|Year : 2020 | Volume
| Issue : 4 | Page : 180-184
Stress-related disorders in health-care workers in COVID-19 pandemic: A cross-sectional study from India
Surabhi Mathur, Divya Sharma, Ram Kumar Solanki, Manish Kumar Goyal
Department of Psychiatry, S.M.S. Medical College, Jaipur, Rajasthan, India
|Date of Submission||04-Jul-2020|
|Date of Decision||08-Sep-2020|
|Date of Acceptance||03-Oct-2020|
|Date of Web Publication||02-Dec-2020|
Dr. Divya Sharma
C-49, Shiv Marg, Dundlod House, Hawa Sarak, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: The coronavirus disease-2019 (COVID-19) outbreak, first detected in Wuhan, China, has turned into a rapidly spreading pandemic ailing the human race throughout the world. Health-care workers (HCWs) are under immense physical and psychological pressure, adversely affecting their efficiency and decision making. Aim: We hereby intend to study the impact of COVID-19 pandemic in HCWs in reference with a variety of factors. Materials and Methods: A nationwide cross-sectional online study using semi-structured pro forma along with the Adjustment Disorder New Module and the Depression, Anxiety, and Stress Scale-21 was conducted among 200 respondents. Results and Discussion: Of the 200 respondents, 174 (87%) were doctors and 26 nursing staff, with a mean age of 42.1 ± 12.2 years, 62% were male, and 63% were working in the government sector. A significant number of respondents were found to be suffering from acute stress (9.5%), depression (17%), and anxiety (19.5%) which they attributed to the negative professional and personal influence of this ongoing pandemic scenario. HCWs on the front lines of this pandemic are facing compounding stressors and need robust psychiatric help to adequately take care of this need.
Keywords: COVID-19, health-care workers, psychological impact
|How to cite this article:|
Mathur S, Sharma D, Solanki RK, Goyal MK. Stress-related disorders in health-care workers in COVID-19 pandemic: A cross-sectional study from India. Indian J Med Spec 2020;11:180-4
|How to cite this URL:|
Mathur S, Sharma D, Solanki RK, Goyal MK. Stress-related disorders in health-care workers in COVID-19 pandemic: A cross-sectional study from India. Indian J Med Spec [serial online] 2020 [cited 2021 Oct 21];11:180-4. Available from: http://www.ijms.in/text.asp?2020/11/4/180/302078
| Introduction|| |
Pandemics are infectious disease covering a wide geographical area and significantly impacting the socioeconomic and political atmosphere. The coronavirus disease-2019 (COVID-19) outbreak has been declared a pandemic, in which the coronavirus causes occurrence of a respiratory illness. The first case was detected in Wuhan, China, but COVID-19 has emerged as a rapid epidemic throughout the world. [3,4] The novel coronavirus has till now infected 649,536 people in India and there have been 18,669 deaths till date (July 3, 2020), and the numbers are rising rampantly. Protracted and dynamic pandemic conditions will draw out the anxiety. Like other pandemics and emerging disease outbreaks, COVID-19 is creating immense psychosocial disturbances, as it is exposing the pandemic preparation of all affected nations. The disease involves an unfamiliar threat as it is transmitted efficiently and has a high mortality rate to distinguish from more benign illnesses. Furthermore, absence of a vaccine, no clear pharmaceutical interventions to prevent infections, and the impact on social interactions and economic exchanges have made the situation grim.
People are in a state of constant fear and deep despair, there is no complacency as there is no final word on how long this pandemic will linger on; every day, new data are pouring in, value chains both regional and global are risking crash, and global economy is grinding to a halt. Everyone’s routine has been thrown out of whack, making them lose the semblance of control over their lives, and everyone is afraid of death now, either of themselves or that of the people they love. It is seen that anxiety and fear usually appear immediately after the disaster and reduce shortly after, but depression and psychophysical symptoms persist for longer.
Health-care workers (HCWs) in India and around the world are facing physical as well as psychological pressure, thereby adding to an existing baseline of psychological pathology.
The fear of contagion spreads to their family, friends, and colleagues; prospect of more and longer shifts; finite supplies of personal protective equipment; unpredictable duty rosters; fear of bringing infection home; quarantine/isolation in hotels away from family and children; and lack of household help have been major sources of stress.
Besides, witnessing coworkers becoming ill, social ostracism, making tough allocation decisions about scarce, lifesaving resources such as mechanical ventilators are some noteworthy issues faced by them leading to high levels of stress, anxiety, and depression symptoms and can have long-term psychological implications suggested by studies.
Liu et al. highlighted that the COVID-19 epidemic has emphasized potential gaps in mental health services during this pandemic while also enabling the resilience of HCW and medical system by online services. It was reported despite the common mental health problems and disorders found among patients and health workers in this pandemic, most health professionals working in isolation units and hospitals do not receive any training for providing mental health care, which is crucial in guiding policies and interventions to maintain their psychological well-being. This study proposed to study the emergence of various stress-related disorders during COVID-19 pandemic in HCW and study the impact of different factors over the incidence of psychiatric disorders in HCW.
| Materials and Methods|| |
This was a cross-sectional, observational study carried out on health-care professionals in India. An online semi-structured questionnaire was used and was aired for a period of 3 days. The questionnaire link was sent through WhatsApp, e-mails, and other social media to the contacts of the investigators. On receiving and clicking the link, the participants were directed automatically to the information about the study. The information given by participants was kept anonymous and confidential and completion of the survey implied consent to participate in the study. All the responses were included barring those who were already suffering from diagnosed psychiatric illness.
Semi-structured performa included age, gender, employment, marital status, qualification, doctor or nursing staff, exposure to COVID patients, quarantine duration, and comorbidities.
Adjustment Disorder New Module (ADNM-6) was used for measuring adjustment disorders; Depression, Anxiety, and Stress Scales (DASS-21) were used to measure the emotional states of depression, anxiety, and stress.
There were three sections in the online questionnaire:
- The first section was for background and sociodemographic data
- The second section consisted of a set of questions assessing the adjustment disorders prevalence through the ADNM-6 scale. The ADNM-6 scale consists of set of 6 questions, with a dichotomous response as yes (1) or no (0)
- In the third section, the DASS-21 was applied. It is based on three subscales of depression, stress, and anxiety, and each subscale consists of seven questions each. The rating of DASS subitems such as depression, anxiety, and stress can be rated as normal, mild, moderate, and extremely severe.
Each item is scored in a self-rated Likert scale from 0 (didn’t apply to me at all) to 3 (much or mostly applied to me) for the past 1 week. It cannot be used as a diagnostic tool as the scale does not cover several domains of depression such as sleep, appetite, and sexual functions but can be applied as an aid to the diagnostic tool as well as to measure treatment response.
SPSS version 25 (IBM SPSS 25, USA) was used for the statistical analysis. For comparisons between the groups, t-test was used for continuous variables and Chi-square tests were used for categorical variables. Statistical significance was determined at P < 0.05. The primary outcome was the prevalence of adjustment disorders, depression, stress, and anxiety, among all HCWs. Secondary outcomes were comparison of the prevalence of depression, anxiety, stress, and adjustment and mean DASS-21 score between staff who received quarantine and those who did not.
| Results|| |
The total responses received were 200, of which 174 (87%) were doctors and 26 were nursing staff. The sample had a mean age of 42.1 ± 12.2 years. Most of the participants were male (n = 138, 62%), working in the government sector (n = 126, 63%), 138 were residing in own house with family (68%), and 151 (75%) were married.
Most doctors had postgraduate qualification (n = 100, 59%). Most of the nursing staff had done bachelor’s degree in nursing (n = 11, 44%), followed by GNM (n = 10, 41%). Of the total respondents, 69 (34%) had been posted in COVID-19 ward duty or had been in contact with a COVID-19-positive patient. Of those 69 posted in COVID-19 ward duties, 43 received quarantine or home isolation [Table 1].
|Table 1: Number of participants on the basis of sociodemographic variables|
Click here to view
Of the 200 respondents, 19 (9.5%) suffered from acute stress, of which 9 were mild and 4, 5, 1 were moderate, severe, and extremely severe, respectively. The mean score of stress subscale was 6.99. Also, 34 (17%) respondents developed new-onset depression, 13 had mild, 11 moderate, 7 had severe and 3 had extremely severe depression respectively. The mean score of depression subscale was 4.65. Of the 39 doctors and nurses in the study; 11 had mild, 14 had moderate, 7 had severe, and 7 had extremely severe anxiety on anxiety subscale. The mean score on anxiety subscale was 3.93 [Table 2].
|Table 2: Prevalence of stress disorder, depression, and anxiety disorders in study participants undergoing coronavirus disease-2019 duty (n)|
Click here to view
Higher score of >3 on the ADNM-6 scale was seen in 37 respondents (18.5%) amongst the sample population. The mean score for adjustment disorder for persons involved in direct care of COVID-19 patients was 2.23. The mean stress perceived by males during this period was higher compared to females though not significantly different. There was no significant difference in mean of adjustment, depression, and anxiety scores for both the gender [Table 3].
|Table 3: Gender-based comparison of mean scores of various psychiatric disorders|
Click here to view
Also, depression, adjustment, stress, and anxiety showed a negative correlation with age, however only stress and anxiety had statistical significance with P = 0.01 and 0.026 respectively.
Factors like staying in own house and presence of premorbid substance use did not show any statistical significance on the incidence of stress-related disorders in our study. However, married HCWs had statistically significantly more anxiety, depression and stress with P = 0.004, 0.006 and 0.001 respectively as compared to their unmarried counterparts. Furthermore, the presence of comorbidities such as hypertension, diabetes, and heart diseases had a statistically significant impact on depression, but not on stress and anxiety in HCW posted in COVID-19 ward.
Doctors participated more in this survey, in comparison to the nursing staff. The mean score of adjustment disorder was significantly higher in nurses (P = 0.01), while the other scores like mean of anxiety, depression, and stress was also higher in nurses but not statistically significant [Table 4].
|Table 4: Comparison of psychiatric issues in government and private sector health-care workers|
Click here to view
Out of 200 participants, 69 were posted in COVID-19 duty, and mean scores for adjustment, anxiety, depression, and stress were significantly higher in them [Table 5]. However, being in either profession had no statistical significance for the prevalence of any disorder. Also, those who were given quarantine following the duty had a statistically significant difference in the presence of stress (P = 0.03); however, no such relation was seen with the prevalence of anxiety, depression or adjustment disorders.
|Table 5: Comparison of psychiatric disorders in health-care workers during and without coronavirus disease-2019 duty|
Click here to view
| Discussion|| |
During the COVID-19 pandemic, HCWs have had high prevalence rates of anxiety, depression, stress, and adjustment symptoms.
In our survey, there was more participation by physicians (n = 173, 87%), while in a study by Lai et al., 1257 health workers were assessed in 34 hospitals, with 60.8% being nurses, 493 physicians, and 522 frontline HCW. Our sample had a mean age of 42.05 (±12.19) years. Most of the participants were male (n = 132, 62%), 138 were residing in own house (68%), and 151 (75%) were married, while in the review by M. S. Spoorthy of six articles, the mean age of HCW was between 26 and 40, with predominant participants being female.
Furthermore, a meta-analysis by Pappa et al. included 13 studies for analysis with 33,062 participants. The median male representation was 18%. While in a study by Tan et al. where 470 personnel comprised the study group, 68.2% were medical health-care personnel (45.6% were physicians and 51% were nurses), with a median age being 30 years, wherein 49% were single and 49.7% married.
There were significant stress and adjustment problem in government-employed personnel, which can be explained by the fact that in most states, only government- and municipal-run hospitals are treating the COVID-19-positive cases. In addition, among those posted in COVID-19 wards, personnel who received institutional quarantine away from family had significantly more stress; however, the number of days of quarantine did not statistically affect the presence of any disorders. Our study is among the first few to assess such a scenario in the Indian context, as being given any quarantine or home isolation is an important factor for stress among health- care professionals, as they have a fear of infecting their family which adds to the stress of the already ongoing pandemic.
A previous study associated insomnia, anxiety, and depression, among HCWs with risk factors such as medical comorbidity, living alone, being posted in COVID-19 ward in hospitals, or being female. However, our study did not reveal any temporal association with risk factors such as using any substances, staying at own house, or being female. Health-care personnel who were staying on rent showed the presence of significant stress due to the hostile attitude of the landlord (P = 0.035).
In our study, 9.5% of the respondents were found to suffer from acute stress, 17% of respondents from depression, and 19.5% of respondents suffered from anxiety. While in a study by Lai et al., there was a prevalence of 50.4% for depression, 44.6% for anxiety, and 71.5% for distress, in a study by Tan et al., the prevalence for depression and anxiety and stress in medical health-care personnel is 8.1%, 10.8%, and 6.4%, respectively. [12,15] Sofia found pooled prevalence for anxiety 23.20% and 22.8% for depression. In subgroup analysis, there was 20.92% and 29.06% pooled prevalence for males and females, respectively. In the analysis of depression, the pooled prevalence of 20.34% for men versus 26.87% for women was found. In an online study by Chatterjee et al., 152 people constituted a study sample with a prevalence rate of 34.9% for depression and 32.9% and 39.5% for anxiety and stress.
Prevalence rates of depression, anxiety, and stress in our study were less than those in a study by Chatterjee et al., which was conducted in West Bengal with similar assessment tools, one possible explanation is that the study was done in the early phase of an epidemic when the knowledge of COVID-19 and its prophylactic management was not clear by the WHO, and hence, frontline workers faced more harassment at the hands of people in absence of clear communication between government, its policies, and the common man.
It was seen that anxiety and depression prevalence was higher in females; however, our study data did not show such results, probably due to the small sample size and less percentage of female participants due to multiple obligations at home and work. Again, in most of the studies, nursing staff showed higher prevalence both for anxiety and depression as compared to doctors; however, our study did not yield such findings, probably due to lesser nursing staff recruitment, which may be a confounding factor.
Similar studies done on HCW found them vulnerable to anxiety and depressive symptoms along with burnout.[17-19] Trends in our study showed that 50% reported stress being mild, 38% reported a mild form of depression, and 28% of people reported mild form of anxiety.
Comparing trends in physicians and nursing staff, there was higher significant mean for adjustment disorders in nurses (P = 0.01), while the other scores such as the mean of anxiety, depression, and stress, although higher in nurses, were not statistically significant. In a meta-analysis by Pappa et al. the pooled prevalence for depression was 29.65% for nurses and 24.5% for doctors. There may be a confounding factor in our study, as more physicians who had COVID duty filled the survey compared to nurses which can be explained as the survey was online and was in English, so some amount of technical knowledge and language fluency was needed.
Our study has the following limitations:
- Since the study had a cross-sectional design, it is difficult to make causal inferences
- Furthermore, we used a web-based survey method to avoid possible infections; hence, the study sample was voluntary conducted by an online system. Therefore, selection bias is a distinct possibility.
| Conclusion|| |
HCWs on the front lines of our pandemic combat are facing compounding stressors which compromise their personal and professional productivity, thereby leading to various psychological disorders and they need robust psychiatric help to adequately address these issues. There is a need for upgradation of all psychiatric departments and National Mental Health Programme at district level need to step up to set up counseling centers in hospitals dedicated to HCWs undertaking COVID-19 care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al
. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med 2020;382:1199-207.
The Lancet. COVID-19: Too little, too late? Lancet Lond Engl 2020;395:755.
Day M. Covid-19: Surge in cases in Italy and South Korea makes pandemic look more likely. BMJ 2020;368:m751.
Walton M, Murray E, Christian MD. Mental health care for medical staff and affiliated healthcare workers during the COVID-19 pandemic. Eur Heart J Acute Cardiovasc Care 2020;9:241-7.
Lung FW, Lu YC, Chang YY, Shu BC. Mental symptoms in different health professionals during the SARS attack: A follow-up study. Psychiatr Q 2009;80:107-16.
Imo UO. Burnout and psychiatric morbidity among doctors in the UK: A systematic literature review of prevalence and associated factors. BJPsych Bull 2017;41:197-204.
Liu S, Yang L, Zhang C, Xiang YT, Liu Z, Hu S, et al
. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry 2020;7:e17-8.
Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al
. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry 2020;7:228-9.
Boer D, Bachem R, Maercker A. ADNM-6. Anpassungsstörungs-Screeningskala. In C. J. Komper, E. Brähler & M. Zenger (Eds.) Psychologische und sozialwissenschaftliche Kurzskalen. StandardisierteErhebungsinstrumente für Wissenschaft und Praxis. (pp. 9-11). Berlin: Medizinisch Wissenschaftliche Verlagsgesellschaft 2014.
Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the beck depression and anxiety inventories. Behav Res Ther 1995;33:335-43.
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.
Spoorthy MS, Pratapa SK, Mahant S. Mental health problems faced by healthcare workers due to the COVID-19 pandemic-A review. Asian J Psychiatr. 2020 Jun;51:102119.
Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain Behav Immun 2020;88:901-7.
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.
Chatterjee SS, Bhattacharyya R, Bhattacharyya S, Gupta S, Das S, Banerjee BB. Attitude, practice, behavior, and mental health impact of COVID-19 on doctors. Indian J Psychiatry 2020;62:257-65. [Full text]
Cheung T, Fong TKH, Bressington D. COVID-19 under the SARS Cloud: Mental Health Nursing during the Pandemic in Hong Kong. J Psychiatr Ment Health Nurs. 2020 Apr 20:10.1111/jpm.12639.
Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: A web-based cross-sectional survey. Psychiatry Res. 2020 Jun;288:112954.
Bohlken J, Schömig F, Lemke MR, Pumberger M, Riedel-Heller SG. COVID-19 pandemic: Stress experience of healthcare workers-A short current review. Psychiatr Prax 2020;47:190-7.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
|This article has been cited by|
||Prevalence and severity of secondary traumatic stress and optimism in Indian health care professionals during COVID-19 lockdown
| ||Manohar K. N.,Neha Parashar,C. R. Satish Kumar,Vivek Verma,Sanjiv Rao,Sekhar Y.,Vijay Kumar K.,Amalselvam A.,Hemkumar T. R.,Prem Kumar B. N.,Sridhar K.,Pradeep Kumar S.,Sangeeta K.,Sangeeta Shivam,Chetan Kumar,Chetan Judith,Leeberk Raja Inbaraj |
| ||PLOS ONE. 2021; 16(9): e0257429 |
|[Pubmed] | [DOI]|
||The Global Prevalence of Depression, Anxiety, Stress, and, Insomnia and Itsí Changes among Health Professionals during COVID-19 Pandemic: A Rapid Systematic Review and Meta-Analysis
| ||Sultan Mahmud,Sorif Hossain,Abdul Muyeed,Md Mynul Islam,Md. Mohsin |
| ||Heliyon. 2021; : e07393 |
|[Pubmed] | [DOI]|
||Psychological distress among healthcare providers during COVID-19 in Asia: Systematic review and meta-analysis
| ||Siew Mooi Ching,Kar Yean Ng,Kai Wei Lee,Anne Yee,Poh Ying Lim,Hisham Ranita,Navin Kumar Devaraj,Pei Boon Ooi,Ai Theng Cheong,Ali Rostami |
| ||PLOS ONE. 2021; 16(10): e0257983 |
|[Pubmed] | [DOI]|
||Unlocking the mental health crisis in health-care providers during COVID-19 pandemic
| ||Jasmine Parihar,Kirat Grewal |
| ||Indian Journal of Medical Specialities. 2020; 11(4): 173 |
|[Pubmed] | [DOI]|