The wounded healer: A narrative review of the mental health effects of the COVID-19 pandemic on healthcare workers.

Health systems and healthcare workers worldwide are experiencing tremendous stress because of the growing Coronavirus Disease 2019 (COVID-19) pandemic. In many ways, the causative virus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is unlike the common flu or the 2003 SARS virus. It is highly contagious and infected persons may remain relatively asymptomatic (Tandon, 2020). Much about the virus also remains unknown, including its incubation period and transmission dynamics (Wang et al., 2020). Cases increase at an exponential rate, may have complicated needs and are typically not discharged until at least 10 days later (Wang et al., 2020).

Expectedly, there have been increasing reports of high rates of anxiety and depressive symptoms amongst frontline medical staff (Lai et al., 2020; Tan et al., 2020), and calls for healthcare workers involved in the fight against COVID-19 to receive screening and counselling by professional mental health providers. A rapid review of the PubMed and Google Scholar databases using the text words, “COVID-19” OR “nCoV” OR “SARS” OR “SARS-CoV-2” AND “mental health” OR “psychiatry” OR “psychology”, “anxiety” OR “depression” OR “stress”, up to 5 May 2020, we found ten observational studies on the mental health effects of the COVID-19 pandemic on healthcare workers. These studies and their key findings were summarised in Table 1 .

Table 1

Studies on the mental health effects of COVID-19 on healthcare workers (arranged alphabetically by first author’s family name).

Author, Year	Country	Study Sample	Key Findings
Chew et al., 2020	Singapore and India	N = 906 healthcare workers involved in the care of COVID-19 patients, from 5 major hospitals in Singapore and India	- 5.3 % of the respondents screened positive for moderate to very severe depression. - Higher prevalence of physical symptoms than emotional distress compared to other Chinese cohorts; a large number (32.3%) of respondents reported headache. - Significant associations between the prevalence of physical symptoms and psychological outcomes (including depression, anxiety and stress).
Du et al., 2020	China	N = 134 healthcare workers in Wuhan, China	- Respondents reported elevated depression (12.7 %) and anxiety (20.1 %) symptoms. 59 % reported moderate to severe perceived stress. - The risk for having at least mild depression was three times higher in local healthcare workers than those deployed to Wuhan. - Risk factors were greater perceived stress, poorer sleep quality, and lacking perceived psychological preparedness
Huang and Zhao, 2020	China	N = 7236 (comprising of 4980 members of public and 2256 healthcare workers) in China	- No significant differences between males and females in terms of psychological symptoms in the general public. - Overall prevalence of anxiety, depressive symptoms, and poor sleep were 35.1 %, 20.1 %, and 18.2 %, respectively. - Healthcare workers had the highest prevalence of poor sleep quality compared to other occupational groups.
Kang et al., 2020	China	N = 994 (comprising of 183 doctors and 811 nurses) in Wuhan, China	- As defined by PHQ-9 scores, most respondents had subthreshold or mild mental health disturbances, and 6.2 % had severe disturbances. - Risk factors were young women and greater contact with suspected or confirmed COVID-19 patients; those with severe disturbances had accessed fewer psychological print or media resources.
Lai et al., 2020	China	N = 1257 health care workers in 34 hospitals in China	- A significant proportion of healthcare workers reported symptoms of distress (71.5 %), depression (50.4 %), anxiety (44.6 %) and insomnia (34.0 %). - Significant risk factors were female gender, nurses and those involved in direct care of COVID-19 patients.
Li et al., 2020	China	N = 740 (comprising of 214 members of public and 526 nurses; 234 front-line nurses (FLNs) and 292 non-front-line nurses (nFLNs) in China	- Significantly lower VT scores observed in FLNs than those in members of public and nFLN groups. - There was no significant difference noted between members of public and nFLNs in terms of VT scores - Risk factors for VT in nFLNs were gender and marriage status
Lu et al., 2020	China	N = 2299 (comprising of 2042 medical staff and 257 administrative staff) in Fujian, China	- Frontline medical staff with direct contact with COVID-19 patients had significantly higher fear, anxiety and depression rating scores - Shortages of PPE, fear of being a vector for contagion to their families are significant contributory areas.
Tan et al., 2020	Singapore	N = 470, health care workers in 2 major tertiary hospitals in Singapore	- Overall lower mean Depression Anxiety Stress Scales (DASS-21) and Impact of Event Scale-Revised (IES-R) scores compared to other Chinese cohorts; could be due to preparedness after the 2003 SARS experience - Nonmedical staff (allied health professionals, pharmacists, technicians, administrators, clerical staff, and maintenance workers) showed significantly higher rates of anxiety compared to medical staff (doctors and nurses).
Xiao et al., 2020	China	N = 180 medical staff in Wuhan, China	- Levels of social support for medical staff were significantly associated with self-efficacy and sleep quality and negatively associated with the level of anxiety and stress. - Levels of anxiety were significantly associated with the levels of stress. This negatively impacted self-efficacy and sleep quality. - Anxiety, stress, and self-efficacy were mediating variables associated with social support and sleep quality.
Zhang et al., 2020	China	N = 2,182 healthcare workers in China (comprising 1,255 nonmedical health workers and 927 medical health workers)	- Both medical and nonmedical healthcare workers had symptoms of insomnia, anxiety, depression, somatization and obsessive-compulsion. - Working in a rural area, female gender and direct contact with COVID-19 patients were significant risk factors.

Abbreviations: DASS-21; Front-line nurses, FLN; Patient health questionnaire, PHQ; Perceived stress scale, PSS; Vicarious Traumatization, VT.

Notably, the studies were all from Asia (Singapore, India and China). The Chinese studies generally found that female gender and direct contact with COVID-19 patients were significant risk factors associated with higher levels of psychological distress (Lai et al., 2020; Lu et al., 2020; Kang et al., 2020; Zhang et al., 2020). Poor sleep quality and insomnia may also be more prevalent amongst healthcare workers (Huang and Zhao, 2020; Xiao et al., 2020; Zhang et al., 2020). Besides the demanding nature of the work and other occupational hazards, being in direct contact with a COVID-19 patient puts healthcare workers at higher risk of disease exposure. There may also be anticipatory anxiety and fear of spreading the virus to family members living in the same household.

The studies conducted in Singapore found overall lower prevalence of psychological symptoms compared to the Chinese studies (Tan et al., 2020; Chew et al., 2020), but reported higher prevalence of physical symptoms e.g. headache, which could reflect somatization. The studies also highlighted the importance of pandemic readiness and preparedness, especially for non-medical staff, who may be less familiar with communicable diseases.

Wearing full PPE is exhausting and proper work-rest cycles should be ensured. Skin damage due to frequent handwashing and enhanced infection-prevention measures could also compound one’s psychological distress (Lan et al., 2020). In the current climate, even the best among us can feel overwhelmed, emotionally distressed and be left with the scars of vicarious traumatization.

An effective pandemic response must also include a mental health response, both for the public and also the healthcare force. It is important to continually support healthcare workers and their psychological needs. As resources could be scarce at the moment, timely psychological support could take many forms (Ng et al., 2020). These include availing counselling services, informal or formal supervision and establishing peer support systems among colleagues. Future studies on this subject should also employ a mixed-methods design to explore specific themes and intervention strategies.

Swiss psychiatrist Carl Jung famously said that, “it is his own hurt that gives the measure of his power to heal [..] this, and nothing else, is the meaning of the Greek myth of the wounded physician.” In the same vein, we hope all healthcare workers can draw strength from their struggles and transform despair into hope.

Authors’ statement

Qin Xiang Ng conceived the original idea for the manuscript. Qin Xiang Ng, Michelle Lee Zhi Qing De Deyn and Hwei Wuen Chan carried out the study, and the relevant data analysis and interpretation. All authors contributed to the writing and proofreading of the final manuscript. The final manuscript was discussed and approved by all authors. All authors are responsible for the content and writing of the paper.

Financial disclosure

None. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

No conflict of interest to declare.