate analysis was done.
Cai et al. also report that the safety of family has a high impact in reducing staff stress (P = 0.37 > 0.05) in health-care workers. Another important factor to reduce staff distress during the outbreak is the positive attitude from their colleagues (P = 0.04). Song et al. also reported that lower level of social support as a risk factor for developing depressive symptoms.
Being a frontline worker is a risk factor and emotional and social support from higher health authorities is a protective factor for depression.
The study was conducted with an online survey as the country is under complete lockdown during the study period. Hence, though we got participation from all districts in Kerala, we could not ensure equal participation from health-care workers from all districts. Furthermore only participants who have access to the internet could participate in the study, hence restricting the generalizability.
| Recommendation|| |
As the case load of COVID-19 increases, there is a need to protect the health-care workers. Special interventions which are comprehensive, persistent, and continuing measures for preventing the mental health issues in health-care workers is the need of the hour, which need to be available for long term into the future. The health-care professional, who is involved in saving lives thousands of people, especially the frontline workers, nurses, and those who are younger age, need particular attention in their mental health and well-being. More studies on the mental health and well-being of health-care workers are required in future.
| Conclusions|| |
Health-care workers reported experiencing poor mental health outcomes, especially frontline health-care workers who are directly involved in the screening, diagnosis, treatment, and care for patients with COVID-19. Emotional and social support from higher health authorities is a protective factor against depression and stress among health-care workers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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 Netw Open 2020;3:e203976.
Zhu Z, Xu S, Wang H, Liu Z, Wu J, Li G, et al
. COVID-19 in Wuhan: Sociodemographic characteristics and hospital support measures associated with the immediate psychological impact on healthcare workers. EClinicalMedicine 2020;24:100443. Published online 2020 Jun 24. doi: 10.1016/j.eclinm.2020.100443.
Liu C, Yang YZ, Zhang XM, Xu X, Dou QL, Zhang WW, et al
. The prevalence and influencing factors for anxiety in medical workers fighting COVID-19 in China: A cross-sectional survey. medRxiv 2020;148:e98. [doi: 10.1101/2020.03.05.20032003].
Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scale. Sydney: Psychology Foundation; 1995.
Chou R, Dana T, Buckley DI, Selph S, Fu R, Totten AM. Epidemiology of and risk factors for coronavirus infection in health care workers: A living rapid review. Ann Intern Med 2020;173:120-36.
Zhang W, Wang K, Yin L, Zhao W, Xue Q, Peng M, et al
. Mental health and psychosocial problems of medical health workers during the COVID-19 epidemic in China. Psychother Psychosom 2020;89:242-50.
Tan BY, Chew NW, Lee GK, Jing M, Goh Y, Yeo LL, et al
. Psychological impact of the COVID-19 pandemic on health care workers in Singapore. Ann Intern Med 2020;173:317-20.
Mohindra R, R R, Suri V, Bhalla A, Singh SM. Issues relevant to mental health promotion in frontline health care providers managing quarantined/isolated COVID19 patients. Asian J Psychiatr. 2020;51:102084. Epub 2020 Apr 7.
Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, et al
. Psychological impact and coping strategies of frontline medical staff in hunan between January and March 2020 during the outbreak of corona virus disease 2019 (COVID-19) in Hubei, China. Med Sci Monit 2020;26:e924171.
Song X, Fu W, Liu X, Luo Z, Wang R, Zhou N, et al
. Mental health status of medical staff in emergency departments during the corona virus disease 2019 epidemic in China. Brain Behav Immun 2020;88:60-5.
[Table 1], [Table 2], [Table 3]