Anxiety among doctors during COVID-19 pandemic in a tertiary care center in India.

Background and
Objectives: The ongoing pandemic of COVID-19 has a severe impact on the health-care system worldwide bringing doctors under immense pressure to work under stressful conditions. The main objective of this study was to assess anxiety among doctors and to understand the perceived causes of anxiety. Methodology: Questionnaires were made available to all willing doctors of SN Medical College, Agra; King George's Medical University, Lucknow, and GSVM Medical College, Kanpur, between May 12, 2020, and June 20, 2020 (during nationwide lockdown). The questionnaire consists of three main sections: details about respondents' working status, questions regarding respondents' reasons for concern, and Becks' Anxiety Inventory (BAI) scale.
Results: Two hundred and fifty responses were received from about 599 doctors presented with the questionnaire. About 32% of the respondents have already done duties in COVID facilities and the rest are awaiting deployment at those facilities. Forty-two percent reported concern regarding transmitting the illness to close ones/loved ones/family members to be a cause of anxiety and 40% were worried about the quality of protective gear closely followed by examination-related worries. About 28.8% of the respondents scored >7 on BAI with 62.5% of these (18% of total respondents) reporting "moderate" levels of anxiety. Conclusions: Our findings underline the fact that pandemics such as COVID-19 cause significant levels of anxiety among doctors. The levels of anxiety differed for age, sex, and specialty. The perceived causes were the risk of transmitting to loved ones and concerns regarding protective gear. These outcomes highlight the need for early interventions to address anxiety and to provide support for doctors during such crises. Copyright:

On December 31, 2019, cases of pneumonia of unknown etiology were detected in Wuhan City.[1] In January 2020, the World Health Organization (WHO) declared this outbreak, a new coronavirus disease, COVID-19, to be a Public Health Emergency of International Concern. In March 2020, the WHO declared COVID-19 a pandemic.[2]

As this spread worldwide, quarantine of suspected individuals evolved to the sealing of affected areas, towns, or districts, and then entire countries went into lockdown. As of July 8, 2020, the disease load globally is 11,669,259 cases and 539,906 deaths.[3] The burden of COVID-19 in India as of July 9, 2020, according to the Ministry of Health and Family Welfare, Government of India website, stands at 269,789 active cases and 21,129 reported deaths.[4]

Along with the specific physical manifestations of the diseases, some symptoms are known to arise due to the psychological sequelae of these infection outbreaks. During an outbreak, doctors are expected to work continuously for unduly long hours under various stresses with inadequate resources, at the same time also accepting the risks inherent in close interaction with ill patients. Multiple studies in doctors and nurses have shown that work-related stressors such as working overtime are associated with impaired mental health.[5678]

A study by Shanafelt et al.[5] and Wallace et al.[7] shows that about half of the physicians experience burnout, it is more in private practitioners, and younger physicians have nearly twice the incidence compared with older colleagues. The study by Wallace et al.[7] finds that suicide rates for physicians are estimated to be six times higher than in the general population, their cardiovascular mortality is higher than average, and about 8%–12% of all practicing physicians are expected to develop a substance abuse disorder at some point in their career.

Furthermore, it is of significance that doctors, like everyone else, are vulnerable both to the disease itself and to misinformation that tends to increases their anxiety levels. Poor understanding of the virus, spreading mechanisms, and management approaches. The very thought of susceptibility to the virus is adding to the anxiety. Such psychosomatic symptoms have been reported with increased prevalence during and after the outbreaks, such as the SARS and Ebola virus.[91011121314]

A study on survivors of the SARS pandemic of 2003 found that psychiatric morbidities such as posttraumatic stress disorder, depression, somatoform pain disorder, panic disorder, and obsessive–compulsive disorder and chronic fatigue persisted and continued to be clinically significant among the survivors at the 4-year follow-up.[9] Health care workers working at facilities catering to Ebola patients were seen to experience greater social isolation.[11] It is also important to note that stigmatizing illness can rapidly generate threat and stigma in the presence of inconsistent health policy and powerful media-propelled risk miscommunication.[10]

It is of great significance that the mental health of HCWs not only affects them but also affects the quality of care they provide and their professional functioning.[615161718]

Therefore, an elaborate and incisive understanding of factors that influence a doctor's mental health is needed to develop and optimize protective measures.[19]

METHODOLOGY

This online study was conducted to assess anxiety levels and perceived factors for stress among doctors during the COVID-19 pandemic. This method imparts several advantages – high efficiency and low cost (Best and Krueger, 2002), added to this, it also ensures that social distancing is maintained which is of utmost importance during such pandemics.

Objectives

The objectives of the study were as follows:

To study the prevalence of anxiety in doctors during the COVID-19 pandemic

To study the severity of anxiety among doctors

To study contributing factors to their anxiety.

In this study, groups of doctors from three different institutes, with similar socioeconomic statuses, were studied. Sarojini Naidu Medical College, Agra, Ganesh Shankar Vidyarthi Memorial (GSVM) Medical College, Kanpur, and King George's Medical University (KGMU), Lucknow, are tertiary care centers in northern India, currently designated as L-3 COVID Hospital. S. N. Medical College, Agra, is running a 100-bedded COVID facility; GSVM Medical College, Kanpur, is running a 150-bedded COVID facility; and KGMU, Lucknow, is running a 185-bedded Isolation facility and each of these is continuously striving to expand their capacity to cater to the increasing requirement. All the above centers are also running 24 × 7 emergency with a triage and holding area.

The emergency department is run by consultants and resident doctors of respective specialties, and the isolation facility is run by consultants and residents of all (preclinical, paraclinical, and clinical) departments on a rotational basis. All the above facilities require working in an environment of considerable risk of exposure, wearing a complete PPE Kit with all the necessary precautions and protocols.

A questionnaire is made available to all the willing doctors of the above-mentioned facilities through e-mail/WhatsApp/SMS and responses collected on an online platform for 40 days during lockdown (May 12, 2020–June 20, 2020). The questionnaire consists of three main sections: details about respondents’ working status, questions regarding respondents’ reasons for concern, and Becks’ Anxiety Inventory (BAI), a frequently used and well-standardized measure of anxiety. BAI scale is a self-report questionnaire. It consists of 21 items, scored 0–3. The total score is calculated by adding the 21 items. Internal consistency is Cronbach's α =0.92 and test–retest reliability (1 week) is 0.75 for BAI (Beck, Epstein, Brown, and Steer, 1988).[20]

Data were analyzed using SPSS (v27, Build: 1.0.0.1406).

Consent was obtained before data collection and confidentiality was maintained. Ethics approval for the study was obtained from the Institutional Ethics Committee, SN Medical College, Agra.

RESULTS

Two hundred and fifty responses were received from 599 doctors (42.4%) presented with the questionnaire. Poor response rate might be due to doctors being busy with their pandemic duties. The demographic characteristics of respondents are shown in Table 1. Data show that the majority of respondents belong to the young age group (21–40 years). The number of male respondents (58%) is marginally more than females (42%). The distribution of samples according to specialty is shown in Table 2. The distribution of respondents among specialties is seemingly even, with MBBS interns understandably being 27% as they are present in all specialties. More than one-third of respondents have worked in COVID facilities where wearing PPE and other infection control protocols are stringent. The remaining are working in non-COVID areas, but it would not be an exaggeration to say that even they are under considerable risk of exposure.

Table 1

Demographic details

	Number of respondents, n (%)
Name of institute
GSVMMC, Kanpur	27 (10.8)
KGMU, Lucknow	25 (10.0)
SNMC, Agra	198 (79.2)
Total	250 (100.0)
Age (years)
≤40	222 (88.8)
41-60	24 (9.6)
≥60	4 (1.6)
Total	250 (100.0)
Mean	29.06
SD	8.403
Sex
Female	103 (41.2)
Male	147 (58.8)
Total	250 (100.0)
Designation
Faculty/consultant	48 (19.2)
Intern	68 (27.2)
Junior resident (academic/nonacademic)	84 (33.6)
MBBS students	50 (20.0)
Total	250 (100.0)

Table 2

Clinical specialty

Specialty	Number of respondents, n (%)
Clinical branches already running ICU facility (anesthesiology and critical care, medicine, pulmonary medicine, geriatric medicine, emergency medicine, cardiology, gastroenterology, neurology, nephrology, pediatrics, medical, hematology, GI surgery, neurosurgery, CTVS, ENT, pediatric surgery, surgical oncology, burns, and plastic surgery)	40 (16)
Clinical specialties with a clinical postgraduation but not currently running ICU/HDU (endocrinology, rheumatology, obstetrics and gynecology, radiotherapy/radiation oncology, orthopedics, and urology)	34 (13.6)
Clinical specialties with limited responsibility for critically sick (dermatology, ophthalmology, PMR, psychiatry, community medicine, and transfusion medicine)	27 (10.8)
All faculty/residents from pre- and paraclinical departments	31 (12.4)
Interns	68 (27.2)
MBBS students	50 (20)

ICU – Intensive care unit; GI – Gastrointestinal; CTVS – Cardiovascular and thoracic surgery; ENT – Ear, nose, and throat; HDU – High dependency unit; PMR – Physical medicine and rehabilitation

Perceived causes of anxiety are enlisted in Figure 1. Maximum respondents (42%) reported concern regarding transmitting the illness to close ones/loved ones/family members to be a cause of anxiety and 40% were worried about the quality of PPE closely followed by examination-related worries (39.6%). Ill-equipped isolation facility (35%), separation from family for a long time (30%), unpredictable course of illness (29%), and irregular daily routine (29%), each of the above-mentioned factor was a cause of worry for about one-third of the respondents.

Figure 1

Perceived causes of anxiety

It is found that 28.8% of the respondents scored >7 on BAI with 62.5% of this (18% of total respondents) reporting moderate levels of anxiety [Table 3].

Table 3

Beck Anxiety Inventory score (severity assessment)

	Number of respondents, n (%)
Mild	47 (18.8)
Moderate	24 (9.6)
Severe	1 (0.4)

8-15 is interpreted as “mild” level of anxiety; 16-25 as “moderate;” 26-63 as “severe”

Respondents were asked if he/she feels the need and is willing to get help from a psychiatrist, it is surprising to note that only 15.3% of the respondents experiencing significant levels of anxiety are willing to consult a psychiatrist.

DISCUSSION

The study was conducted during the initial few months of the pandemic COVID-19 when a nationwide lockdown was imposed to limit the spread. The understanding of the nature of the illness and modes of spread was poor. The sites of the study were experiencing a rising number of cases. More than one-third of the study sample had worked in a designated COVID-19 unit wearing a complete PPE Kit with all the necessary precautions and protocols. Approximately 4000 patients were seen and managed at these hospitals during the duration of the study.

Out of 250 respondents, 18% of the respondents screened positive for moderate-to-severe levels of anxiety, this is significantly higher than a study by Chew et al. (8%)[21] but lower than Lai et al. (44%).[22] The majority (83%) of respondents who had done duty in dedicated COVID-19 units belonged to the younger age group (≤40 years). It is an indication of a conscious effort to protect doctors with a higher risk of developing complications due to COVID-19.[23] Table 4 shows greater levels of anxiety in the 41–60 years age group in comparison to the 20–40 years age group. It is understandable as the higher age is a risk factor for complications in COVID-19. However, it stands in contrast with the findings of Nickell et al. where age 50 years or more was seen to be associated with decreased levels of concern.[24] Anxiety in age groups higher than 60 years cannot be assessed reliably as the number of respondents is few.

Table 4

Severity of anxiety

Severity and age (years)
Severity	Age (years)			n (%) of age
Mild	20-40			39 (17.6)
	41-60			7 (29.2)
	≥60			1 (25.0)
Moderate	20-40			20 (9.0)
	41-60			4 (16.7)
	≥60			0
Severe	20-40			1 (0.5)
	41-60			0
	≥60			0
Severity and sex
Severity	Sex			n (%) of sex
Mild	Male			31 (21.1)
	Female			16 (15.5)
Moderate	Male			9 (6.1)
	Female			15 (14.4)
Severe	Male			1 (0.7)
	Female			0
Designation and anxiety levels
Designation	Mild	Moderate	Moderate	Total (%)
Faculty/consultant	13	4	0	17/48 (35)
Junior resident	16	9	1	26/84 (31)
Intern	8	7	0	15/68 (22)
MBBS students	10	4	0	14/50 (28)

Table 4 shows that 14.4% of females experience “moderate” levels of anxiety as compared to only 6.2% of males. This shows that females are experiencing greater anxiety. It is consistent with findings of Nickell et al.,[24] Lai et al.,[22] and Weilenmann et al.[25]

It is seen that a higher designation is associated with a greater prevalence of significant levels of anxiety [Table 5]. It is in contrast to Lai et al.[22] which reported similar levels of anxiety in juniors and seniors. It can be attributed to the higher age of this group and therefore worries about complications of COVID-19.

Table 5

Correlations

	BAI score total	Sex	Age	Designation	Department	Duty status
BAI score total
Pearson correlation	1	0.202*	−0.114	−0.068	−0.022	0.027
Significant (one tailed)	0.044	0.169	0.285	0.426	0.412
n	72	72	72	72	72	72
Sex
Pearson correlation	0.202*	1	0.062	0.059	−0.059	−0.246*
Significant (one tailed)	0.044	0.303	0.312	0.311	0.019
n	72	72	72	72	72	72
Age
Pearson correlation	−0.114	0.062	1	0.781**	0.542**	0.386**
Significant (one tailed)	0.169	0.303	0.000	0.000	0.000
n	72	72	72	72	72	72
Designation
Pearson correlation	−0.068	0.059	0.781**	1	0.834**	0.569**
Significant (one tailed)	0.285	0.312	0.000	0.000	0.000
n	72	72	72	72	72	72
Department
Pearson correlation	−0.022	−0.059	0.542**	0.834**	1	0.646**
Significant (one tailed)	0.426	0.311	0.000	0.000	0.000
n	72	72	72	72	72	72
Duty status
Pearson correlation	0.027	−0.246*	0.386**	0.569**	0.646**	1
Significant (one tailed)	0.412	0.019	0.000	0.000	0.000
n	72	72	72	72	72	72

*Correlation is significant at the 0.05 level (one tailed), **correlation is significant at the 0.01 level (one tailed). BAI – Becks’ Anxiety Inventory

Clinical branches already running ICU facilities have a marginally higher proportion of respondents reporting anxiety compared to faculty/residents from pre- and paraclinical departments. It shows a positive association with higher expertise which is consistent with Weilenmann et al.[25] [Table 5]. However, interesting to note is that a lesser proportion of clinical branches already running ICU facility suffers from moderate levels of anxiety, it indicates toward a better coping mechanism. MBBS students report the least anxiety and it is understandable as they are mostly viewed as a reserve force and are not yet deployed in active COVID care.

It is also seen that duty in dedicated COVID-19 units with imminent exposure while wearing PPE is associated with greater levels of anxiety. It is consistent with the findings of Nickell et al.[24] and Weilenmann et al.[25] This can be attributed to worries about the quality of protective equipment in an environment of direct interaction with COVID-19-positive patients. Along with this, extremely hot weather of summer months in a tropical country aggravated by the absence of air conditioning facilities posed another challenge. Masks, an essential part of protective gear, are known to cause physical discomfort and are considered the most bothersome precaution.[24] There have been instances of doctors fainting during such duties.[26] While wearing PPE, there is persistent concern regarding breach or failure to comply with protocols.

A question was posed to enquire about the perceived causes of anxiety in doctors. Maximum respondents (42%) reported concern regarding transmitting the illness to close ones/loved ones/family members. It is also seen that about 40% of respondents are concerned about the adequacy of measures of protection. This is considerably lower compared to the study by Chen et al. (91.4%)[27] but more than Maunder et al. (20%).[28] This shows the health-care system has been quite successful in allaying fears regarding PPEs. This can also be seen in the light of the rapid increase in the production of PPE and masks across the nation to meet the increasing demand.

About 39% of respondents reported academic-related worries, especially examinations. It can be attributed to the fact that the three institutions in this study are medical colleges and the majority of respondents are keen academicians. The pandemic has halted almost all academic activities. There are prevailing uncertainties regarding various examinations (admission and completion examinations).

Responses suggest that being away from family for a prolonged period provoked stress. This observation emphasizes that social support is known to be an effective buffer of stress.[2930] The lack of social interaction was further accentuated by decreased interaction among coworkers.

The natural history of COVID-19 was not well understood at the beginning of the pandemic. It contributed to the anxiety of 29% of the respondents. The perception of personal danger was heightened by the modification of infection control procedures and public health recommendations day to day, the poorly understood lethality of the syndrome, and intense media coverage of the outbreak and its effects.

Newer challenges to health-care setup such as issues getting viral on the Internet/social media (13%) and official inquiries being setup/strict scrutiny (8%) are affecting doctors. Persistent fear of being monitored and being hassled by inquiries significantly brings down efficiency. This is a major area of concern and requires compassionate redressal by authorities. Action should be aimed to not only address the viral news but also pragmatically analyze the varied stresses faced in COVID-19 management by doctors and provide support rather than punitive actions. Another significant issue – xenophobia among doctors (10%) – raises concern as it stands against the ethics of medical practice. It can be attributed to the media portrayal of illness and factors contributing to its spread. It demands prompt action and can be modified significantly by responsible reporting and dispensing of appropriate information by media outlets.

Query about willingness to consult a psychiatrist for anxiety symptoms experienced yielded results that are an area of concern. Only 15.8% of the respondents experiencing significant anxiety symptoms are willing to consult an expert despite themselves belonging to a high intellectual group concerned with patient care and with easy access to mental health care. This might suggest discomfort in consulting a psychiatrist probably due to stigma.[31] It becomes important to increase awareness and acceptance of psychiatric illnesses as stigma is known to decrease the probability of recovery.[32]

There are multiple limitations to the study. The study is cross-sectional and no control group restricts from concluding changes in symptoms. The response rate is poor and there is a lack of information about the nonrespondents. Coverage error is a well-known problem of such online surveys, but in this case, doctors were contacted through personal calls messages, and e-mail, and an attempt was made to minimize such errors. It is worth noticing that selection bias can be significant. The small sample size further limits the interpretation of the study results in the general population.

CONCLUSIONS

In the study, it is seen that duty in dedicated COVID facilities wearing PPE is associated with greater levels of anxiety, and females suffer greater levels of anxiety compared to their male counterparts. The perceived causes were risk of transmitting to loved ones, concerns regarding PPE, academic-related worries, lack of optimal care in case one is exposed/sick, being away from family for a prolonged period, and unpredictable course of illness. It is important to note that concerns regarding the adequacy of protection are significant, but a sufficient supply of good quality equipment has played a key role in allaying concerns. It is learned from the study that there is a need for interventions to mitigate the adverse effects of social and interpersonal isolation. There is an urgent need to look into and alleviate issues regarding academics and to provide practical support such as better housing conditions and care if exposed or infected. It becomes imperative to attend to the effects of media portrayal of health-care workers as well as the disease. Further studies should be undertaken to study the effect of a pandemic on anxiety among doctors as the pandemic progresses. Steps to ensure a better response rate should be taken in future studies. Furthermore, a conscious effort to create awareness about these symptoms, their acceptance, and destigmatization of psychiatric consultation should be made.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.