Stress and substance abuse among workers during the COVID-19 pandemic in an intensive care unit: A cross-sectional study.

OBJECTIVE: Professionals working in intensive care units (ICUs) during the COVID-19 pandemic have been exposed to stressful situations and increased workload. The association between symptoms of traumatic stress disorders, substance abuse and personal/occupational characteristics of Brazilian COVID-19-ICU workers is still to be addressed. Our aim was to evaluate the prevalence of those conditions and to find if those associations exist.
METHODS: In this observational, single-center, cross-sectional study, all professionals working in a COVID-19 ICU were invited to fill an anonymous form containing screening tools for traumatic stress disorders and substance abuse, and a section with questions regarding personal and occupational information.
RESULTS: Three hundred seventy-six ICU professionals participated. Direct exposure to patients infected by COVID-19, history of relatives infected by COVID-19, and sex (female) were significantly associated with signs and symptoms of traumatic stress disorders. 76.5% of the participants had scores compatible with a diagnosis of traumatic stress disorders. Moreover, the prevalence of scores suggestive of Tobacco and Alcohol abuse were 11.7% and 24.7%, respectively.
CONCLUSION: ICU workers had significantly elevated scores on both screening forms. Providing psycho-social support to ICU professionals may prevent future problems with traumatic stress disorders or substance abuse.

Introduction

As the COVID-19 pandemic progresses, several hospitals have gone through changes in their usual work dynamics, among which are the elevated demand for intensive care unit (ICU) beds, the increased death rate, and preventive measures to avoid infection during healthcare. All of those elements are present in the daily routine of the ICU staff, interfering with their mental and physical health. Those factors may lead to increased workload and stress, therefore enhancing the risk of developing acute or chronic psychological disturbances (e.g., burnout, substance abuse [SA], acute stress disorder [ASD], and post-traumatic stress disorder [PTSD]) [1-4].

Even in non-pandemic periods, healthcare professionals working in ICUs suffer high stress loads possibly due to the environment and the severity of patients [5]. In this context, recurrent stressful stimuli may lead the professionals developing SA [6, 7] and ASD [8], more often than in other areas of healthcare [9-11]. Additionally, recent studies suggest those workers have been experiencing a high impact in their mental health during the pandemic [12, 13]. However, limited research has been conducted on the occurrence of those phenomena in healthcare professionals working in Brazilian ICUs during the COVID-19 pandemic. Furthermore, there is no data providing an independent analysis of the eventual associations between each single stressor element that may be present in the ICU environment and the occurrence of SA, PTSD, and ASD in that population [14].

Therefore, the aim of this study was to evaluate the occurrence of SA, PTSD, and ASD in professionals working in Brazilian ICUs, either having direct contact with patients or not, using validated questionnaires as tools to assess the prevalence of those conditions. The secondary objective was to identify associations between epidemiological and labor characteristics of those workers and the development of those psychological disturbances in that population.

Methods

Study design

This was an observational, single-center, cross-sectional, online questionnaire-based study. This study was carried out in an intensive care unit in an oncological hospital in São Paulo, Brazil.

Study participants

All the professionals working in an oncological COVID-19 ICU, regardless of their role (health professionals and non-health professionals), who were on duty for at least during one shift through the period of July to October/2020, were invited to participate in this study. Exclusion criteria were as follows: age under 18, refusal to participate or to sign written informed consent, and being part of the group that contributed to the organization of this study. Additionally, those who were absent from work during the data collection period were excluded, regardless of the reason for absence (e.g., vacations, medical leave). All participants received a standardized approach. The study was approved by institutional ethics committees. All participants filled the questionnaires after signing the consent form during one of their work shifts, without interruptions. This project followed the guidelines of the Declaration of Helsinki.

Approach to participants

To avoid constraints and exposure, all participants were approached and invited to participate individually. A reserved, isolated room was always offered, and the participants could use it while filling the online forms. Participants from all shifts and sections working in the COVID-19 ICU were invited. All answers were kept private and anonymous, and were obtained in one visit.

Measurements

Participants filled a standardized form containing personal and professional information (see Supporting Information section); they also answered screening forms for SA (Alcohol Smoking and Substance Involvement Screening Test [ASSIST 2.0]) [15, 16], ASD, and PTSD (using the Impact of Events Scale-Revised [IES-R]) [17, 18]. The IES-R scores were categorized as follows: 1–11 = few/no signs of ASD/PTSD; 12–32 = several signs of ASD/PTSD, patient monitoring is recommended; ≥33 = highly suggestive of ASD/PTSD, immediate psychiatric evaluation is recommended [17]. The ASSIST 2.0 scores were categorized as follows: 0–3 = occasional substance use; 4–15 = suggestive of substance abuse; ≥16 = suggestive of substance dependence [15]. The ASSIST 2.0 provided separate scores for each substance category. Frequencies were calculated and associations between the participants characteristics and the results of the questionnaires were made. Questionnaires were made available as Supporting Information S1–S6 Files.

Statistical analysis

Categorical variables were expressed in frequencies. The Quantitative variables were classified according to normal or non-normal distribution using Shapiro-Wilk’s test and were expressed with mean and standard deviation or median and interquartile range. The means of continuous variables with normal distribution were compared using Student T test for independent variables. The medians of continuous variables with non-normal distribution were compared using Mann-Whitney’s U test. Categorical variables were compared using Chi-square test or Fisher’s exact test when indicated. When appropriate, multivariate logistic regression analyses were used to explore the relationship among variables, calculating measures of association among variables expressed by odds ratio and a 95% confidence interval. Moreover, the regression analyses were used to adjust eventual confounding factors given the variable number of participants according to different specialties and roles in the ICU. All tests were two-sided. Values of p<0.05 were considered statistically significant. All statistical analyses were performed using STATA/MP Version, 16.1 (for MAC) (StataCorp. 2019. Stata Statistical Software: Release 16. College Station, TX: StataCorp LLC).

Results

Three hundred seventy-six ICU professionals agreed to participate in this survey, 340 with direct exposure to COVID-19 infected patients (see Table 1). Professionals directly exposed to infected patients included 54 physicians (14%), 53 physiotherapists (14%), 226 nurses/technicians (60%), 38 pharmacists (10%), 5 nutritionists (1%), 7 psychologists (1.5%) and 3 social service professionals (0.7%). 71.5% of the participants were female. The age variable was categorized, and participants who were less than 38 years of age were the most frequent (56.4%). More than 80% of the workers who were directly exposed participated in this study. It was not possible to determine the answer ratio among workers without direct exposure as most of them (e.g., security, cleaning services) were employed by third-party companies. Less than ten individuals refused to participate.

Table 1

Socio demographic, personal, and occupational characteristics of participants.

Baseline characteristic	ICU professionals
	n	%
Gender
Female	269	71.5
Male	107	28.5
Age*
> 38 years of age	161	43.6
< 38 years of age	215	56.4
Occupational exposure to infected patients (exposed)	340	90.6
Time exposed to infected patients
Non-exposed	39	10.4
Less than 24h/week	87	23.1
Over 24h/week	250	66.5
History of psychiatric diseasesa	43	11.5
Infected by COVID-19a	187	50.0
Relative infected by COVID-19a	143	38.0
Living with high-risk group relatives for COVID-19a	240	63.8
Sought alternative accommodation away from homea	80	21.3

Note. N = 376 (total number of participants); n = number of participants within the subgroup; ICU = Intensive Care Unit.

*Age groups were categorized and ages <38 years of age were the most frequent.

a Reflects the number and percentage of participants answering “yes” to this question.

Most participants (66.5%) had a weekly exposure greater than 24 hours. 50% of the participants had been infected by COVID-19, and 38% of them had had a relative infected. Although most of them shared their homes with individuals from vulnerable populations (e.g., elderly relatives), only 21% of them sought alternative accommodation away from home during the pandemic. Forty-three participants (11.5%) declared to have a history of psychiatric disease. Table 1 describes the characteristics of the studied individuals.

IES-R score results

Most participants (76.3%) had scores ≥12 (see Table 2). One-hundred twenty-seven (33.8%) of them had scores higher than 33, which strongly suggests a diagnosis of PTSD and the need of psychiatric evaluation as soon as possible. Eighty-nine (23.7%) participants were free from PTSD signs or only had a few of them. Results are summarized on Table 2.

Table 2

Frequencies of IES-R score categories.

Score Categories	ICU professionals
	n	%
1–11	89	23.7
12–32	160	42.5
≥33	127	33.8

Note. N = 376 (total number of participants); n = number of participants within the subgroup.

Mean IES-R score = 26.6, Standard Deviation = 17.9

IES-R = Impact of Event Scale–Revised; scores were categorized according to the clinical interpretation of the results.

*Categories: 1–11 = few/no signs of traumatic stress disorder, 12–32 = several signs of traumatic disorder, patient follow up is recommended, >33 = high probability of ongoing traumatic stress disorder, immediate psychiatric evaluation is recommended [17].

Psychiatric medical history

The relationship between IES-R scores and history of psychiatric disease was assessed, but those factors did not present a statistically significant association (p = 0.341, OR = 2.68 [95% CI = 0.35–20.51]) (see Table 3). Then, the relationship between IES-R scores and history of anxiety disorders (which included ASD and PTSD) was assessed, but those factors also did not present a statistically significant association (p = 0.44, OR = 2.23 [95% CI = 0.29–17.13]). Table 3 summarizes those findings.

Table 3

Factors without an association with IES-R scores.

Logistic parameter	IES-R scores
	OR	CI	p
History of psychiatric disease	2.68	0.35–20.51	0.341
History of anxiety disorders	2.23	0.29–17.13	0.44
Sought alternative accommodation away from home	5.72	0.75–43.32	0.091

Note. OR = Odds Ratio, CI = 95% confidence interval, IES-R = Impact of Event Scale–Revised.

Personal and occupational factors

Among personal factors, being a female and having a relative infected by COVID-19 were associated with higher IES-R scores (Table 4). When compared to men, women had a higher median score (27 vs 19 in males [p = 0.0001]) even after adjustment with Wilcoxon rank sum test. Professionals with infected relatives (OR = 3.91 [p = 0.031, 95% CI = 1.13–13.50]) were also significantly more likely to score higher in the IES-R, therefore more likely to suffer from PTSD or ASD (Table 4). The relationship between those who had sought alternative accommodation away from home during the pandemic in order to protect their relatives and IES-R scores was also assessed, but it was not statistically significant (OR = 5.72 [p = 0.091, 95% CI = 0.75–43.32])—see Table 3 above.

Table 4

Results of multivariate logistic regression of factors associated with increased IES-R scores.

Logistic parameter		IES-R scores
	M	OR	CI	p
Sex (female)	27	-	-	0.0001
Direct exposure to infected patients	-	5.62	2.10–15.03	0.001
Relative infected by COVID-19	-	3.91	1.13–13.50	0.031

Note. M = Median IES-R score, OR = Odds Ratio, CI = 95% confidence interval, IES-R = Impact of Event Scale–Revised.

IES-R scores of Female and Male participants were compared and then adjusted using Wilcoxon rank sum test (Male Median = 19).

Among occupational factors, direct exposure to infected patients was associated with higher IES-R scores. When compared to professionals who were not directly exposed, those who had a direct exposure were more likely to achieve higher scores, with an OR = 5.62 (p = 0.001, 95% CI = 2.10–15.03). Those findings are presented in Table 4.

Associations with substance abuse

Results indicate that, according to the ASSIST 2.0 form, 24.7% of ICU workers had scores suggestive of alcohol abuse. Scores compatible with tobacco abuse and dependence were seen in 11.2% and 2.3%, respectively. Eighteen workers (4.8%) had scores compatible with hypnotics abuse.

There was no statistically significant association between personal or occupational factors and substance use. However, two association trends were found. For tobacco and alcohol, higher scores had an association trend towards history of psychiatric disease, direct exposure to infected patients and those who sought alternative accommodation away from home during the pandemic in order to protect their relatives.

For cannabis, stimulants, and cocaine, higher scores had an association trend towards history of psychiatric disease and direct exposure to infected patients. The prevalence of each substance use is detailed on Table 5 below.

Table 5

Prevalence of substance use according to the ASSIST 2.0 categories.

Baseline characteristic	Suggestive of Substance Abuse		Suggestive of Substance Dependence
	n	%	n	%
Tobacco	42	11.2	8	2.1
Alcohol	93	24.7	0	0
Cannabis	5	1.3	0	0
Cocaine	0	0	0	0
Stimulants	2	0.5	0	0
Inhaled drugs	0	0	0	0
Hypnotics	18	4.8	1	0.3
Hallucinogens	1	0.3	0	0
Opioids	2	0.5	0	0
Intravenous drugs	3	0.8	0	0
Other drugs	1	0.3	0	0

Note. N = 376 (total number of participants); n = number of participants within the subgroup.

ASSIST 2.0 = Alcohol, Smoking and Substance Involvement Screening Test (version 2.0); scores were categorized according to the clinical interpretation of the results.

*Categories: 0–3 = occasional substance use; 4–15 = suggestive of substance abuse; ≥16 = suggestive of substance dependence [15].

Discussion

This research found associations between participants’ personal and occupational factors and signs of ASD/PTSD in a COVID-19 ICU in this Brazilian hospital. Sex (female), direct exposure to infected patients and having a relative infected by COVID-19 were significantly associated with higher IES-R scores. Other factors such as history of psychiatric disease, history of anxiety disorders, and seeking alternative accommodation away from home during the pandemic were assessed but did not present a statistically significant association with higher IES-R scores. The prevalence of alcohol and tobacco abuse was high. The evaluation of substance use among ICU workers with the ASSIST 2.0 form was not able to determine any statistically significant associations with personal or occupational factors and higher scores. Nonetheless, there was an association trend towards tobacco, alcohol, cannabis, stimulants, and cocaine use in those with a history of psychiatric disease and with direct exposure to infected patients. In a recent study evaluating the mental health of ICU workers in England [19], authors found similar results, with high prevalence of traumatic stress disorders and alcohol abuse, especially among nurses (which account for the most numerous subpopulation of the presenting study).

We believe that those factors associated with higher IES-R scores were directly related to an increased stress load in those individuals. Whilst the cause is unclear, it could be suggested that, when compared to most of the occupational factors, personal life characteristics, as well as direct exposure to infected patients, were more strongly related to the likelihood of having PTSD or ASD symptoms. Researchers investigating the impact of personal and occupational factors on the mental health of Canadian ICU workers exposed to COVID-19 infected patients found that, following a multivariate analysis, those elements related to the anxiety about being infected during work were the best predictors of scores indicative of traumatic stress disorders [20]. We further hypothesize that worrying about the safety of their relatives is another possible cause of this overwhelming stress.

In terms of substance use, the most frequently consumed were tobacco and alcohol. Those were also the substances with higher frequencies of abuse and dependence. It is possible that those results reflected the availability of those substances. Also, the abusive consumption of those substances could be a coping mechanism during the pandemic. Even considering the socio-cultural differences among countries, the current results are in accordance with those presented by other authors, in other populations of ICU workers (e.g., Netherlands [4], Canada [20], United States [21], and England [19]). Thus, it is likely that the findings of the presenting study could be generalizable to ICU workers from different populations and should be taken into consideration by professionals working globally.

This study has several limitations. Firstly, as reported and studied in the field of substance abuse, this study may be subject to social desirability bias, which is the tendency of a participant providing answers based on what is considered a desired behavior within a specific socio-cultural environment [22, 23]. The fear of being treated with prejudice by their peers may also be a contributing factor for this bias in ICU workers [24]. Secondly, some ICU staff during the application of this study either refused to participate or were on medical leave. Given that some of those workers may have had psychological or psychiatric reasons for work leave, our findings can be underestimated. Thirdly, the lack of statistical significance could be due to a small sample size in some sub-groups and thus statistical testing lacked power. However, with regards to the non-statistically significant results, we believe they should be taken into account because it is reasonable to hypothesize that some of those factors may also contribute to the psychological burden in the ICU workers. Fourthly, this study had no follow-up sessions. Therefore, it was not possible to determine causal relationships or risk factors. Finally, it was a single-centered research and, therefore, influenced by local environmental biases. Nevertheless, our sample was large enough to find some statistically significant associations between participants characteristics and the development of PTSD/ASD symptoms during the COVID-19 pandemic. It was also possible to highlight the alarming prevalence of substance use among those individuals, which may carry devastating consequences for their personal and professional lives.

Considering the duration and the consequences of the COVID-19 pandemic, specifically for the population of this study, our results should bring to light the need for institutional support for those individuals. From the experiences with the severe acute respiratory syndrome virus (SARS) outbreak in the early 2000’s, it has been demonstrated that ICU professionals may need long term support for mental health issues developed during their work time with infected patients [25]. As recently proposed by other authors [26, 27], intervention plans should be traced not only during the pandemic but also after it, due to the prolonged course of diseases such as PTSD, ASD, and SA. For that reason, we believe that this study could be used for guiding larger, multicenter studies and institutional interventions to prevent and reduce the suffering of professionals dealing with similar situations in Brazil and in other countries.

Personal and occupational information (English version).

(DOCX)

Click here for additional data file.

Personal and occupational information (Portuguese version).

(DOCX)

Click here for additional data file.

ASSIST 2.0 (English version).

(DOCX)

Click here for additional data file.

ASSIST 2.0 (Portuguese version).

(DOCX)

Click here for additional data file.

IES-R (English version).

(DOCX)

Click here for additional data file.

IES-R (Portuguese version).

(DOCX)

Click here for additional data file.

Minimal anonymized data set (English [translation]).

(XLSX)

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Minimal anonymized data set (Portuguese [original]).

(XLSX)

Click here for additional data file.

15 Oct 2021

Stress and Substance Abuse among workers during the COVID-19 Pandemic in an Intensive Care Unit: a cross-sectional study.

PLOS ONE

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Reviewer #1: The study provides findings on an important topic that is of concern during this pandemic. Nonetheless, there are several major amendments that will need to be made before it can be considered for publication.

1. I am not certain that the claim the authors make about how there are only a few research studies that have examined the occurrence of mental health problems in healthcare workers working in the ICU during the pandemic is valid. From what I understand, this topic has garnered a lot of interest and there is substantial literature that has emerged since the pandemic. Perhaps it may be more appropriate to limit this statement to the context of Brazil.

2. Although the discussion does follow from the findings of the analysis, there is a lack of reference to existing literature about the topic. Authors should attempt to use existing literature to support their conclusions, or to posit reasons for their findings. Similarly, the limitations section suggests that participants may have been afraid of suffering retaliation, leading to report bias. Reasons for this should be provided in greater detail, or citations for studies that have looked into this phenomenon should be given. Lastly, the section on practical implications of this study should have references to studies that have highlighted the importance of institutional support and/or long term intervention plans.

3. The appropriate statistical methods were chosen.

4. The authors are unable to make the data publicly available due to its sensitive nature, but it is available upon reasonable request.

5. The language errors make it difficult to understand at times, and the awkward expression of certain terms may cause readers to misunderstand what the authors are trying to convey.

e.g "licensed from work" -- I believe the authors were trying to say that these healthcare workers were absent from work?

"Although most of them shared their homes with individuals with greater risk for severe infection, only 21% of them left home during the pandemic" -- It is unclear why or how these individuals are at greater risk of severe infection. Do you mean to say they belong to a vulnerable population (e.g chronic illnesses/elderly)? The term "left home" should be more appropriately expressed as "sought alternative accommodation away from home".

"However, with regards to the non-statistically significant associations, we believe they should be taken into account because of the biological plausibility they carry within them." -- Am not sure what biological plausibility means in this context

"Pharmaceuticals" -- I believe it should be "pharmacists"

6. Other comments:

- The abstract should not contain abbreviations that have not been spelled out in full at first mention.

- Please provide a citation for the way the IES-R and ASSIST 2.0 scores were categorized. Are there scoring guidelines available?

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Reviewer #2: The study is interesting but is single-centre. There is no comparison between the different critical care professions.

The authors do not report anxiety or depression scores.

Finally, the authors did not go into enough depth in their analyses.

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The aims of the study are clearly stated

The study is original

The study is useful and relevant to the aims of the Journal

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Modesto Leite Rolim Neto - Faculdade de Medicina - Universidade Federal do Cariri - UFCA

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27 Nov 2021

Response to the Editor and Reviewers

Dear Reviewers and Dr. Carels (Editorial Board of PLOS One). We are pleased to share with you our response to the comments made regarding our manuscript entitled “Stress and Substance Abuse among workers during the COVID-19 Pandemic in an Intensive Care Unit: a cross-sectional study”. We hope that our replies can properly address the issues highlighted by you. Thank you for your attention to this.

Sincerely,

Diego V. S. Pestana (on behalf of the authors)

Comments – Editor:

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

Author’s Reply: Dear Dr. Carels, thank you for your help during this process and for your important comments. The manuscript has been edited to meet PLOS ONE’s requirements. We conducted a thorough review of the requirements and we believe that the manuscript now completely meets the publishing requirements. Also, we reviewed the text once more in search for eventual typos or misspellings that may have been unnoticed so far. Finally, as mentioned below in one of the replies, the text has been reviewed by 2 independent native English speakers to improve the quality the written English used on it and facilitate readers understanding. Nevertheless, if you or the reviewers happen to have any other suggestion regarding this topic, we will be glad to work on it.

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Author’s Reply: We apologize for the inconvenience regarding this topic. As suggested, we uploaded 6 files as Supporting Information, accounting for each one of the components of the questionnaire used in this project (the ASSIST 2.0, the IES-R, and the questions regarding personal and occupational information developed by our research group) and both, an English and a Portuguese version of them.

3 & 4

3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For more information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

Author’s Reply: Thank you for your guidance over this topic. As mentioned, we had not submitted the data set along with the other files given it involves information of sensitive nature. Nevertheless, after carefully reviewing PLOS ONE’s data policy, we believe that it is reasonable to share the data set, as it has no legal or ethical restrictions and can be publicly available as the minimal anonymized data set. In that way, data can be safely shared with readers without harming participants privacy.

Comments - Reviewer #1

The study provides findings on an important topic that is of concern during this pandemic. Nonetheless, there are several major amendments that will need to be made before it can be considered for publication.

1. I am not certain that the claim the authors make about how there are only a few research studies that have examined the occurrence of mental health problems in healthcare workers working in the ICU during the pandemic is valid. From what I understand, this topic has garnered a lot of interest and there is substantial literature that has emerged since the pandemic. Perhaps it may be more appropriate to limit this statement to the context of Brazil.

Author’s Reply: Dear Reviewer 1, thank you for your valuable comments! Indeed, within the last months several articles have been published, most of them exploring the consequences of the COVID-19 pandemic to the mental health of health care professionals working in ICUs. After carefully considering this comment, we conducted another search on literature, focusing on those evaluating Brazilian ICU workers. Our findings and conclusions are summarized below:

#1: Most of these articles approach mental health issues on Brazilian physicians and nursing staff. The present article evaluates not only physicians, but also all the nursing staff, physiotherapy professionals, nutritional professionals, cleaning staff, maintenance staff, administrative staff, and security staff. We believe that all of these professionals are essential to provide adequate conditions for an ICU, and, therefore, this would be an interesting feature of the present article.

#2: We used different searching methods and sources in order to identify other articles that evaluated the impact of COVID-19 on Brazilian ICU workers, specifically on the issue of substance abuse. Also, the presenting manuscript evaluated several personal and/or occupational characteristics rarely found in other studies of this nature However, we were not able to find any other study addressing these concerns in the studied population (Brazilian ICU workers). Therefore, we believe that this aspect would also provide scientifically relevant information to readers of PLOS One.

#3: We agree with your comment, and our manuscript has been properly changed to provide more accurate information. The reviewed version limits its claims to Brazilian ICU workers.

2. Although the discussion does follow from the findings of the analysis, there is a lack of reference to existing literature about the topic. Authors should attempt to use existing literature to support their conclusions, or to posit reasons for their findings.

Similarly, the limitations section suggests that participants may have been afraid of suffering retaliation, leading to report bias. Reasons for this should be provided in greater detail, or citations for studies that have looked into this phenomenon should be given.

Lastly, the section on practical implications of this study should have references to studies that have highlighted the importance of institutional support and/or long term intervention plans.

Author’s Reply: After carefully considering this comment, we reviewed our Discussion section. While reviewing it, we also searched for references that support the points highlighted in this comment. Below we addressed each point made in the comment above, using references that illustrate the topic under discussion.

#1: The concern about mental health among ICU workers during the COVID-19 pandemic has been widely studied within the last 2 years [1.1], [1.2], [1.3]. In a study with a structure similar to the one used in the present manuscript, with similar studied populations, Greenberg et al (2021) [1.4] identified alarmingly high prevalence of post-traumatic stress disorder symptoms, depressive symptoms, and signs of alcohol abuse among participants. Even before the COVID-19 pandemic, both substance abuse [1.5], [1.6] and traumatic stress disorders [1.7] were identified as being serious problems among healthcare professionals, often more intensely present in subspecialties such as Anesthesiology, Emergency Care, and Critical Care. Therefore, we believe that the findings reported in the present manuscript are in accordance with what could be expected, based on the pre-existing literature on this topic. Also, although we present novel scientific data, the pre-existing literature seems to support our findings and conclusions. We are thankful for this suggestion, and the Discussion section of the presenting manuscript has been properly adjusted after it.

#2: Substance abuse is a sensitive topic, often associated with stigmatization. Even in the context of healthcare, when it comes to individuals suffering with substance abuse, providers may act based on prejudice, as described by Stone et al (2021) [2.1]. This phenomenon may be associated with another factor known as “social desirability bias”, often described in self-report studies regarding substance abuse. According to Latkins et al (2017) [2.2]: “Social desirability bias is the tendency to underreport socially undesirable attitudes and behaviors and to over report more desirable attributes”. Early in the study of social desirability bias, Welte et al (1993) [2.3] concluded that “social desirability response bias probably results in underestimates of rates of heavy drinking and drug use” in self-reported studies. After reviewing these concepts and searching deeper into the literature, we believe that the Discussion section of our manuscript should approach the aforementioned sources of bias using the term “social desirability bias” instead of “report bias”. Accordingly, we re-wrote this section using the proper terminology and adjusting it to the proper phenomena described. Of note, there were no reports or any signs of retaliation during this study, and the incorporation of this element to the manuscript was a result of our misinterpretation of the involved biases.

#3: In terms of background, from the experiences with the 2003 SARS outbreaks, Maunder et al (2006) [3.1] demonstrated that healthcare providers are found to have an increased risk of developing mental health problems following a contagious disease pandemic. The awareness of this potential issue stimulated researchers worldwide to investigate the need for psychosocial support to healthcare workers, specifically those working at ICUs. Among recently published studies regarding the COVID-19 pandemic, Roberts et al (2021) [3.2] highlighted the importance of supporting ICU workers to prevent and/or diminish the harms involved with mental health issues in this population, claiming that "It is also clear that psychological support and services for nurses and the wider healthcare team need to be available and quickly convened in the event of similar major incidents, either global or local" [3.2]. Finally, the British Medical Journal published an article from their own authorship stressing the need for psychosocial support to these workers [3.3]. Those were only a couple of illustrative examples among several other articles our team was able to find. Therefore, we believe that it is possible to claim that other studies and/or authors also highlighted the importance of institutional support and/or long-term intervention plans.

We were happy to incorporate the aforementioned topics into the Discussion section of the presenting manuscript.

REFERENCES

[1.1] Kok, N., van Gurp, J., Teerenstra, S., van der Hoeven, H., Fuchs, M., Hoedemaekers, C., & Zegers, M. (2021). Coronavirus Disease 2019 Immediately Increases Burnout Symptoms in ICU Professionals: A Longitudinal Cohort Study. Critical care medicine, 49(3), 419–427. https://doi.org/10.1097/CCM.0000000000004865

[1.2] Binnie, A., Moura, K., Moura, C., D'Aragon, F., & Tsang, J. (2021). Psychosocial distress amongst Canadian intensive care unit healthcare workers during the acceleration phase of the COVID-19 pandemic. PloS one, 16(8), e0254708. https://doi.org/10.1371/journal.pone.0254708

[1.3] Danet Danet A. (2021). Psychological impact of COVID-19 pandemic in Western frontline healthcare professionals. A systematic review. Impacto psicológico de la COVID-19 en profesionales sanitarios de primera línea en el ámbito occidental. Una revisión sistemática. Medicina clinica, 156(9), 449–458. https://doi.org/10.1016/j.medcli.2020.11.009

[1.4] Greenberg, N., Weston, D., Hall, C., Caulfield, T., Williamson, V., & Fong, K. (2021). Mental health of staff working in intensive care during Covid-19. Occupational medicine (Oxford, England), 71(2), 62–67. https://doi.org/10.1093/occmed/kqaa220

[1.5] Bryson, E. O., & Silverstein, J. H. (2008). Addiction and substance abuse in anesthesiology. Anesthesiology, 109(5), 905–917. https://doi.org/10.1097/ALN.0b013e3181895bc1

[1.6] Baldisseri M. R. (2007). Impaired healthcare professional. Critical care medicine, 35(2 Suppl), S106–S116. https://doi.org/10.1097/01.CCM.0000252918.87746.96

[1.7] Rodríguez-Rey, R., Palacios, A., Alonso-Tapia, J., Pérez, E., Álvarez, E., Coca, A., Mencía, S., Marcos, A., Mayordomo-Colunga, J., Fernández, F., Gómez, F., Cruz, J., Ordóñez, O., & Llorente, A. (2019). Burnout and posttraumatic stress in paediatric critical care personnel: Prediction from resilience and coping styles. Australian critical care : official journal of the Confederation of Australian Critical Care Nurses, 32(1), 46–53. https://doi.org/10.1016/j.aucc.2018.02.003

[2.1] Stone, E. M., Kennedy-Hendricks, A., Barry, C. L., Bachhuber, M. A., & McGinty, E. E. (2021). The role of stigma in U.S. primary care physicians' treatment of opioid use disorder. Drug and alcohol dependence, 221, 108627. https://doi.org/10.1016/j.drugalcdep.2021.108627

[2.2] Latkin, C. A., Edwards, C., Davey-Rothwell, M. A., & Tobin, K. E. (2017). The relationship between social desirability bias and self-reports of health, substance use, and social network factors among urban substance users in Baltimore, Maryland. Addictive behaviors, 73, 133–136. https://doi.org/10.1016/j.addbeh.2017.05.005

[2.3] Welte, J. W., & Russell, M. (1993). Influence of socially desirable responding in a study of stress and substance abuse. Alcoholism, clinical and experimental research, 17(4), 758–761. https://doi.org/10.1111/j.1530-0277.1993.tb00836.x

[3.1]Maunder, R. G., Lancee, W. J., Balderson, K. E., Bennett, J. P., Borgundvaag, B., Evans, S., Fernandes, C. M., Goldbloom, D. S., Gupta, M., Hunter, J. J., McGillis Hall, L., Nagle, L. M., Pain, C., Peczeniuk, S. S., Raymond, G., Read, N., Rourke, S. B., Steinberg, R. J., Stewart, T. E., VanDeVelde-Coke, S., … Wasylenki, D. A. (2006). Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerging infectious diseases, 12(12), 1924–1932. https://doi.org/10.3201/eid1212.060584

[3.2]Roberts, N. J., Kelly, C. A., Lippiett, K. A., Ray, E., & Welch, L. (2021). Experiences of nurses caring for respiratory patients during the first wave of the COVID-19 pandemic: an online survey study. BMJ open respiratory research, 8(1), e000987. https://doi.org/10.1136/bmjresp-2021-000987

[3.3] What organisations around the world are doing to help improve doctors’ wellbeing

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1541

3. The appropriate statistical methods were chosen.

Author’s Reply: None.

4. The authors are unable to make the data publicly available due to its sensitive nature, but it is available upon reasonable request.

Author’s Reply: None.

5. The language errors make it difficult to understand at times, and the awkward expression of certain terms may cause readers to misunderstand what the authors are trying to convey.

e.g:

"licensed from work" -- I believe the authors were trying to say that these healthcare workers were absent from work?

"Although most of them shared their homes with individuals with greater risk for severe infection, only 21% of them left home during the pandemic" -- It is unclear why or how these individuals are at greater risk of severe infection. Do you mean to say they belong to a vulnerable population (e.g chronic illnesses/elderly)? The term "left home" should be more appropriately expressed as "sought alternative accommodation away from home".

"However, with regards to the non-statistically significant associations, we believe they should be taken into account because of the biological plausibility they carry within them." -- Am not sure what biological plausibility means in this context

"Pharmaceuticals" -- I believe it should be "pharmacists"

Author’s Reply: We appreciate the suggestions made regarding the proper use of the English language. They were incorporated into the manuscript. Also, as an attempt to improve the quality of the text, two native English speaker biomedical scientists, by any means involved with this project, blindly and independently reviewed the text, and further suggestions were also incorporated to improve the overall quality of the text.

6. Other comments:

- The abstract should not contain abbreviations that have not been spelled out in full at first mention.

Author’s Reply: the abstract has been re-write without abbreviations and with a clearer language.

- Please provide a citation for the way the IES-R and ASSIST 2.0 scores were categorized. Are there scoring guidelines available?

Author’s Reply:

#1 IES-R: the citation for the score categorization of the IES-R can be found below; note that we used the most recent version of the tool which was validated to the Brazilian population. In the manuscript we included the original citation as well as the citation for the validation study.

REFERENCE

[4.1] Weiss, D.S. (2007). The Impact of Event Scale: Revised. In J.P. Wilson & C.S. Tang (Eds.), Cross-cultural assessment of psychological trauma and PTSD (pp. 219-238). New York: Springer.

#2 ASSIST 2.0: the citation below refers to the article led by the World Health Organization (WHO), in which it is possible to find the interpretation for the scoring categories of the ASSIST tool. Similarly to the IES-R, we selected the most updated version of the ASSIST questionnaire which was validated to the Brazilian population.

REFERENCE

[4.2] WHO ASSIST Working Group (2002). The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction (Abingdon, England), 97(9), 1183–1194. https://doi.org/10.1046/j.1360-0443.2002.00185.x

As suggested, both references were properly incorporated to the manuscript.

- Please refer to a standardized format (e.g APA) for the presentation of data in tables. The way it is currently organized can be confusing for readers. Also, all abbreviations in tables and its title (e.g ICU, IES-R) should be explained in the footnotes.

Author’s Reply: Tables were properly formatted according to the APA Publishing Manual (7th edition), and footnotes now describe all abbreviations used; also, explanations regarding the presented variables were provided whenever needed, to facilitate interpretation by readers.

Comments - Reviewer #2

The study is interesting but is single-centre.

Author’s Reply: Dear Reviewer #2, thank you for your valuable comments! We agree with you in the sense that being a single-centre project is a limitation of the presenting study. Collaborations with other institutions were discussed, but due to logistical constraints, we could not perform a multi-centre project. Nevertheless, we believe that this study has been done over solid methodological basis, which may account for its internal validity. Also, although the studied population is from Brazil, our results are in accordance with results from studies conducted in different countries, which may indicate that the presenting study also has appreciable external validity.

There is no comparison between the different critical care professions.

Author’s Reply: We are glad you mentioned this issue, as this has been discussed within our research group. On the contrary of what we expected to see, there was no significant difference in the scores among the various critical care professions. We hypothesize that this may be due to lack of statistical power. Interestingly, the larger group in the study sample accounts for nurses and nursing assistants, which, again, is in accordance with which has been found by other similar studies conducted in other countries. Thus, the present study may help to demonstrate that larger sample sizes may be required to evaluate differences in the stress burden among the various professions involved in running an ICU; alternatively, the results presented in this study may also suggest that profession per se is not independently associated with higher risks of developing traumatic stress disorders and/or substance abuse.

The authors do not report anxiety or depression scores.

Author’s Reply: We appreciate your attention to this detail. Indeed, anxiety and depression have been recurrently reported as common mental health problems among ICU workers. During the development of the research question for this study, we conducted a thorough literature review, and we identified a significant gap in the knowledge regarding substance abuse and traumatic stress disorders in the studied population. Thus, although we were aware that depression and anxiety disorders could also be elevated in the studied population, we aimed to explore other severe comorbidities, trying to fill a specific knowledge gap previously identified by our literature review.

Finally, the authors did not go into enough depth in their analyses.

Author’s Reply: Dear Reviewer #2, we are sorry to hear that. While planning this project, we tried to build a strong investigation, deep enough to contribute with our scientific community in this moment of collective efforts. We understand the limitations of the study, but we hope that, as a result of this manuscript, ICU workers can benefit from better institutional support. Nonetheless, we appreciate your comments and suggestions, and we believe they have helped to improve this manuscript.

Comments - Reviewer #3

The title is accurate or relevant. The aims of the study are clearly stated. The study is original. The study is useful and relevant to the aims of the Journal. The design of the study is appropriate. The sample size, selection and composition are appropriate. Methods used to collect data (e.g. validated questionnaires and instruments, observational techniques) are appropriate. Qualitative or quantitative methods used to analyse the data are appropriate. Details of the methods (including settings and locations, procedures, dates of recruitment and follow-up or main outcomes) are clearly reported. The data are less than 5 years old. The study was approved by a research ethics committee prior to data collection. Participants were asked for informed consent prior to data collection or informed consent was not required. The qualitative or quantitative analyses were applied appropriately. Missing data, e.g. non-respondents, drop-outs or non-responses, have been accounted for. The results are clearly presented and explained. No further qualitative or quantitative analysis is required. The authors reflect on the strengths and limitations of the study. The results are compared to related findings in the literature. The results are discussed in relation to the relevant research, practice or policy issues. The discussion and conclusions do not speculate beyond what has been shown in this study. The article has a logical construction in a suitable format. The article has an appropriate length (not unnecessarily long or too short to be useful). The writing is in a good standard of English, grammatically correct and easy to understand. The abstract is in an unstructured format and is sufficiently informative. Any tables and figures are all necessary, clearly annotated and easy to follow.

Author’s Reply: Dear Reviewer #3, we were extremely happy to receive your comments. Thank you for your time and consideration while evaluating our manuscript, we really appreciate it.

Submitted filename: Response to Reviewers.docx

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14 Dec 2021

24 Jan 2022

Response to the Editor and Reviewers

Dear Reviewers and Dr. Patel (Editorial Board of PLOS One). We are pleased to share with you our response to the comments made regarding our manuscript entitled “Stress and Substance Abuse among workers during the COVID-19 Pandemic in an Intensive Care Unit: a cross-sectional study”. We hope that our replies can properly address the issues highlighted by you. Thank you for your attention to this.

Sincerely,

Diego V. S. Pestana (on behalf of the authors)

Comments – Editor:

1. 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.

Author’s Reply: Dear Dr. Patel, thank you for your help with this manuscript. We reviewed the reference list completely and, although we could not find any retracted paper, we identified some points that could be optimized, as discussed below (between brackets we informed which action was made regarding each reference). Additionally, we checked all the references to make sure they were available online at their original publisher/journal website, without retraction notes. All references were written according to the Vancouver style, as indicated at PLOS One website.

Reference #7: Baldisseri MR. Impaired healthcare professional. Critical Care Medicine. 2007 Feb;35(Suppl):S106–16.

[Substitution]

Although the article appears after a simple search on PubMed, whenever we tried to access it using the publisher/journal website the link led us to a blank webpage. We searched for retraction notes or such type of publication regarding this paper but there was none. Therefore, we decided to look for a new reference article to substitute it. After reading several other papers, we chose the article below, which also supports what we wrote in the respective excerpt of the presenting manuscript.

“DeFord S, Bonom J, Durbin T. A review of literature on substance abuse among anaesthesia providers. Journal of Research in Nursing. 2019 Dec 22;24(8):587–600.”

Reference #15: Group WAW. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction. 2002 Sep;97(9):1183–94.

[Substitution]

Although the previous reference also contained information regarding the ASSIST 2.0 tool, interpreting scores based solely on this paper could be difficult for readers. The new reference refers to the manual more recently published on behalf of the World Health Organization and allows readers to quickly find the information to which our study refers. Therefore, we thought it should substitute the former reference.

“Humeniuk R, Ali R, Babor TF, Farrell M, Formigoni ML, Jittiwutikarn J, et al. Validation of the alcohol, smoking and substance involvement screening test (ASSIST). Addiction. 2008 Jun;103(6):1039–47.”

Reference #17: Weiss DS. The Impact of Event Scale: Revised. In: Wilson JP, Tang CS, editors. Cross-cultural assessment of psychological trauma and PTSD . New York: Springer; 2007. p. 219–38.

[Correction]

The first citation was incorrect. It improperly mixed information regarding the book and the chapter being cited. We corrected it with the proper citation, as listed below.

“Weiss DS. The Impact of Event Scale: Revised. In: Cross-Cultural Assessment of Psychological Trauma and PTSD. Boston, MA: Springer US; p. 219–38.”

Comments - Reviewer #1

I thank the authors for careful consideration of my previous comments. I am largely satisfied with the revisions made, but still have a few areas of concern as highlighted below:

1. In the Results section, Paragraph on "Psychiatric Medical History", I believe the p-values reported are erroneous. It should be p = .034 and p = .044. Similarly, the p-values in Table 3.2 will need to be checked again to ensure that they correspond to the text.

Author’s Reply: Dear Reviewer #1, thank you for your very constructive comments. After carefully reviewing the paragraph you mentioned, we identified a discordance between the p values presented in the paragraph and in Table 3.1. We reassessed our statistical tests and the correct values are p = 0.341 (history of psychiatric disease) and p = 0.44 (history of anxiety disorders). The values were properly corrected (please find our STATA output below, with the respective p values). Also, we corrected the tables’ titles according to the new order they were cited in the text. Former Table 3.1 was renamed to Table 3.2; former Table 3.2 was renamed to Table 3.1.

In this paragraph we highlighted some factors that had exhibited what we considered an association trend towards higher IES-R scores. Although they provided some interesting insights regarding the issues involved with stress and substance abuse among participants, those factors did not achieve statistical significance when considering p <0.05. Therefore, we believe that the terms used to describe those findings should be substituted: we chose “Factors without an association with IES-R scores”. Although the association between those factors and IES-R scores did not achieve statistical significance, the presenting results may still be interesting to readers, and future studies with more statistical power may show different results. Finally, we chose to present those elements in a different table (i.e., Table 3.1) to make sure readers would not confuse them with the ones that achieved statistical significance (i.e., Table 3.2).

Finally, we merged the subtopics “Personal factors” and “Occupational factors”, creating a new subtopic entitled “Personal and occupational factors”. We believe that this change made the excerpt conciser to eventual readers.

We hope your concerns regarding this topic were properly and satisfactorily addressed. Thank you for your valuable suggestions!

2. There are still issues with the language in multiple areas, although I greatly appreciate the effort undertaken by the authors to improve the language of the manuscript thus far.

Author’s Reply: Again, we are pleased to fully accept your suggestions regarding English issues. Below you will find a list with corrections made after your suggestions, following the same order you presented them. We hope those changes shall address your concerns regarding this matter.

- [Incomplete sentence] "All the professionals working at an oncological COVID-19 ICU, regardless of their role (health professionals and non-health professionals), who were on duty for at least during one shift through the period of July to October/2020."

Author’s Reply: we added the excerpt “were invited to participate in this study” after the sentence mentioned.

- [Error indicated in caps] "Professionals with infected relatives .... significantly more likely to score higher in the IES-R, therefore more likely to suffer WITH PTSD or ASD."

Author’s Reply: we substituted the word “with” by “from” (i.e., to suffer from PTSD or ASD).

- [Error indicated in caps] "There was an association trend between higher scores and those who had sought alternative accommodation AWAY FROM during the pandemic ...."

Author’s Reply: we completed the sentence with the word “home” (i.e., away from home during the pandemic). To ensure this error wasn’t present in other similar sentences, we checked the other parts in which this term was used, and they were properly written.

- [Error indicated in caps] "For cannabis, stimulants, and cocaine, higher scores had an ... direct EXPOSITION to infected patients."

Author’s Reply: we substituted the word “exposition” by “exposure”. Like what we did in the previous suggestion, all other similar excerpts were checked for mistakes, and they were properly written.

- [Error indicated in caps] "It is possible that those results REFLEX the availability of those substances."

Author’s Reply: we substituted the word “reflex” by “reflected”. No other similar mistakes were found.

- ["Provided that" should be replaced with "GIVEN that some of those workers MAY HAVE HAD.."] Provided that some of those workers had psychological or psychiatric reasons for work leave, our findings can be underestimated.

Author’s Reply: we replaced the terms as mentioned above.

- [Should be phrased as "study had no FOLLOW-UP sessions] "Fourthly, as a cross-sectional study, it was not possible to determine causal relationships nor risk factors and the participants were not followed."

Author’s Reply: we rephrased this excerpt as “Fourthly, this study had no follow-up sessions. Therefore, it was not possible to determine causal relationships or risk factors”.

3. Minor suggestion to change the header "ASSIST 2.0 Results" to "Associations with substance abuse" instead.

Author’s Reply: we changed the header as suggested; we agree that the suggested version is more suitable to readers. Thank you!

4. Please provide the citation for the cut-off points/categorization of IES and ASSIST 2.0 scores after listing the cut-offs in order to allow readers to easily search for the original paper that provides these cut-offs.

i.e "The IES-R scores were categorized as follows: 1-11 = few/no signs of ASD/PTSD; 12-32 = several signs of ASD/PTSD, patient monitoring is recommended; ≥33 = highly suggestive of ASD/PTSD, immediate psychiatric evaluation is recommended [INSERT CITATION HERE]."

Author’s Reply: we inserted the respective citations to the IES-R and ASSIST 2.0 scores whenever those categorizations were mentioned.

5. Authors should consider elaborating a little on how their findings may be generalizable to ICUs outside Brazil. A suggestion is given below.

"the current results are in accordance those presented by other authors, in other populations of ICU workers (e.g., Netherlands [4], Canada [20], United States [21], and England [19]), suggesting that findings from this study are applicable and should be taken into consideration by professionals working in ICUs globally."

Author’s Reply: after reading your suggestion, we added the excerpt “Thus, it is likely that the findings of the presenting study could be generalizable to ICU workers from different populations and should be taken into consideration by professionals working globally”. We agree that such a phrase may clarify the main idea of this paragraph. Thank you!

Comments - Reviewer #2

The authors have responded in a satisfactory manner to all comments. I have no additional comments to make.

Author’s Reply: We appreciate your attention when reviewing this manuscript. We hope the corrections made after your previous comments had satisfactorily addressed your concerns and improved the quality of the current manuscript.

Comments - Reviewer #3

The design of the study is appropriate. The writing is in a good standard of English, grammatically correct and easy to understand. The results are clearly presented and explained.

Author’s Reply: We are glad to read your comments to this manuscript, thank you for your help during this review process.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

31 Jan 2022

Stress and Substance Abuse among workers during the COVID-19 Pandemic in an Intensive Care Unit: a cross-sectional study.

PONE-D-21-17265R2

Dear Dr. Pestana,

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.

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3 Feb 2022

PONE-D-21-17265R2

Stress and substance abuse among workers during the COVID-19 pandemic in an intensive care unit: a cross-sectional study.

Dear Dr. Vinicius Santinelli Pestana:

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on behalf of

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Academic Editor

PLOS ONE