Link between physical, mental states of COVID-19 frontliners may be bidirectional

In the fight against the coronavirus disease 2019 (COVID-19) pandemic, healthcare workers experience a range of physical symptoms, which are strongly related to psychological distress, according to a study, suggesting a bidirectional relationship between physical symptoms and psychological outcomes.

Frontliners battling an outbreak harbour a fear of transmitting COVID-19 to colleagues and family members, in addition to facing the dilemma of applying for sick leave in an already strained healthcare sector should they become infected. As such, many of them develop burnout and experience a sense of intense stigmatization and ostracism when displaying physical symptoms suggestive of the virus infection. These could, in turn, lead to negative psychological pain. [Brain Behav Immun 2020;doi:10.1016/j.bbi.2020.04.027; Int J Environ Res Public Health 2020;doi:10.3390/ijerph17051729; J Nurs Res 2015;23:217-224]

“We postulate a bidirectional complex relationship between psychological distress and physical symptoms, where an inadvertent psychological distress exacerbates physical symptoms and vice versa,” the authors said.

The present analysis involved 906 healthcare workers (median age, 29 years; 64.3 percent female) from major hospitals, which were involved in the care for COVID-19 patients, in Singapore (n=480) and India (n=426). They completed a self-administered questionnaire comprising questions related to demographics, medical history, symptom prevalence in the past month, Depression Anxiety Stress Scales (DASS-21) and the Impact of Events Scale-Revised (IES-R) instrument.

The population consisted of nurses (39.2 percent), physicians (29.6 percent), allied healthcare professionals (10.6 percent), clerical (6.2 percent) and maintenance (5.7 percent) staff, technicians (4.4 percent), and administrators (4.3 percent). More than half of them (55.1 percent) were Indian, 33.7 percent were Chinese, and 4.8 percent were Malay. There were 205 participants who presented with comorbidities, including migraine, eczema and asthma.

Frequently reported physical symptoms included throat pain (33.6 percent), headache (31.9 percent), anxiety (26.7 percent), lethargy (26.6 percent) and insomnia (21.0 percent). Within the 1-month period preceding the survey, 302 (33.3 percent) respondents did not report any symptom, while 115 (12.7 percent) reported one symptom, 113 (12.5 percent) two, 73 (8.1 percent) three, and 303 (33.4 percent) more than four. Symptoms were generally mild in severity.

With respect to psychological outcomes, 48 participants (5.3 percent) screened positive for moderate to very severe depression, 79 (8.7 percent) for moderate to extremely severe anxiety, 20 (2.2 percent) for moderate to extremely severe stress, and 34 (3.8 percent) for moderate to severe levels of psychological distress.

Participants who did vs did not report physical symptoms in the preceding month were more likely to be older, have pre-existing comorbidities, and be diagnosed with depression, anxiety, stress and post-traumatic stress disorder (PTSD).

Multivariable logistic regression analysis revealed that the presence of physical symptoms in the preceding month was associated with a higher likelihood of screening positive for depression (odds ratio [OR], 2.79, 95 percent confidence interval [CI], 1.54–5.07; p=0.001), anxiety (OR, 2.18, 95 percent CI, 1.36–3.48; p=0.001), stress (OR, 3.06, 95 percent CI, 1.27–7.41; p=0.13) and PTSD (OR, 2.20, 95 percent CI, 1.12–4.35; p=0.023). Additionally, mean scores in the IES-R and DASS anxiety, stress and depression subscales were higher in the presence of physical symptoms. [Brain Behav Immun 2020;doi:10.1016/j.bbi.2020.04.049]

“The true association of physical symptoms and psychological stress is indeed challenging to determine… Nevertheless, somatic symptoms may be more prevalent during periods of stress, and these are hypothesized to represent a way of communicating emotions,” the authors pointed out.

In line with the finding of the significant association of the presence of comorbidities and physical symptoms among frontliners, the authors believe “that various symptoms of throat pain, cough and myalgia during the current COVID-19 outbreak may be over-represented as a result of the psychological stress, and further exacerbated by the presence of various comorbidities—[an] observation [that] is also commonly evident in patients with depression, with the somatization of back pain and headache.

“Targeted multidisciplinary interventions are needed to support healthcare workers by addressing both the psychological manifestations and physical symptoms. All efforts should be made to offer psychological support and interventions once an acute infection has been excluded,” they said.

The authors suggested conducting dedicated counselling to allay the frontline healthcare workers’ fear of transmitting the infection to their family members, as well as to boost their confidence and morale.

“We intend to re-evaluate our study participants if the current COVID-19 outbreak escalates further in the region, as well as after it subsides to obtain much reliable explanations about the association of psychological sequelae and various physical symptoms,” they added.