Anxiety and depression among medical doctors in Catalonia, Italy, and the UK during the COVID-19 pandemic.

Healthcare workers have had the longest and most direct exposure to COVID-19 and consequently may suffer from poor mental health. We conducted one of the first repeated multi-country analysis of the mental wellbeing of medical doctors (n = 5,275) at two timepoints during the COVID-19 pandemic (June 2020 and November/December 2020) to understand the prevalence of anxiety and depression, as well as associated risk factors. Rates of anxiety and depression were highest in Italy (24.6% and 20.1%, June 2020), second highest in Catalonia (15.9% and 17.4%, June 2020), and lowest in the UK (11.7% and 13.7%, June 2020). Across all countries, higher risk of anxiety and depression symptoms were found among women, individuals below 60 years old, those feeling vulnerable/exposed at work, and those reporting normal/below-normal health. We did not find systematic differences in mental health measures between the two rounds of data collection, hence we cannot discard that the mental health repercussions of the pandemic are persistent.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has affected many individuals both directly and indirectly, disrupting routines and introducing new stressors [1]. Recent studies have shown that the pandemic has unequal effects on the psychological wellbeing of individuals, with women, younger individuals, and ethnic minorities being disproportionately affected [2, 3]. Effects also vary by occupational groups as certain jobs expose workers more directly to the disease [4-6]. The mental wellbeing of healthcare workers has been particularly affected by the pandemic [7-10].

Healthcare workers have been directly involved in the management of COVID-19 patients since the beginning of the pandemic. Drawing on the experiences of healthcare workers during the 2003 SARS outbreak, various mental health risk factors have been identified: lack of personal protective equipment (PPE), overwhelming workload, lack of institutional support, and fear of infecting others [11-14]. Several studies have documented high rates of anxiety and depression symptoms among healthcare workers during the COVID-19 pandemic, with various risk factors such as fear of infection being identified as important [7, 8]. Most of the studies are from China [8, 9, 15] and a handful document similar patterns in other regions [10].

Various local and national mental health institutions around the world have begun to offer psychological assistance to those in need, with some services targeted specifically at healthcare workers [16-19]. Poor mental health among healthcare workers may have downstream effects on patients via worsened attention span, cognitive function, and clinical decision making [10]. Providing such assistance to healthcare workers requires understanding the state of their mental wellbeing, factors associated with mental health symptoms, and how these outcomes and factors vary across time and countries.

The aim of this study is to estimate the prevalence of anxiety and depression symptoms among medical doctors in multiple countries during the pandemic, as well as the risk factors associated with those symptoms. Drawing on the existing literature [7–9, 20–23], we hypothesize that certain demographic characteristics (e.g. sex and age), workplace safety (e.g. lack of necessary PPE), COVID-19 experience (e.g. directly treating COVID-19 patients), and health and lifestyle factors (e.g. long working hours) are associated with anxiety and depression.

This study provides one of the first repeated cross-country analyses of mental wellbeing among healthcare workers during the COVID-19 pandemic. Our sample comprises medical doctors working in Catalonia, Italy, or the UK in June (first data collection round) and November/December 2020 (second data collection round). Both the monthly COVID-19 prevalence and mortality rates increased between the two data collection rounds (S1 Table in S1 Appendix). COVID-19 cases per 100,000 increased from 33.3 (June 2020) to 809.6 (November 2020) in Catalonia, from 12.5 (June 2020) to 836.3 (December 2020) in Italy, and from 55.6 (June 2020) to 927.1 (November 2020) in the UK. Between the two rounds of data collection, COVID-19 deaths per 100,000 increased from 2.4 to 22.2 in Catalonia, from 2.2 to 30.7 in Italy, and from 4.4 to 17.8 in the UK.

In contrast to existing studies, our data allow us to quantify the prevalence of and risk factors associated with anxiety and depression symptoms across countries and to examine these outcomes at two timepoints. While previous studies have investigated heterogeneous samples of healthcare workers, our analysis focuses on medical doctors. The results of our study can inform how to protect and promote the mental wellbeing of medical doctors in current and future pandemics.

Methods

We conducted an anonymous survey, The Healthcare Workers Survey, approved by the University of Exeter Business School Research Ethics Committee (eUEBS003024). Informed written consent was provided by all survey participants prior to their participation. Participants understood that they may withdraw from the study at any time. We followed the reporting guidelines of the American Association for Public Opinion Research (S2 Table in S1 Appendix).

The study is a repeated cross-sectional survey among members of 6 medical organizations: the COMB (Barcelona Medical Council) and the COMG (Girona Medical Council) in Catalonia (Spain), Anaao-Assomed (Union of physicians and healthcare executives) and the FIMMG (Union of general practitioners) in Italy, as well as the RCPSG (Royal College of Physicians and Surgeons of Glasgow) and the RCSEd (Royal College of Surgeons of Edinburgh) in the UK.

Due to different membership rules, members of the Catalan and Italian institutions work in Catalonia and Italy, while the Scottish institutions have members who work in different parts of the UK (S3 Table in S1 Appendix). The survey was designed in Qualtrics and was distributed via email by the corresponding institutions.

Participants

Our data collection relied on the mailing lists of the respective medical organizations. The COMB invited 5,062 members in June and November 2020 (19.9%), focusing on those with medical license numbers ending in 1 or 2 (S1 Fig in S1 Appendix). This random sampling was chosen to avoid over-burdening members, given that other surveys were taking place at the same time. The other institutions sent invitations to all members. The COMG invited 3,120 members in June and November 2020. Similarly, the Anaao-Assomed invited 23,379 members, and the FIMMG invited 17,686 members in June and December 2020. The RCPSG invited 3,990 members in June 2020 and 4,300 members in November 2020 (S2 Fig in S1 Appendix). The RCSEd invited 4,992 members in June 2020 and 4,912 members in November 2020 (S3 Fig in S1 Appendix).

We included in our final sample those respondents that satisfy the following criteria (see S4 Table in S1 Appendix): (a) for whom we had information on sex, age, household composition, occupation, and specialty; (b) were working in the same region/country as the medical institution that they are a member of; (c) were medical professionals; (d) had typical work arrangements when surveyed (not retired, on leave, or shielding). In the first round, out of approximately 55,000 invited members, the final sample size was 3,025 (5.5%). In the second round, the final sample size was 2,250 (4.1%). The total number of respondents by region/country was: 1,849 in Catalonia (n = 876 in round 1, n = 973 in round 2); 2,574 in Italy (n = 1,637 in round 1, n = 937 in round 2); 852 in the UK (n = 512 in round 1, n = 340 in round 2). (S5 Table in S1 Appendix) documents the response rates across institutions.

Due to regional/country differences, including language differences (Catalan, English, Italian), the medical doctors at each institution have different occupation titles. For example, in the UK the occupational categories were: Consultant, Specialty Doctor and Associate Specialist (SAS), Specialty registrar, Junior doctor core training, Junior doctor foundation year, General practitioner, General practitioner trainee. In our statistical analysis, we accounted for both country and institutional differences in occupational titles.

Outcomes and covariates

The outcomes of the study are anxiety and depression symptoms. Anxiety is measured with the Generalized Anxiety Disorder (GAD-7) questionnaire, a seven-item self-report anxiety questionnaire designed to assess health status during the previous two weeks [24, 25]. It has been validated as an anxiety screening tool and severity measure in different populations [24, 26–28]. GAD-7 scores range from 0 to 21. When used as a binary anxiety indicator, a score of 10 is the recommended threshold for referral for further evaluation [24, 29]. Using this threshold, the GAD-7 has sensitivity of 89% and specificity of 82% for generalized anxiety disorder [24, 29].

Depression is measured with the depression module of the Patient Health Questionnaire (PHQ-9), which focuses on the nine diagnostic criteria for DSM-IV depressive disorders [30]. It is a useful tool to assist clinicians in diagnosing depression and a reliable and valid measure of depression severity [30, 31]. It has been validated in a variety of populations [25, 32, 33]. PHQ-9 scores range from 0 to 27. When used as a binary depression indicator, 10 is the recommended cut-off point. Using this threshold, the PHQ-9 has sensitivity and specificity of 88% for major depression [30, 32].

The following covariates were included in our analysis: demographic characteristics (sex, age, household composition), survey round (June vs. November/December 2020), perceptions about workplace safety (availability of PPE, reported feelings of vulnerability and exposure, perceived workplace concerns about workers safety), COVID-19 exposure (symptoms, directly treating COVID-19 patients, helping with COVID-19 tasks, healthcare worker deaths due to COVID-19 in the workplace), and health and lifestyle factors (self-reported health status, underlying health condition, working over 40 hours in the previous week, smoking behavior, whether the respondent had a flu vaccine this season). We created a binary variable “normal/below-normal health” that equals 1 if the respondent reported 3 or below on the 1–5 Likert scale for health status, where higher values correspond to better health, and zero otherwise. (S6 Table in S1 Appendix) describes all the variables. The replication data and code are available in S1 File.

Statistical analysis

First, we described the demographic characteristics of our respondents. Second, we calculated the prevalence of anxiety and depression symptoms by country over time. Third, we calculated the prevalence of anxiety and depression by sex and age in each country. Fourth, we estimated the perceptions of workplace safety and exposure to COVID-19 by country over time. Finally, we used multivariable logistic regression to estimate odds ratios (ORs) for the association between anxiety (and depression) symptoms and the aforementioned covariates, controlling for occupational indicators and institutional indicators (i.e. COMB, COMG, Anaao-Assomed, FIMMG, RCPSG, RCSEd). The inclusion of both country-specific occupational indicators and institutional indicators allows us to account for region/country and institutional differences in occupational titles. Stata statistical software version 16.1 (StataCorp) was used for statistical analyses. P-values were 2-sided and statistical significance was set at p<0.05. Data were analyzed from March 4 to June 4, 2021.

Results

presents demographic characteristics of the participants by region/country and round. The percentage of respondents who were women and men differed across countries. In Italy, it was similar (50%). However, over 64% of respondents were women in Catalonia and below 35% were women in the UK. The age distribution of respondents also varied by country. The percentage of respondents younger than 60 years was over 83% in the UK, below 73% in Catalonia and below 60% in Italy.

documents the prevalence of moderate/above-moderate symptoms of anxiety (GAD-7≥10) and depression (PHQ-9≥10) by country over time. In June 2020 the prevalence of moderate anxiety (panel A) was higher in Italy (24.6% [95% CI, 22.5%-26.7%]) than in Catalonia (15.9% [95% CI, 13.4%-18.3%]) and the UK (11.7% [95% CI, 8.9%-14.5%]). A similar conclusion emerges when looking at round 2. In June 2020, the prevalence of moderate/above-moderate depression (panel B) was highest in Italy (20.1% [95% CI, 18.2%-22.0%]), second highest in Catalonia (17.4% [95% CI, 14.8%-19.9%]), and lowest in the UK (13.7% [95% CI, 10.7%-16.7%]). In round 2, the prevalence of moderate/above-moderate depression was higher in Italy (21.7% [95% CI, 19.0%-24.3%]) than in Catalonia (15.9% [95% CI, 13.6%-18.2%]). There were no differences in the prevalence of anxiety and depression across the two rounds of the survey in any of the countries/regions, suggesting that the mental health repercussions of the pandemic might be persistent. (S4 Fig in S1 Appendix) presents a further breakdown of the prevalence of symptoms depending on intensity.

Prevalence of anxiety and depression symptoms by country over time.

Grey bars correspond to Nov 2020 for Catalonia and UK, and to Dec 2020 for Italy. Anxiety symptoms = 1 if GAD-7 ≥ 10 and depression symptoms = 1 if PHQ-9 ≥ 10. 95% confidence intervals.

investigates the differences in the prevalence of moderate/above-moderate symptoms of anxiety and depression by sex and age across countries. Panel A shows that the prevalence of moderate/above-moderate symptoms of anxiety was higher among women than among men in Catalonia (women: 17.3%, [95% CI, 15.2%-19.5%], men: 10.2%, [95% CI, 7.9%-12.6%]) and Italy (women: 32.4%, [95% CI, 29.8%-35.0%], men: 19.7%, [95% CI, 17.6%-21.9%]). Panel B shows that the prevalence of moderate/above-moderate symptoms of depression was higher among women than among men in Catalonia (women: 19.0%, [95% CI, 16.8%-21.2%], men: 12.1%, [95% CI, 9.6%-14.6%]) and Italy (women: 26.3%, [95% CI, 23.8%-28.7%], men: 15.3%, [95% CI, 13.4%-17.3%]). Panel C shows that the prevalence of moderate/above-moderate symptoms of anxiety was higher among younger (<60 y) than older (≥60 y) respondents in all three countries: Catalonia (<60 y: 17.0%, [95% CI, 15.0%-19.0%], ≥60 y: 9.3%, [95% CI, 6.8%-11.9%]), Italy (<60 y: 29.3%, [95% CI, 26.9%-31.6%], ≥60 y: 21.5%, [95% CI, 19.0%-23.9%]), and the UK (<60 y: 15.6%, [95% CI, 12.9%-18.2%], ≥60 y: 7.2%, [95% CI, 2.8%-11.5%]). Similarly, Panel D shows that the prevalence of moderate/above-moderate symptoms of depression was higher among younger (<60 y) than older (≥60 y) respondents across all countries.

Prevalence of anxiety and depression by sex and age across countries.

Grey bars are for women (panel A and B) and over 60 (panels C and B). Anxiety symptoms = 1 if GAD-7 ≥ 10 and depression symptoms = 1 if PHQ-9 ≥ 10. 95% confidence intervals.

describes perceptions of workplace safety and exposure to COVID-19. Around half of Italian respondents did not agree with the statement “my workplace is providing me with the necessary PPE” in June 2020 (50.1%, [95% CI, 47.6%-52.6%] (panel A). This decreased to 30.1% [95% CI, 27.1%-33.1%] in December 2020. In Catalonia, the percentage was 25.8% [95% CI, 22.8%-28.7%] in June 2020, and decreased to 15.4% [95% CI, 13.0%-17.7%] in November 2020. In the UK, 16.1% [95% CI, 12.9%-19.4%] of respondents disagreed with this statement in June 2020 and only 1 in 10 respondents disagreed with this statement in November 2020 (10.1%, [95% CI, 6.8%-13.3%]). Panel B shows that the percentage of respondents who agreed with the statement “I feel vulnerable and exposed at work” remained constant between rounds; including 1 in 5 respondents in Catalonia and the UK, and nearly 1 in 2 in Italy. It is notable that the country with the lowest rates of perceived workplace safety (Italy) also has the highest rates of anxiety symptoms.

Perceptions of safety and COVID-19 exposure in the workplace.

Panel A: Percentage of respondents who did not agree with the statement “my workplace is providing me with the necessary Protective Personal Equipment”. Panel B: Percentage of respondents who agreed/strongly agreed with the statement “I feel vulnerable and exposed at work”. Panel C: Percentage of respondents who “directly looked after COVID-19 patients last week”. Panel D: Percentage of respondents who were aware of “at least one COVID-19 death among healthcare workers in their workplace”.

Panel C illustrates that the percentage of respondents that have “directly looked after COVID-19 patients last week” increased between June and November 2020 in Catalonia (29.6%, [95% CI, 26.6%-32.7%] to 43.4%, [95% CI, 40.4%-46.8%]) and between June and November 2020 in Italy (25.0% [95% CI, 22.9%-27.1%] to 58.0% [95% CI, 54.8%-61.2%]). In contrast, the percentage remained similar between the two rounds in the UK (30.2% [95% CI, 26.1%-34.2%] vs. 34.3% [95% CI, 29.2%-39.4%]). Lastly, Panel D shows that 1 in 5 respondents in Catalonia were aware of at least one COVID-19 death among healthcare workers in their workplace in June 2020 and November 2020. In Italy, this ratio increased from 1 in 3 in June 2020 (31.4%, [95% CI, 29.1%-33.7%]) to 2 in 5 in December 2020 (40.6%, [95% CI, 37.4%-43.8%]). In the UK, it remained constant at about 1 in 3 respondents. The increase across survey rounds in the percentage of medical doctors directly treating COVID-19 patients in the last week in Catalonia and Italy matches the evolution of the pandemic reported in S1 Table in S1 Appendix.

After pooling together all countries and the two rounds of data, displays the odds-ratios (ORs) of various risk factors estimated using a multivariable logit specification with binary anxiety and depression indicators as the dependent variables. In this figure, we focus on factors that related literature has demonstrated to be correlated with mental health [7–9, 20–23]. In addition to the variables listed in the figure, the regression also controls for indicators for smoking, a flu vaccine this season, living with a child under 5, living with someone over 60, occupational indicators, and institutional indicators. (S7 Table in S1 Appendix) reports full regression tables for the pooled sample and separate countries.

Risk factors of anxiety and depression symptoms, odds ratios and 95% CI.

The figure displays the odds ratio of each variable (and its corresponding 95% CI) from a multivariable logistic regression pooling across all countries and timepoints. The dependent variables are binary indicators for anxiety (circle markers) or depression (diamond markers).

Controlling for health behaviors, household composition, occupational indicators and institutional indicators, women, younger individuals (< 60 years), those who feel vulnerable and exposed at work, those who think that their workplace has shown little concern for their safety, those who directly looked after COVID-19 patients last week, those with normal/below-normal health status (i.e. with a self-reported health status of 3 or below on a 1–5 Likert scale, where higher values correspond to better health), and those who worked over 40 hours last week had higher odds of anxiety and/or depression symptoms.

Women had higher odds of anxiety (OR = 1.77 [95% CI, 1.50–2.07]) and depression (OR = 1.76 [95% CI, 1.49–2.09]) compared to men. Compared with individuals above 60 years, younger individuals had higher odds of anxiety (OR = 1.49 [95% CI, 1.22–1.82]) and depression (OR = 1.58 [95% CI, 1.28–1.96]). A reported lack of necessary PPE in the workplace was associated with higher odds of anxiety (OR = 1.39 [95% CI, 1.15–1.68]) and depression (OR = 1.27 [95% CI, 1.04–1.56]). Respondents who felt vulnerable or exposed in their workplace had greater odds of anxiety and depression symptoms compared with respondents who did not feel vulnerable or exposed (OR = 1.68 [95% CI, 1.41–2.00]; OR = 1.72 [95% CI, 1.43–2.06]). Compared with respondents who reported above-normal health (i.e. above 3 on a 1–5 scale), individuals who reported a normal/below-normal health status (i.e. 3 or below on a 1–5 scale), had higher odds of anxiety (OR = 2.58 [95% CI, 2.13–3.13]) and depression (OR = 3.35 [95% CI, 2.76–4.06]). Compared with individuals who worked below 40 hours, those who worked 40 hours or more last week had higher odds of anxiety (OR = 1.44 [95% CI, 1.21–1.70]) and depression (OR = 1.27 [95% CI, 1.07–1.52]). (S6 Table in S1 Appendix) shows that these patterns hold for specific countries too.

Discussion

This is one of the few studies to provide a multi-country analysis of the mental wellbeing of medical doctors at two timepoints during the COVID-19 pandemic. Among respondents from Catalonia, Italy and the UK, the prevalence of anxiety and depression was highest among medical doctors in Italy, with 1 in 4 suffering from anxiety symptoms in June and December 2020 and 1 in 5 suffering from depression symptoms over the same period. Within each country, no difference in the prevalence of anxiety and depression were reported between the first and second rounds of the survey. Hence, we cannot discard that the mental health repercussions of the pandemic are persistent.

In Catalonia, Italy, and the UK, higher risk of anxiety and depression symptoms was found among women, individuals below 60 years old, those feeling vulnerable/exposed at work, and those reporting normal/below-normal health. These associated risk factors provide a few possible reasons for the variation in the prevalence of anxiety and depression across countries. For example, the percentage of respondents who reported a lack of necessary PPE and reported feeling vulnerable and exposed at work was highest in Italy, where rates of anxiety and depression were also highest.

Our findings are consistent with other studies that have examined the rates of anxiety and depression among healthcare workers during the pandemic. In Spain, Alonso et al. [20] find that among 9,138 respondents (26.4% physicians, 77.3% women) working in 6 places (including Catalonia) during May and September 2020, the prevalence of depression (PHQ-8≥10) and anxiety (GAD-7≥10) was 22.4% (vs. 16.5% in our Catalan sample) and 17.0% (vs. 14.9% in our Catalan sample). In Italy, Rossi et al. [21] find that among 1,379 respondents (31.4% physicians, 77.2% women) surveyed in March 2020, the prevalence of depression (PHQ-9≥15) and anxiety (GAD-7≥15) was 24.7% (vs. 6.6% in our Italian sample) and 19.8% (vs. 9.5% in our Italian sample). Conti et al. [34, 35] find similar magnitudes. In the UK, Greenberg et al. [36] find that among 709 staff (41% doctors) working in English hospitals in summer 2020, the prevalence of moderate (PHQ-9≥10) and severe (PHQ-9≥20) depression was 37% and 6%, respectively (26% and 6% among doctors, vs. 16.2% and 2.7% in our UK sample), and that the prevalence of moderate (GAD-7≥10) and severe (GAD-7≥15) anxiety was 27% and 11%, respectively (20% and 8% among doctors, vs. 14.2% and 5.9% in our UK sample). Greene et al. [37] find comparable rates.

Our findings are also consistent with studies investigating risk factors of mental health among healthcare workers. In a review of 24 studies, De Kock et al. [7] show that risk factors included underlying health, being female, concerns about workplace safety [22, 23], contact with COVID-19 [8, 38, 39], and concerns about the wellbeing of others [22]. In Spain, Alonso et al. [20] find that healthcare professionals frequently exposed to COVID-19 patients were statistically significantly more likely to experience mental health disorders (OR = 3.98, 95% CI: 3.27–4.85). In Italy, Rossi et al. [21] find that being female was associated with higher GAD-7 (OR = 2.18, 95% CI: 1.49–3.19) and PHQ-9 scores (OR = 2.03, 95% CI: 1.44–2.87). In the UK, Siddiqui et al. [40] find that among 558 healthcare professionals (51% doctors, 31% nurses), concerns about exposure to COVID-19 and the lack of PPE were important causes of anxiety.

Contributions

Our study contributes to monitoring the mental wellbeing of medical doctors during the COVID-19 pandemic. Including multiple countries and timepoints allow comparison between different settings, and improves our understanding about how medical doctors have been affected at different points during the pandemic. The similar patterns across countries suggest that our findings may be generalizable to other European settings. Rather than relying on online convenience samples, our sampling technique relies on the institutional mailing lists of medical organizations. In comparison to previous studies, we focus on medical doctors rather than a broader group of healthcare workers.

Limitations

This study has several limitations. First, when comparing two cross-sectional surveys for each country, we were not necessarily comparing the same individuals. Differences in prevalence of mental health symptoms could be driven by changes in sample composition across waves. Relatedly, the survey did not take place at the same point during an epidemic wave in data collection rounds 1 and 2.

Second, participants in our survey are not necessarily representative of the underlying populations of medical doctors and may be self-selected since they voluntarily take part in the survey. Reporting bias is likely. If individuals with symptoms were more likely to respond (e.g. to express grievances), then our estimates may be higher than the population average. Conversely, if individuals with above-average symptoms were less likely to respond (e.g. due to time constraints), then our estimates may be below the population average.

Third, anxiety and depression symptoms may not be comparable across countries due to different reporting norms in the GAD-7 and PHQ-9 questionnaires. Reassuringly, our pooled multivariable logistic regressions produce similar results even when controlling for occupation and institution indicators.

Finally, our measures of anxiety and depression are not based on an objective diagnosis made by a clinician.

Conclusion

The COVID-19 pandemic has been classified as a traumatic event [1]. Healthcare workers have arguably had the most direct and longest exposure to this disease. Our study identified a high prevalence of anxiety and depression among medical doctors in both the first and second waves of the pandemic, contributing to a wider literature examining the effects of traumatic events on mental wellbeing [41], especially on those who are most exposed because of the demands of their occupation. The results of this study suggest that institutional support for healthcare workers, and in particular medical workers, is important in protecting and promoting their mental health in the current and in future pandemics.

Online supporting materials.

(PDF)

Click here for additional data file.

Files (code and data) to replicate the findings in this article.

(7Z)

Click here for additional data file.

24 Aug 2021

PONE-D-21-22042

Anxiety and Depression among Medical Doctors in Catalonia, Italy, and the UK during the COVID-19 Pandemic

PLOS ONE

Dear Dr. Quintana-Domeque,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 08 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Gabriel A. Picone

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

4. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I am pleased to send my comments for the Manuscript “Anxiety and Depression among Medical Doctors in Catalonia, Italy, and the UK during the COVID-19 Pandemic”. This manuscript describes a cross-country study aimed to investigate the prevalence of anxiety and depression in medical doctors at two-time points during the COVID-19 pandemic. The Authors address an important topic, the manuscript is a valuable contribution to the literature and is written clearly. I would ask the Authors to address minor amendments, as follows:

1. In the Introduction section, the Authors should specify the aims and the hypotheses of the study.

2. In the Methods section:

- The inclusion and exclusion criteria of the sample should be specified.

- In the Participants section, I suggest describing the occupational categories of participants. For example, in the Statistical Analysis section, the Authors reported the following occupational categories for UK participants (line 102, p. 6): “Consultant, SAS doctor, Specialty registrar, Junior doctor core training, Junior doctor foundation year, General practitioner, General practitioner trainee”. To avoid repetitions, this sentence could be moved and extended in the description of the sample.

3. In the Results section:

- To avoid reader confusion, the sentence on lines 109-112 (p. 6) should be moved to the Participants section. In fact, this sentence refers to the original and final sample sizes and not to Table 1 of the Results.

- The sentence on lines 116-121 (pp. 6 - 7) describes the increase in COVID-19 cases during the data collection period. It is a description of the context in which the study was carried out, rather than a result of the Authors. For this reason, I suggest moving this sentence to the Introduction section. Panel B could be moved to supplementary material.

- I recommend summarizing the description of Figure 4 (lines 199-205, p. 10) and reporting only the essential information. The sentence at lines 202-205 [“In addition to the variable listed in the figure, the regression also controls for indicators for smoking, a flu vaccine this season, living with a child under 5, living with someone over 60, occupational codes, and institutional codes. Table S6 (S1 Appendix) reports full regression tables for the pooled sample and separate countries”] could be eliminated.

- Referring to logistic regression analysis, it is unclear why the Authors did not show results for some covariates (i.e., health behaviors, household composition, occupational categories, and medical organization indicators). This should be clarified, and the results described.

4. In the Discussions section, the Authors state that “Within each country, no difference in the prevalence of anxiety and depression were reported between the first and second rounds of the survey” (lines 224 – 226, p. 11). However, this is not specified in the Results section. I recommend describing these results also in the Results section, referring to the table where the data are reported.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

7 Sep 2021

[1.] In the Introduction section, the Authors should specify the aims and the hypotheses of the study.

Answer: Thank you for this suggestion. We have now specified the aims and hypotheses of the study in Paragraph 4 of the introduction. Specifically, our aim is to estimate the prevalence of anxiety and depression symptoms among medical doctors in multiple countries during the pandemic, as well as the risk factors associated with those symptoms. Drawing on the existing literature, our hypothesis is that certain demographic characteristics (e.g. sex and age), workplace safety (e.g. lack of necessary PPE), COVID-19 experience (e.g. directly treating COVID-19 patients), and health and lifestyle factors (e.g. long working hours) are associated with anxiety and depression.

[2.] In the Methods section:

The inclusion and exclusion criteria of the sample should be specified.

Answer: Thank you for this suggestion. Paragraph 2 of the “Participants” section specifies the criteria for including respondents in our sample.

In the Participants section, I suggest describing the occupational categories of participants. For example, in the Statistical Analysis section, the Authors reported the following occupational categories for UK participants (line 102, p. 6): “Consultant, SAS doctor, Specialty registrar, Junior doctor core training, Junior doctor foundation year, General practitioner, General practitioner trainee”. To avoid repetitions, this sentence could be moved and extended in the description of the sample.

Answer: In Paragraph 3 of the “Participants” section, we clarify that due to regional/country differences, including language differences (English, Catalan, Italian), the medical doctors at each institution have different occupation titles. We provide the UK occupation category as an example to avoid translation-related issues. In this paragraph, we also clarify that we account for institutional differences in occupational titles in our statistical analysis. Our methods for doing so (including indicators for all occupational categories and institutions) is expanded further in the “Statistical analysis section”.

[3.] In the Results section:

To avoid reader confusion, the sentence on lines 109-112 (p. 6) should be moved to the Participants section. In fact, this sentence refers to the original and final sample sizes and not to Table 1 of the Results.

Answer: Thank you for this suggestion. We have moved sentences on lines 109-112 in the original manuscript to the “Participants” section.

The sentence on lines 116-121 (pp. 6 - 7) describes the increase in COVID-19 cases during the data collection period. It is a description of the context in which the study was carried out, rather than a result of the Authors. For this reason, I suggest moving this sentence to the Introduction section. Panel B could be moved to supplementary material.

Answer: Thank you for this suggestion. We have moved sentences on lines 116-121 in the original manuscript to the introduction. The information in Table 1, Panel B of the original manuscript is now presented in S1 Appendix, Table S1.

I recommend summarizing the description of Figure 4 (lines 199-205, p. 10) and reporting only the essential information. The sentence at lines 202-205 [“In addition to the variable listed in the figure, the regression also controls for indicators for smoking, a flu vaccine this season, living with a child under 5, living with someone over 60, occupational codes, and institutional codes. Table S6 (S1 Appendix) reports full regression tables for the pooled sample and separate countries”] could be eliminated.

Answer: Thank you for this suggestion. We have condensed the legend of figure 4 and moved the additional detail to the main text.

Referring to logistic regression analysis, it is unclear why the Authors did not show results for some covariates (i.e., health behaviors, household composition, occupational categories, and medical organization indicators). This should be clarified, and the results described.

Answer: Thank you for this clarification. We chose to focus on the variables in figure 4 because these are the key variables that the related literature has demonstrated to be correlated with mental health (namely demographic characteristics, workplace safety, COVID-19 experience, lifestyle factors) and therefore forms the basis of our hypotheses. In the updated manuscript, we provide an explanation for why we focus on these sets of covariates.

[4.] In the Discussions section, the Authors state that “Within each country, no difference in the prevalence of anxiety and depression were reported between the first and second rounds of the survey” (lines 224 – 226, p. 11). However, this is not specified in the Results section. I recommend describing these results also in the Results section, referring to the table where the data are reported.

Answer: Thank you for this suggestion. We have included a sentence at the end of Paragraph 2 of the “Results” section describing the similarity of anxiety and depression rates across the two rounds of data collection.

Submitted filename: Answers_to_R1.docx

Click here for additional data file.

15 Oct 2021

Anxiety and Depression among Medical Doctors in Catalonia, Italy, and the UK during the COVID-19 Pandemic

PONE-D-21-22042R1

Dear Dr. Quintana-Domeque,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Gabriel A. Picone

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I believe the Authors have responded well to my comments and suggestions. Thus, I endorse the current version of the manuscript for publication.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Roberta Lanzara

20 Oct 2021

PONE-D-21-22042R1

Anxiety and Depression among Medical Doctors in Catalonia, Italy, and the UK during the COVID-19 Pandemic

Dear Dr. Quintana-Domeque:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Gabriel A. Picone

Academic Editor

PLOS ONE

Table 1

Demographic characteristics of respondents.

	Catalonia		Italy		UK
	Round 1	Round 2	Round 1	Round 2	Round 1	Round 2
Men	311 (35.50)	326 (33.50)	846 (51.68)	468 (49.95)	358 (69.92)	358 (65.00)
Women	565 (64.50)	647 (66.50)	791 (48.32)	469 (50.05)	154 (30.08)	154 (35.00)
Age < 60	633 (72.26)	702 (72.15)	907 (55.41)	562 (59.98)	427 (83.40)	427 (84.12)
Age ≥ 60	243 (27.74)	271 (27.85)	730 (44.59)	375 (40.02)	85 (16.60)	85 (15.88)

Notes: Percentages reported in parentheses. Round 1 corresponds to June 2020 for all countries; Round 2 corresponds to November 2020 for Catalonia and the UK and December 2020 for Italy.