COVID-19 frontline HCPs at increased risk of psychological problems

Frontline healthcare workers who are directly diagnosing, treating, or caring for patients with COVID-19 have increased risks for depression, anxiety, insomnia, and distress, according to a study from China.

“[O]ur findings present concerns about the psychological well-being of physicians and nurses involved in the acute COVID-19 outbreak,” said the researchers.

Frontline healthcare workers had an increased risk of depression symptoms (odds ratio [OR], 1.52; p=0.01), insomnia (OR, 2.97), distress (OR, 1.60), and anxiety (OR, 1.57; p<0.001 for all). [JAMA Netw Open 2020;3:e203976]

The study also showed that women had increased risks of depression (OR, 1.94; p=0.003), anxiety (OR, 1.69; p=0.001), and distress (OR, 1.45; p=0.01). Working in secondary vs tertiary hospitals was linked to increased risks of depression and anxiety (OR, 1.65; p=0.004 and OR, 1.43; p=0.01, respectively). Participants with intermediate professional titles were at higher risk for depression (OR, 1.77; p=0.001), anxiety (OR, 1.82; p<0.001), and distress (OR, 1.94; p<0.001) compared with junior professionals.

Participants from outside the Hubei province had a lower risk of distress compared with those in Wuhan (OR, 0.62; p=0.008).

The findings were based on cross-sectional surveys completed by 1,257 healthcare workers from 34 hospitals in China between 29 January and 3 February 2020. The participants were primarily aged 26–40 years (64.7 percent), female (76.7 percent), and worked in tertiary hospitals (74.2 percent). Almost 61 percent of respondents were nurses, 60.5 percent were working in Wuhan, China, and 41.5 percent were frontline healthcare workers.

The researchers used Chinese versions of the 9-item Patient Health Questionnaire, the 7-item Generalized Anxiety Disorder scale, the 7-item Insomnia Severity Index, and the 22-item Impact of Event Scale–Revised (IES–R) to assess degree of depression, anxiety, insomnia, and distress symptoms, respectively.

Distress was the most commonly reported outcome (71.5 percent), followed by depression (50.4 percent), anxiety (44.6 percent), and insomnia (34.0 percent).

Scores for all conditions were higher in nurses vs physicians, women vs men, frontline vs second-line workers, and participants in Wuhan vs those outside Wuhan but in Hubei and those outside Hubei. Scores for insomnia, depression, and anxiety were higher in those in secondary vs tertiary hospitals.

According to the researchers, factors that may lead to psychological symptoms include concerns regarding loss of control, isolation, virus spread, lack of supplies, and personal and family health. These may be amplified by COVID-19-associated mortality and morbidity.

The increased risk of mental health issues among women, nurses, and frontline workers warrants specific attention to these populations, they noted. The evolving COVID-19 situation also suggests the potential for increasing severity of mental health symptoms, necessitating long-term studies.

“Protecting healthcare workers is an important component of public health measures for addressing the COVID-19 epidemic. Special interventions to promote mental well-being in healthcare workers exposed to COVID-19 need to be immediately implemented,” they said.

In a commentary, Professor Roy Perlis from Massachusetts General Hospital, Boston, Massachusetts, US, said several pertinent questions were unanswered in this study, including the potential existence of pre-existing psychological issues in the population and whether the findings were due to the respondents’ roles as healthcare workers or to being in the middle of an epidemic. [JAMA Netw Open 2020;3:e204006]

“The [findings provide] a reminder of the toll that will likely linger: the consequences of chronic stress, including major depression and anxiety disorders [post-epidemic],” he said. “[J]ust as the world has joined efforts to manage COVID-19 infection, it will be critical not to neglect the mental health consequences of the fight against the epidemic.”

 

On the home front

A separate study conducted between 19 February and 13 March 2020 at two tertiary institutes in Singapore assessed psychological distress, stress, anxiety, and depression experienced by healthcare workers during the COVID-19 outbreak.

Psychological outcomes of the 470 participants (median age 31 years, 68.3 percent female) were assessed by self-administered questionnaires which included the Depression, Anxiety, and Stress Scales (DASS-21) and the IES–R instrument.

Anxiety was the most common outcome, occurring in 14.5 percent of the participants. This was followed by depression (8.9 percent), clinical concern for post-traumatic stress disorder (PTSD; 7.7 percent), and stress (6.6 percent). [Ann Intern Med 2020;doi:10.7326/M20-1083]

The incidence of depression, anxiety, and PTSD was numerically higher among non-medical* compared with medical healthcare workers (10.3 percent vs 8.1 percent [depression], 20.7 percent vs 10.8 percent [anxiety], and 10.9 percent vs 5.7 percent [PTSD]). After adjustment, the prevalence of anxiety was significantly higher among non-medical vs medical staff (adjusted prevalence ratio, 1.85, 95 percent confidence interval, 1.15–2.99; p=0.011).

Compared with medical staff, non-medical staff also had higher DASS scores for anxiety and stress (mean 3.57 vs 2.45 [anxiety] and 6.10 vs 3.82 [stress]) and a higher total IES–R score (mean 9.40 vs 5.85).

“Reasons for [the increased prevalence of anxiety among non-medical staff] may include reduced accessibility to formal psychological support, less first-hand medical information on the outbreak, [and] less intensive training on personal protective equipment and infection control measures,” said the researchers led by Drs Benjamin Tan and Nicholas Chew from the National University Health System, Singapore.

“Our study identified a vulnerable group susceptible to psychological distress. Educational interventions should target non-medical healthcare workers to ensure understanding and use of infectious control measures. Psychological support could include counselling services and development of support systems among colleagues,” they added.