Evaluation of Psychological Impact of COVID-19 on Health-Care Workers.

BACKGROUND: Little information is available from India about the psychological impact of COVID-19 on helath-care workers. AIM: The current study aimed to evaluate the psychological issues among the health-care workers (HCW) during the COVID-19 pandemic.
MATERIALS AND METHODS: An online survey using Survey Monkey® platform was carried out to evaluate depression (using Patient Health Questionnaire-9), anxiety (using Generalized Anxiety Disorder Questionnaire-7), and other psychological issues (using a self-designed questionnaire).
RESULTS: The study sample comprised 303 participants with a mean age of 41.2 (standard deviation: 11.1) years. A majority of them were male (69%) and married (79.9%). Nearly half (46.2%) of the participants had either anxiety disorder or depression or both and 12.9% of HCW had suicidal behavior. Higher level of anxiety and depression scores were associated with being female, having undergone quarantine, directly involved in the care of COVID-19 patients, and younger age (<30 years). Higher prevalence of depression and anxiety disorder was seen in younger (<30 years) age group, being a doctor (compared to paramedics). In addition, higher prevalence of depression was seen in those who were directly involved in the care of patients with COVID-19 infection.
CONCLUSION: About half of the HCWs are suffering from psychiatric morbidity, specifically anxiety, in the wake of the COVID-19 pandemic. There is a need to assess all the HCWs for psychiatric morbidity and provide them with psychological support. Copyright:

INTRODUCTION

COVID-19 has emerged as a highly infectious and contagious, acute severe respiratory syndrome, which was declared as a pandemic by the World Health Organization in March 2020 (Huang et al., 2019). According to the data from some of the previous infectious epidemics, such as severe acute respiratory syndrome (SARS), middle-east respiratory syndrome, influenza H1N1, or Ebola, it is evident that the onset of a sudden and immediate life-threatening illness leads to a tremendous amount of the pressure on health-care workers (HCWs). As generally known, the COVID-19 pandemic is more contagious than SARS, and it has led to a severe threat to the general population at large and HCWs too.[123] Increased workload, mental unpreparedness, physical and psychological exhaustion, unavailability of the personal protective equipments (PPEs),[4] risk of infection to self and spreading the infection to others, lack of support from the organization,[5] and need to make ethically and morally difficult decisions to save the life of patients are some of the issues, which are threatening the psychological integrity of the HCWs across the globe. The resilience of the HCWs is further compromised by the prevalent stigma,[67] lack of social support,[6] isolation,[8] fear of contagion to their loved ones,[9] working with new and frequently changing protocols, and caring for their colleagues who have fallen sick.[10] In views of these factors, HCWs are more vulnerable to have mental health problems including anxiety, depression, sleep disturbance, and stress.[1112]

Available data from the studies done during the various epidemics and current COVID-19 pandemic suggest that the prevalence of anxiety disorder among HCWs ranges from 10.5% to 44.6%, with a pooled prevalence of 23.2%.[13] Among the doctor and nurses, the pooled prevalence was 17.9% for mild anxiety and 6.9% for moderate-severe anxiety.[1014151617] In terms of depression, the prevalence rate varies from 8.9% to 50.4%, with the pooled prevalence of 22.8%.[13]

In terms of risk factors associated with psychiatric morbidity among the HCWs, some of the studies suggest that psychological morbidity is more among the women,[101819] younger HCWs,[7] nurses (compared to doctors),[10] frontline HCWs (compared = to the administrative staff),[17] parents of dependent children,[8] need to undergo quarantine,[20] working for longer hours than the usual,[1] less experienced,[19] inadequate training,[19] part-time employee,[7] and those with preexisting physical or psychological problems.[18]

Little is understood about the psychiatric morbidity of HCWs from India, in the time of COVID-19 pandemic and only one study so far (n = 152) had evaluated the mental health impact of COVID-19 on doctors in West Bengal which had found that about 34.9% surveyed doctors were depressed, and about 40% had anxiety.[21] In this background, the current study aimed to evaluate the psychological morbidity among HCWs.

MATERIALS AND METHODS

This was a cross-sectional, web-based study, in which data were collected between April 2, 2020, and May 5, 2020. The online bilingual (English and Hindi) survey questionnaire was circulated using e-mail, WhatsApp, text message, etc. Snowball sampling technique was used. The survey link was sent to various HCWs at different hospitals across the country, and they were requested to forward it further. The link was designed in such a way, that only one response can be generated using one device. Approval for this study was obtained from the Ethics Committee of the Indian Psychiatric Society, and the survey was conducted under the aegis of Research and Education Foundation Committee of the Indian Psychiatric Society. Participation in the survey implied consent. The survey questionnaire was designed to collect information about:

Demographics and personal characteristics

A basic information sheet includes the subject's age, gender, marital status, educational qualifications, and current work profile.

A self-designed questionnaire to evaluate the effect of quarantine on stress, anxiety, and feeling of scared and reaction of a family toward the person were included.

Patient Health Questionnaire-9

The Patient Health Questionnaire (PHQ) is a 9-item validated questionnaire, which evaluates depression as per the Diagnostic and Statistical Manual, Fourth revision. Each item is rated on a 4-point scale of “0” (not at all) to “3” (nearly every day), with higher scores indicating a higher level of depression. The scale has excellent reliability and validity, sensitivity and specificity of 88% for major depression. A cutoff score of ≥10 is considered to be an indicator of depression.[22] Hindi translated version of the scale was used which had been well-validated in many previous studies.

Generalized Anxiety Disorder-7 scale

Generalized Anxiety Disorder-7 (GAD-7) is a 7-item anxiety scale, with each item rated on a 4-point scale of 0–3, with higher scores indicating a higher level of anxiety. Cutoff scores of 5, 10, and 15 are interpreted as representing mild, moderate, and severe levels of anxiety on the GAD-7. The scale has adequate psychometric properties in the form of reliability and validity, sensitivity, and specificity.[23] Hindi translatd version of the scale was used which had been well validated in many previous studies.

Data were analyzed using statistical package for social sciences, sixteenth edition (SPSS-16) (SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. Chicago, SPSS Inc.). Continuous variables were analyzed in the form of mean, standard deviation (SD), and median. Categorical variables were assessed as frequency and percentages.

RESULTS

The total number of responses received were 303 responses. The mean age of the participants was 41.2 (SD: 11.1) years. A majority of them were male (69%), married and living with their spouse (69.3%). Majority of the participants had done their postgraduation, were working as faculty members in different institutes, and were posted in speciality outpatient setting at the time of participation in the survey [Table 1]. A small proportion (10.9%) of the respondents had undergone quarantine before the participation in the survey.

Table 1

Demographic and workprofile of the participants (n=303)

Variables	Frequency, n (%)
Age (years), mean (SD)	41.2 (11.1)
Gender
Male	209 (69.0)
Female	94 (31.0)
Marital status
Married and living with spouse	210 (69.3)
Married and staying away from spouse	32 (10.6)
Currently single	61 (31.1)
If you are a health care worker, kindly mention your position
Junior resident	29 (29.6)
Senior resident	38 (12.5)
Faculty member	101 (33.5)
Medical officer	58 (19.1)
Nursing staff	5 (1.7)
Paramedical Staff	72 (23.0)
Place of current work profile
General ward duties	36 (11.9)
Emergency medical OPD	21 (6.9)
Emergwency surgical OPD	3 (1.0)
Specialty OPD	103 (34.0)
Screening of COVID-19 patients (i.e., fever, URTI infection OPD)	14 (4.6)
Managing COVID-19 patients in isolation wards/ICUs	34 (11.2)
Involved in sampling of COVID-19 patients	10 (3.3)
Working in laboratory testing COVID-19 samples	4 (1.3)
Involved in imaging/neuro-imaging testing/X-ray in COVID-19 patients	4 (1.3)
Contact tracing	4 (1.3)
Managing COVID-19 patients in quarantine	3 (1.0)
Part of back-up team	9 (3.0)
Involved in training of healthcare workers	6 (2.0)
Others	52 (17.2)
Have you been quarantine
Yes	33 (10.9)
No	270 (89.1)

OPD - Outpatient department; URTI - Upper respiratory tract infection; ICU - Intensive care unit; SD - Standard deviation

Anxiety and depression in the study participants

Nearly half (46.2%) of the participants had either anxiety disorder or depression or both [Table 2]. One-eighth (12.9%) of HCWs had suicidal behavior (as rated as 1 or more for the item number 9 of PHQ-9).

Table 2

Anxiety and depression in the study participants (n=303)

Variables	Whole sample, frequency, n (%); range, median
Mean GAD-7 score, mean (SD), range (median)	4.8 (5.0), 0-21 (4.0)
Severity of anxiety
Normal (0-4)	164 (54.1)
Mild (5-9)	92 (30.4)
Moderate (10-14)	27 (8.9)
Moderate-severe (15-19)	14 (4.6)
Severe (≥15)	6 (2.0)
Mean PHQ-9 score, mean (SD), range (median)	4.7 (5.5), 0-27 (3.0)
Severity of depression
Minimal (0-4)	191 (63.0)
Mild (5-9)	71 (23.4)
Moderate (10-14)	21 (6.9)
Moderate severe (15-19)	9 (3.0)
Severe (≥20)	11 (3.6)
Overall prevalence
Percentage of responders reporting GAD score ≥5	139 (45.9)
Percentage of responders reporting PHQ-9 score ≥10	41 (13.5)
Number of participants has anxiety disorder only	99 (32.7)
Number of participants has depressive disorder only	1 (0.3)
Number of participants has both anxiety and depressive disorder	40 (13.2)
Any psychiatric illness present	140 (46.2)

GAD-7 - Generalized Anxiety Disorder-7; PHQ - Patient Health Questionnaire-9; SD - Standard deviation

When enquired about the response of the family, about half the participants reported that their family was “mostly/always” happy about their being on duty, worried about they getting ill [Table 3].

Table 3

Reaction of the family toward the health-care workers

Variables	Not at all (%)	Sometimes (%)	Mostly (%)	Always (%)
My family is happy for me being on duty	60 (19.8)	102 (33.7)	98 (32.3)	43 (14.2)
My family is worried about me getting ill	27 (8.9)	138 (45.5)	88 (29.0)	50 (16.5)

Feeling and emotions due to COVID-19 infection

When asked about their emotional response, about two third reported “mostly/always” feeling useful, feeling optimistic, and about half of them reporting feeling proud of self. About one-third were “mostly/always” scared of not getting the PPE [Table 4]. Negative emotions were less often rated as “mostly/always” [Table 4].

Table 4

Feelings and emotions due to corona virus infection

Variables	Not at all (%)	Sometimes (%)	Mostly (%)	Always (%)
Feeling sad	136 (44.9)	137 (45.2)	21 (6.9)	9 (3.0)
Feeling scared	92 (30.4)	164 (54.1)	37 (12.2)	10 (3.3)
Feeling tense	91 (30.0)	152 (50.2)	49 (16.2)	11 (3.6)
Feeling anxious	94 (31.0)	166 (54.8)	30 (9.9)	13 (4.3)
Feeling angry	165 (54.5)	119 (39.3)	15 (5.0)	4 (1.3)
Feeling demoralized	148 (48.8)	126 (41.6)	17 (15.6)	12 (4.0)
Feeling irritable	137 (45.2)	140 (46.2)	22 (7.3)	4 (1.3)
Feeling numb	218 (71.9)	70 (23.1)	9 (3.0)	6 (2.0)
Feeling lonely	168 (55.4)	91 (30.0)	33 (10.9)	11 (3.6)
Feeling socially disconnected	159 (52.6)	97 (32.0)	35 (11.6)	12 (4.0)
Feeling useful	30 (9.9)	72 (23.8)	123 (40.6)	78 (25.7)
Feeling being used	143 (47.2)	97 (32.0)	36 (11.9)	27 (8.9)
Feeling pathetic about self	206 (68.0)	67 (22.1)	19 (6.3)	11 (3.6)
Feeling like running away from work	197 (65.0)	73 (24.1)	19 (6.3	14 (4.6)
Feeling optimistic	38 (12.5)	79 (26.1)	115 (38.0)	71 (23.4)
Feeling helpless	152 (50.4)	114 (37.6)	25 (8.3)	12 (4.0)
Feeling hopeless	188 (62.0)	84 (27.7)	22 (7.3)	9 (3.0)
Scared of contacting the infection	56 (18.5)	170 (56.1)	59 (19.5)	18 (5.9)
Scared of death	179 (59.1)	111 (36.6)	9 (3.0)	4 (1.3)
Feeling proud of yourself	50 (16.5)	85 (28.1)	84 (27.7)	84 (27.7)
Feeling stigmatized	212 (70.0)	71 (23.4)	13 (4.3)	7 (2.3)
Scared that you will not get the support from the administration	88 (29.0)	117 (38.6)	58 (19.1)	40 (13.2)
Scared that you will not get PPEs	83 (27.4)	130 (42.9)	62 (20.5)	28 (9.2)
Feeling angry that there are no adequate safety equipment to function	77 (25.4)	137 (45.2)	61 (20.1)	28 (9.2)
Not able to sleep	159 (52.5)	108 (35.6)	30 (9.9)	11 (3.6)
Worried issues such as food and saftey	148 (48.8)	111 (36.6)	33 (10.9)	11 (3.6)
Tense about increase in workload	173 (57.1)	88 (29.0)	35 (11.6)	7 (2.3)
Tense about getting infected with COVID-19	70 (23.1)	169 (55.8)	44 (14.5)	20 (6.6)
Tense about unknowingly spreading the infection	47 (15.5)	178 (58.7)	58 (19.1)	20 (6.6)

PPE - Personal protective equipment

More than half of the participants responded that they were satisfied with the availability of PPEs such as N95 mask, sanitizers, food, cleanliness, testing, and other supports provided by the organizations [Table 5].

Table 5

Availability and provision of personal protective equipment, food, and testing

Variables	Extremely dissatisfied (%)	Slightly dissatisfied (%)	Neither satisfied nor dissatisfied (%)	Slightly satisfied (%)	Extremely satisfied (%)
Availability of sanitizers	38 (12.5)	40 (13.2)	44 (14.5)	81 (26.7)	100 (33.0)
Availability of masks (n-95)	75 (24.8)	55 (18.2)	34 (11.2)	69 (22.8)	70 (23.1)
Availability of masks other than (n-95)	33 (10.9)	46 (15.2)	49 (16.2)	75 (24.8)	100 (33.0)
Availability of PPEs	75 (24.8)	55 (18.2)	45 (14.9)	74 (24.4)	54 (17.8)
Cleaning of the area	47 (15.5)	50 (16.5)	36 (11.9)	82 (27.1)	88 (29.0)
Transport	45 (14.9)	29 (9.6)	69 (22.8)	81 (26.7)	79 (26.1)
Food	31 (10.2)	32 (10.6)	66 (21.8)	71 (23.4)	103 (34.0)
Provision of testing	66 (21.8)	54 (17.8)	57 (18.8)	82 (27.1)	44 (14.5)
Provision of qauratnine, in case if you are suspected/infected with COVID-19	62 (20.5)	38 (12.5)	81 (26.7)	60 (19.8)	62 (20.5)

PPE - Personal protective equipment

Factors associated with Psychiatric morbidity

When those who had undergone quarantine were compared with those who had not undergone quarantine, it was seen that those who had undergone quarantine had a higher level of anxiety (<0.001***) and depression (<0.001***) scores. They also had a higher prevalence of anxiety disorder (<0.001***). Compared to males, female participants had significantly higher anxiety (0.001***) and depression (0.002**) scores. When those who were aged <30 years were compared with those ≥30 years, it was seen that younger people had more anxiety (0.001***) and depression (<0.001***) scores and also had a higher prevalence of depression (<0.001***) and anxiety disorder (0.019*). When doctors were compared with paramedical staff, doctors had higher anxiety (0.03*) and depression (0.004**) scores and also had a higher prevalence of depression (0.037*) and anxiety disorder (0.006**). When those who had done duty in the COVID areas and those who had not done duty in the COVID area were compared, it was seen that those who had done duty in COVID area had higher depression (0.002**) and anxiety (0.013*) scores and had a higher prevalence of depression (<0.001***).

DISCUSSION

In the challenging times of outbreak of the COVID-19, HCWs across the globe are at the forefront of prevention of spread of COVID-19 and treatment of patients who developed COVID-19 infection. This has not come without the extra-effort by the HCWs belonging to all the cadres. The present study reflects the psychological impact of the pandemic on the HCWs. In the present study, nearly half of the HCWs reported anxiety or depression or both. Prevalence of anxiety was significantly higher than that reported for depression. Studies done on HCWs, using the similar scales across the different parts of the globe, suggest the prevalence of anxiety to varying between 10.5% and 44.7% and that of depression vary between 8.9% and 50.7%.[10141516171824252627] Findings of the present study are in this reported range. The prevalence of current depressive and anxiety disorders as per the National Mental Health Survey (NMHS) data is 0.8% and 3.6%, respectively, in India.[28] Although, it can be argued that the NMHS relied on diagnosing psychiatric disorders using Mini International Neuropsychiatric Interview, and the present study relied on the use of PHQ-9 and GAD-7, the considerable difference in the prevalence cannot be attributed entirely to the methodological differences. Hence, it can be said that the pandemic has led to an increase in the psychiatric morbidity among the HCWs, who has been working in adverse situations and facing multiple mental health issues.[29] Another survey, which was done during this pandemic, has also come up with similar prevalence rates for depression and anxiety among the HCWs.[30] All these findings suggest that there is an urgent need to screen all the HCWs for mental morbidity and they must be provided adequate psychological support while providing the services during this COVID times. In the present study, participants who were females and had undergone quarantine reported higher level and higher prevalence of anxiety and depression. Previous studies have also shown a similar association of higher level of anxiety and depression with female gender.[1026] Higher prevalence of anxiety and depression among those who had undergone quarantine and had done COVID-19 duties is understandable. Previous studies have also reported a higher prevalence of common mental disorders (such as anxiety and depression) in people who undergo quarantine[3132] and worked with patients with COVID-19 infection.

Besides psychiatric morbidity, in terms of emotional response, about two-thirds of the participants reported “mostly/always” feeling useful, feeling optimistic, and about half of them reporting feeling proud of self. These factors possibly reflect the personality dimension of the HCWs, who despite working in adverse situations and at risk of infection for themselves and their family members, were dedicated to their work like soldiers. Similarly, nearly half of the participants also reported that, despite their families being worried about them getting ill were happy about them being on duty. These factors also reflect the supportive nature of the families of the HCWs. Previous studies have not assessed these dimensions. Hence, it is not possible to compare these findings with the existing literature. About one-fourth to one-third of the participants were not happy with various measures such as availability of PPEs, N-95 mask, availability of sanitizers, and provisions made for quarantine. These findings are worrisome and suggest that there is a need to improve these provisions, for the HCWs to feel safe while working. Governments should not compromise on these and should provide adequate protection to all the HCWs.

The present study has certain limitations, which include small sample size and relying on snowball sampling. Information was not available about the speciality of the participants; hence, the present study does not provide any information about the level of anxiety and depression across different speciality areas. The present study did not evaluate other factors such as social support, support from the organization, access to psychological intervention, training received or not, any extra compensation received or not for COVID duties, history of physical or psychological disorder, societal support, and self-stigma. Further, the present study also did not evaluate the personality dimension, sleep disorders, coping, substance dependence, and duration of duty hours. All these variables can influence the prevalence of psychiatric morbidity. Further, other limitations associated with web-based surveys (using Whatsapp®platform) such as unable to determine the response rate, inability to get the information of nonresponders, possibility of one responder participating through different browser/second sim card/device, etc., are applicable to the current study too.

CONCLUSIONS

To conclude, the present study suggests that about half of the HCWs were suffering from psychiatric morbidity, in the wake of the COVID-19 pandemic. Psychiatric morbidity is mainly in the form of issues related to anxiety. Accordingly, there is a need to develop a plan to assess all the HCWs for psychiatric morbidity and provide them with psychological support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.